Comment by ggrrhh_ta | Hacker News Reader

Comment by ggrrhh_ta | Hacker News Reader

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"Blaming the clinics doesn't work" - I trying to wrap my head around to put myself in your frame of mind to shift the blame from who is to blame to the government. If those clinics recommend and perform unnecessary procedures on people that can afford them (and do not benefit from govt. aid), does "blaming the clinics not work", because the actual problem is people being able to afford it? or would you go one step ahead and then say that the government is still to blame for allowing the possibility of wealth accumulation by individuals that results in unnecessary spending? or is the government still to blame because of not further regulating and auditing dental clinics? or is the government to blame because of allowing the mere existence of private dental clinics?

I guess that the government did not "set things up so that the rise of clinics to exploit the rules was legal and inevitable". I am going to guess that individuals, knowing that that was not the intention of the government aid, decided they could get around it to profit.

edit: typos

If you have a plan that relies on everyone in a nation of 300 million behaving ethically and honestly when there is a big incentive not to, you have a bad plan.

The moral failing is on the clinics, sure, but if you want to fix the problem, you have to look at the government.

Dentists take the Hippocratic Oath just like doctors. First and foremost, this wasn't just a moral failing, this was a major professional violation, regardless of any government incentives. They put patients in unnecessary risk of complications and likely caused harm in some cases, in direct violation of the one of the most important oaths in any profession. It is the job of healthcare professionals to cater to the health of their patients, not their billing departments.

You can't write all laws like we're living in a Mad Max dystopia - some laws will need to assume that other laws are functioning correctly in order to be practically implementable as a law - just like software has dependencies that must uphold some invariants for the interface to work. The issue isn't subsidizing healthcare, it's unethical professionals abusing our trust.

"Dentists take the Hippocratic Oath just like doctors. First and foremost, this wasn't just a moral failing, this was a major professional violation, regardless of any government incentives. They put patients in unnecessary risk of complications and likely caused harm in some cases, in direct violation of the one of the most important oaths in any profession."

Generally true, but the judgment call on "is this patient better off by being left alone" vs. "is this patient better off by having a surgery" is not easy, especially in our culture which worships heroic medicine. Patients often demand that something be done because they are primed so from the popular media they consume.

This can be even seen in the end-of-life care. Too many families demand that their dying grandma is given expensive and invasive care to live three weeks longer, even though its not just pointless, but outright cruel.

> Generally true, but the judgment call on "is this patient better off by being left alone" vs. "is this patient better off by having a surgery" is not easy, especially in our culture which worships heroic medicine. Patients often demand that something be done because they are primed so from the popular media they consume.

That's why it's a problem with professional ethics in healthcare first and foremost. Nobody in the bureaucratic chain is qualified to make or judge medical decisions and them trying would only be a monumental disaster because they don't even meet the patient and they're probably not medical professionals themselves. Hell, the patients and their family are rarely qualified to make the decisions - just look at what doctors chose for end of life care versus what their patients end up doing.

The system doesn't work if we don't police the professionals making the decisions at the point of care. The trick is not overdoing it like we did with opiates, scaring doctors from prescribing them even for patients genuinely in need.

Isn't the answer to this better accountability? Incentives without accountability usually lead to this type of outcome.

Define accountability. Now you have a cost benefit ratio. If there is personal liability who can be blamed so you get the benefit and they get the detriment.

In this specific case, it would be an independent audit of the procedures to determine whether they were actually necessary or not.

it's not rocket science. Poor people don't have the money required to go to the dentist and properly take care of your teeth. Since having a healthy populace is a good thing, we say "okay, we're all going to pitch in so everyone can be as healthy as possible."

If people start to take advantage of that for personal gain (which we know there are always people who are going to do that), we need to have a plan in place for dealing with those assholes.

The presence of assholes in society shouldn't mean we don't even try to take care of each other. It should mean that we have plans for recognizing when someone is an asshole and taking measures to change that behavior.

Now you've created a new problem of bureaucrats that are just as susceptible to incompetence, incentives, and malfeasance as the dentists.

This is going to be the problem with every system of mandatory funding. Doesn't matter if it's housing, dentistry, food stamps, etc. People were abusing the disability program, so we made a bunch of hurdles to get funding. Now there's companies who train you how to get over those hurdles: what to write on the forms, what to say to your doctor, etc. And guess what? The companies that train you what to say to get disability then get to bill the government for this new service they provided you. I'm sure it's easy to imagine their incentives.

And yet there are ways we can address those issues too. I don't get why we gotta stop trying to take care of each other simply because there are assholes who try to take advantage of things.

>I don't get why we gotta stop trying to take care of each other

How would ending food stamps stop you from taking care of other people?

Removing a massive mechanism for being able to address a need that most people feel shame for and explicitly try to hide due to social pressure?

