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Comment by goopthink | Hacker News Reader

The article proposes prepayment options. Why not go to the "other, other obvious" solution, which is results-based payments? In healthcare, that's value-based care. In other industries w/ agent-principle problems, it's called "taking on risk". You're incentivizing results and outcomes, rather than whatever specific actions lead up to those results. It means that the focus is no longer on the activity provided by the agent, but on the desired outcomes from the principle. Pure alignment and it helps filter out those who are good at getting results from those who are good at doing the actions.

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> Why not go to the "other, other obvious" solution, which is results-based payments?

There is a story about doctors in ancient China who are paid by their clients only so long as the client is healthy. When they fall sick, the doctor is not paid again until the patient is healthy again. Then the goal is not a cure for a disease but the prevention of disease.

I don't know if any such thing ever really happened but it seems like it might be worth exploring even if only to illuminate the various possibilities.

It's an interesting idea but the pessimist in me just sees this as incentivizing under-diagnosing, running fewer tests, etc.

Running fewer tests is not necessarily bad, especially if your baseline is a system where the system is paid per-test.

Also they have no interest in treating elderly (or anyone all that ill) if it requires any effort at all, as future healthy payments will not cover the expense.

It is easy to see an optimal strategy of never treating anything.

Well the other option, which is to pay when a problem is found, can lead to over-diagnosis and finding issues where there are none. Its 'taking your car to an unknown mechanic' problem, he _will_ find a problem, and that is a problem too.

what if the diagnosing and treatment were done by different doctors?

I think this only works if there's a scarcity of patients but it's rarely true that patients are rare. This will probably suffer from the real estate agent problem: in theory, real estate agents are incentivized to get you the best price because they get a cut for their efforts, but in practice it's more lucrative for them to flip more houses than put in the extra effort into your case. Likewise, I suspect doctors will find it easier & cheaper to not care about you and just move onto taking in other healthy patients.

Then doctors filter what patients they take to guarantee these good outcomes. This is already done by some surgeons. Surgery is already a subset of medicine heavily judged on outcomes.

This is featured in the Doctor Strange movie, in fact. IIRC the good doctor is presented with a patient whose case is so difficult that he's one of the only people in the world with a chance at successfully performing the procedure they need—but he turns it down because he thinks the odds would still be too low, and it might hurt his record. I think there might also be a karmic turn with that when his hands get messed up—I wanna say there's a scene or short sequence of the same thing happening to him, at least implicitly.

Cherry picking and lemon dropping does happen in value-based systems, but there has been work to address the issue. No simple answer, but basically you pay doctors more for select patients.

https://relentlesshealthvalue.com/audios/ep322/

Within the context of the article though, if one assumes greedy doctors, then essentially cooperating doctors can cooperate to refuse treatment N times, where N is an equilibrium between the lemon-picking bonus and never accepting any patients at all (and therefore never having any revenue), in order to get the system to label non-lemons as lemons.

I got the impression that the same phenomenon was present with driving instructors and driving test pass rates. If it's clear after a dozen or so lessons that they might not pass then say that you will stop teaching and suggest a different instructor.

I think that the author is assuming that you, the patient, have no way to assess whether the diagnosis was correct. I think that eliminates what I also thought of as a strategy, which is how this works in real life - some combination of being able to tell, as the patient, when treatment is working, combined with (the threat of) second opinions, and of course all the “human” stuff that the author sets aside about doctors wanting to help people etc.

The thing is, in many cases you don't need to know if the diagnosis is correct, so long as the results are directionally correct. If the outcome is an improvement in health, that meets your threshold for value delivered, hence payment rendered. I think there are many cases when you don't need to be smarter than the other person to benefit from their expertise. You can take it a step further and make the distinction between absolute value versus perceived/relative value -- if we have a patient with cancer, absolute value might mean destroying all cancer cells (which is an absolute metric but extremely hard to model). But perceived value might be "feeling better". It's important to make this distinction particularly in healthcare because absolute benefits and relative benefits are extremely important. Hospice/end-of-life care is a good example of this (as is the cancer example above). Most people would prefer relative or perceived comfort as opposed to absolute results that only end up prolonging a painful process.

Outside of healthcare, for another example example, you don't need to understand engineering and tension dynamics in order to appreciate that the second floor of your home support you and your roof doesn't cave in on itself. I don't have examples on hand, but in medicine we've had cases where people do some logical variation of "the right thing for the wrong reasons." I.e., rituals that correlate with healthy outcomes because there is some not-yet-understood principle at play (i.e, you don't need to understand germ theory to benefit from cleanliness rituals).

I think this is one of those logical conundrums which falls into the trap of "in theory, in practice". The artificial constraints around the problem space result in artificial logical conundrums.

It is a balancing act, to be sure, regarding "feeling better" vs "less sick". Hospice care is indeed very important. It can go too far in this direction, however, and I have real sympathy for docs that get it "wrong" in either direction (too much "comfort" or too much "let's give you more years").

Notably: the prescription opioid epidemic is a great example of how this can go wrong in the opposite direction of healthcare providers valuing "relative" benefit vs "absolute" benefit.

My spouse is a primary care provider, and there was a period a couple decades ago where the prevailing wisdom was "if a patient says they are in pain, they are in pain, and you treat that pain. We are experts in medicine, but the patient is the expert of their own perception." This is still a complicated issue today, but there are clearly outcomes where we can make people "feel better" all the way to an early grave.

For the terminally ill, it seems absolutely appropriate to me to let the patient guide whether they wish to accelerate their death in exchange for quality of life. But "terminally ill" is often not such a black and white issue...we are all eventually mortal.

If things like heroin don't inspire a sense of horror or dread, then we just aren't speaking the same language. I, for one, don't want to live in a world where the human priority-at-large is everyone defining "living" as maximizing pleasure until their death. For the hedonists, I get why this makes a certain nihilistic sense, but I think the horror of the reality of it outweighs any momentary benefit.

In the very abstract, maybe it doesn't really matter one way or the other. In the concrete day-to-day reality of it, it's absolutely awful to see anyone struggling with any kind of addiction, out of control of their own lives...sometimes because they got on a treadmill-to-death on the _expert_ advice of someone trying to "help them out."

This is such an awful take. So if a doctor prescribes a medicine and the patient never takes it and the patient dies it is somehow the doctor's fault or they don't get paid?

Some doctors are greedy. Some ________ are greedy. There are major factors in the waste in our health care system but by and large it isn't doctor's fees. There are so many rent seekers taking a cut.

There are other models than fee-for-service. They have tried population health models where the Provider (Dr, nurse, etc.) get $X per person per year. They are incentivized to be more preventative where they basically get to keep whatever they don't spend on patient care. However, you can lead a horse to water but can't make him drink. Ask yourself this: would you write web code where you got paid based on how many unique visitors viewed the page your wrote?

We can easily fix health care with a few simple changes but there is no real appetite to do so. One simple change is to go to referenced based pricing. You can't charge more than 1.2 the Medicare reimbursement. This change alone would reduce our spending by 25%.

> One simple change is to go to referenced based pricing. You can't charge more than 1.2 the Medicare reimbursement.

Agree that this is huge. Price transparency, reference pricing. You know "the law of one price" is supposed to be a pillar of market economics, so this should be a no-brainer. Additionally, don't allow charging more than the insurance will pay with the exception of an agreed upon co-pay ahead of time. If a hospital accepts insurance, then it shouldn't be able to send you a bill later on that the insurance refuses to pay. That needs to be worked out between the hospital and the insurer. I would also like to see binding quotes before any procedure, with no surprise billing.

Most of us have been in a codebase for an issue that turns out larger or more complex than first understood. I don’t want to undergo surgery for cancer X, have the surgeon see nearby, related cancer Y and sew me back up and tell me I also have cancer Y but that he didn’t want to go over the estimate.

When asked for a choice by a medical professional (or a home improvement contractor for that matter), I will more often than not ask “if you were in my shoes, what would you do?” I don’t 100% of the time go with what they say, but I think it helps me understand their expertise and judgment better.

In the surgical case above, if the surgeon would have taken it out and given me a single recovery experience and told me about the bill when I woke up, I’m probably better off for it.

So in a surgery situation where you are under and something else is discovered, then that's a situation of unexpected costs. So you look to who is best able to bear them and that's who bears them. What exactly is the purpose of insurance if they do not cover you from unexpected costs? And if there is no insurance (say a cash procedure), then the hospital bears the cost and bakes the possibility of complications into the price.

Point is, you need clarity of prices rather than the situation today where you sign a promise to pay whatever costs the hospital decides to charge you, and you may not even know what those are until weeks after the procedure. There is no meaningful way a market can operate under conditions in which blank checks are demanded in order to get anything done.

If that can't work, and the hospital insists it cannot quote you a cost at all, then go full socialized healthcare since obviously no market is possible.

And then you have the current bs where the anesthesiologist for your operation at the hospital system that you always use is somehow un-affiliated and out of network even if everything else in that system is in network.

One potential difficultly here is that good metrics are hard, and outcomes for a lot of medicine are hard to evaluate. Obviously not true everywhere.

So a potential path will be that the incentives start to line up with measurable impact on symptoms short term (easy outcome to evaluate) instead of meaningful shift in root causes (difficult and/or slow to measure)

Really good take, actually. In the extreme case you find that doctors actually have no responsibility to their patients. You can read board investigations. They are unusually soft on very horrible doctors.

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