If I'm acting on my own, my reach is very limited. By using the government, we have the potential to make a much larger impact, and in this case, create the expectation that no one should go hungry in this country. We're not there yet, mainly because there are many people around here who don't believe that expectation is valid. I'll fight them for the rest of my life.

There is a specific term relevant to this, which is applicable to many problems of misaligned risk/incentive, governmental and otherwise: "Moral Hazard"

Seems like existing whistle blower incentives could be beefed up and better publicized.

A new "moral heroes" national holiday celebrating those who uncover fraud. More resources dedicated to investigating claims, more leeway to fine corporations for bad faith activity in order to increase the incentive to blow the whistle.

I think you are implying the following when you say "you have to look at the government": "if you want to fix the problem of people/clinics/etc. abusing (dodging/fraudulently take advantage of) government programs/policies you have to ..." ----- And the "..." is not filled in. I guess I could fill it in with: "stop implementing policies/programs if you are not at the same time investing as much as it is necessary to guarantee nobody gets around the law" - that is, do not trust, add more inefficiency (clinics already need to attest the procedure is necessary) and cost.

Dentists and doctors are not all of one mind about treatment effectiveness or necessity, so the tails of the bell curve matter. There may very well be some small percentage of dentists who believe that procedure X is beneficial in almost all cases. They might be quacks, but most quacks I've met believe what they are selling (even if they are wrong.)

If there also is a government program that reimburses for X in almost all cases, then you could see the emergence of clinics that "exploit" the rule even if everyone involved believes they are behaving ethically.

There are feedback loops that then exacerbate the problem- for example a successful clinic might bring on additional dentists, who despite misgivings will be influenced by existing practice at the clinic and begin self justifying the procedures to conform to the senior partner. After all, they clearly know what they are doing, right?

While I have no idea if that's what happened here, it is well with in the realm of possibility. The government does bear some responsibility to ensure that thier programs and rules provide sufficient oversight and feedback to keep fringey participants within the bounds of what the government considers acceptable.

I understand your arguments, which in my view, "shift the blame", and in your view, "charge with at least some responsibility" to the government. The problem I see is that this sort of arguments, if accepted as OK/inevitable and universalized lead to a dilution of responsibility that would make no one fully accountable for any intentional wrongdoing: for example, if you pay for your car to be repaired at your regular car repair shop, but the mechanic knowingly used parts that were not certified or due to time pressure skipped standard checks, and you let someone drive your car a year later, and there is an accident that was caused as a consequence of that sloppy repair-work, do you share responsibility for your oversight? - You might argue you do; well, I would argue you don't.

The government is not an individual- appropriate morality and responsibility at scale are different then as an individual. Additionally, if insurance / the government agrees to pay for a procedure that serves as a form of confirmation for the end user - after all, the department of health and human services approved the procedure!

A better example would be if a Sr Director of a rental car company shifted sourcing of thier repair contractor. If the new repair contractor consistently did way more repairs then the rental company needed, should the director of fleet maintenance be held responsible? Absolutely.

The moral blame rests fully on the clinic, but the responsibility to fix the system rests fully on the government (in this case). It's really no different than a production line with a quality problem. You can yell and scream about the morality of the workers all you want, but you can't expect them to improve if you don't fix the system and incentives that cause the problems.

the reason the analogy doesn’t hold up is there isn’t a system there — that’s a set of actually individual choices. When you see systematic behavior, you need to look for the system to fix it. The problem with blame is it doesn’t get you far enough, even if it feels good or right. Finding and fixing incentives is the only way to systematically enact change. Whether it feels good or not.

btw, I think it is important to place the blame correctly and take whatever action is possible on the perpetrators to deter such behavior and at the same time patch systemic loopholes that are identified. They are not incompatible actions. If anything, they are complementary.

is the threat of punishment for wrongdoing not enough?

Clearly not--when there is systemic rulebreaking, the point is that it's impossible to enforce the rules in a way that is "enough".

The same dynamic exists for private insurance companies. The existence of incentives for illegal activity doesn't shift the blame off the criminal.

We don't say that an ATM mugging victim bears some responsibility just because a criminal knows that such people will almost always pay out.

blame/responsibility is a red herring here. mugging is already illegal and, if caught, the perpetrator faces imprisonment. the salient question to ask here is what changes we can make to reduce the unwanted behavior.

possible actions:

politely ask the general public not to mug one another

increase penalties or rate of apprehension for perpetrators

encourage people to minimize their ATM visits, not walk around with debit cards, etc.

give people money so they don't feel the need to mug other people

You're right, "blame" is too loaded of a word, and also inadequate. However, in order to identify the actions to take, you still need something like a full systems analysis of weak points. Your list is a pretty good start on representing those.

That requires setting up objective bureaucratic rules, which are the same problem as "Management by metrics leads us astray."

I think we can safely blame both owners and employees of the clinics and the people in government who devised and implemented the program.

We can blame the owners of the clinics because we have a right to expect people to to make morally correct decisions. We will never invent the perfect system of laws to incentivize everyone's good behavior. At the end of the day, society only functions when the majority of people are at least somewhat selflessly contributing to it.

We can blame those who devised and implement the program because we can expect them to do more auditing as well and ensuring the program isn't gamed. People in government are responsible for spending taxpayer money wisely.

The trouble is that blame doesn’t address the problem either. We want the government to make wiser, less gameable policy. We want businesses to act ethically. How do we acheive those? It’s not blame.

I think the answer is incentives. The government had the incentive to “help the poor” - so they did. The clinics had the incentive to “fix teeth for people in need” - so they did.

Just like in software development, so much rests on properly defining the desired outcome.

The problem is also that in the game of "helping people afford all their needs", governments will rarely construct solutions that involve less government. Which might well be the right answer.

Can you exemplify this?

Examples are impossible: governments are too complex. Any government that does this (however it is done), that government is also doing other things that are confounding factors.

The idea is simple: a government that does less costs less, so it needs to collect less taxes. That means people just over the edge could pay for their dental work instead of the government and all the overhead of having a third party involved.

It doesn't help those completely unable to care for themselves, but those who are close are no longer pushed over the edge.

Deregulation of airlines led to the modern era of cheap air travel.

That may have helped, but you can't ignore other factors such as relatively stable inflation adjusted fuel costs, combined with better fuel efficiency, lowering operating costs, or the trend towards eliminating amenities and increasing passenger density. Or the continued increase in airline safety while overseen by the not deregulated role of the FAA. Deregulation was only part of the picture.

Deregulation of energy companies led to Enron.

What exactly did you just prove by this overly generalising statement?

"less gameable policy" -> clinics do not get a blank check, for good or bad, they have to comply with government's bureaucracy requirements, i.e., explicitly take action that attests that the clinic considers the procedure to be necessary and covered under that particular government aid. That is, if the clinic does the bureaucratic 'work' when the procedure would not have been recommended otherwise, their actions border: fraud and healthcare crime.

"The clinics had the incentive to “fix teeth for people in need” - so they did", in the case at hand, being the procedures unnecessary, the incentive was not "fix teeth for people in need", but "increase profits".

I agree completely that “increase profits” was a goal for the clinics, but I mean something a little different by incentive. I mean “a behavior that is being encouraged or rewarded by others.”

You are asserting that the government’s policy was sufficiently specific regarding “medical necessity” that would clearly show these claims would not qualify. If that were the case, then the government itself should not have paid out those claims in the first place. The fact that they did pay the claims (at least until someone blew a whistle) suggests either that their policy was vague enough to not be so enforceable, or that their review and enforcement was lax (or both).

That’s my point - if the policy and enforcement had been clear from the get go this wouldn’t have been so big a deal. One or two bad apples try something and get sanctioned and the whole thing stops being an incentive to bad actors.

We agree that something changed in the situation such that this is no longer occurring, right? What was that change, and why was it not so in the first place?

In my experience, people who are paying the bill tend to ask more questions and be more skeptical the higher the price is.

The government is asking those questions, that is the "work" the clinics do when they say they "would do the work" to be able to bill the government for such procedures.

Yes, but this skepticism is problematic when it comes to healthcare. Particularly when it comes to high-deductible plans -- people are too skeptical, and will avoid seeking the care they need. Even when the cost of that early care is less than what they would otherwise be playing in premiums.

edit: retracted: (sometimes leading to more expensive measures needed down the road) — see replies

I wouldn't be so quick to retract: According to that wikipedia link, while costs may not have changed much, mental & physical health were improved. Essentially, the cost per-unit of overall patient wellbeing was decreased because costs remained the same while patient care increased.

The Oregon Medicaid expansion didn’t reach this conclusion. On balance people were happier because of lower stress, and people with diabetes were better served, but there wasn’t a huge macro effect of cost reduction via early intervention.

We already know the thing about diabetes, to the point that even private insurance companies will throw money at compliance because it’s cheaper than care. Outside that, vaccinations, and maybe a few more specific cases, the conventional wisdom of early intervention saves money is false.

https://en.m.wikipedia.org/wiki/Oregon_Medicaid_health_exper...

patients also had a "higher self-reported mental and physical health"

I think that's a heck of an important thing to mention here. Costs didn't change much, but health was improved.

Thanks for the link, I edited my comment

The price of dental work is not very high. A few thousand dollars would cause you or me to ask questions, but the government deals with billions, so that little bit gets lost in the noise. It can make a lot of many for those in the scam without being easy to notice.

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