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Comment by jeanlucneptune | Hacker News Reader

Veteran doc and health services executive here. Three recommendations to improve your overall healthcare experience as a patient.

Number one recommendation: spend $$$ on a concierge primary care doc. Depending on your market can be anywhere from $1,500 to $15,000 per year. Why? Concierge doc will help you triage your problems, give you great access, keep you out of the hospital/ER, and help you cut through red tape if you need to engage the system.

Number two recommendation: seek care in facilities in high-income communities with relatively small general hospitals (i.e. Greenwich Hospital in CT) UNLESS you need tertiary/quarternary care. Why? Much better staffing. Much less riff-raff common people stuff (i.e. like homelessness) and much higher patient expectations about quality of care.

Number three recommendation: pay up for/seek out a cadillac insurance plan from a high quality insurer like Aetna or United with a low deductible (not high) and low copays. Why? Makes the patient experience much better on the back end with much less paperwork if you do engage the system.

Yes, I understand that I'm saying "be rich", but if you can afford any of the three recommendations above your healthcare experience will be MUCH better.

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Undoubtedly all of this is true and an effective set of strategies for people of means to navigate the system. But this is precisely why healthcare reform will never take root in the U.S. There is no vision for public health. As an academic discipline, public health is robust in the U.S.; but there is no traction in the practical realm because the ghosts of Puritanism still inhabit the the sociopolitical structures. The poor apparently deserve their poor health access.

For leaders, this is the beauty of health insurance companies (better called managed care organizations, MCOs).

For places like UK and Canada, leaders have to answer to everyone for why access and quality of healthcare is declining. In the US, using the MCOs, leaders can more easily direct sufficient healthcare to who they want it to go to without being able to be identified as the cause.

For example, leaders can tell MCOs to reimburse healthcare providers less for Medicaid (poor people), and more for Tricare (military) and Medicare (old people who vote), and even more for federal government employee health plans (for themselves). Or they can tell MCOs to require more “prior authorization” (PA) for Medicaid so people give up more quickly at getting medicine, whereas federal government employee plans can require fewer PAs.

Add employer specific risk pools/deductibles/copays/out of pocket maximum limits into the mix, and there are multitude of levers that can be pulled to ensure people are getting the quantity and quality of healthcare corresponding to their socioeconomic level.

Rich people always had concierge medical care. But with the use of MCOs, you can drill it down to income/wealth/political quintiles or even deciles.

"The poor apparently deserve their poor health access." Exactly what a large percentage of Americans believe. I disagree with them, but hard to make an argument for a better system when many believe that the poor shouldn't have quality healthcare.

Healthcare in this country is so broken. This industry should be made as simple efficient and affordable as visiting Walgreens. The regulations, the cartel-like barriers to competition, the behemoth corporate powers. The only way to get adequate care is to become so rich you can escape the whole thing.

I've received COVID vaccinations at Walgreens, but nothing else you'd call health care. I would imagine that if the industry limited itself to filling prescriptions (though prescribed by whom?) and selling aspirin etc., it could be very simple, efficient, and affordable.

> keep you out of the hospital/ER

You're a veteran doctor. You are presumably fully aware of the health statistics in this country. And yet, you did not list the number one correct recommendation:

If you are overweight, lose the weight.

~80% of healthcare costs in this country are attributable to chronic conditions, and ~80% of chronic conditions are caused by obesity or lifestyle directly connected to obesity.

You improve your own health outcomes, and reduce the burden on the healthcare system as a whole, by ~64% if you're not fat.

And your response, as a doctor, mirrors the most infuriating thing about your profession:

  Hi, you're 260lbs and pre-diabetic. I'm going to put you on Metformin. 
  Hi, you're 280lbs and your LDL/HDL is WAY too high. Here's a prescription for statins.
  Hi, you're 190lbs at 5'1 and your infertility is caused by LH/FSH imbalances. Take this Clomid.

When the hell are the "professionals" in your line of work going to stop medicating away the consequences of this absolutely absurd epidemic and actually address it? The only time I've ever heard of a physician actually advising an obese person to lose weight is for conditions where pharmaceutical interventions don't exist, such as non-alcoholic fatty liver disease. The rest of the time? Take these drugs so you have a couple more years to enjoy your triple bacon cheeseburgers and large fries.

It's absolutely maddening.

You're not wrong about the root cause of chronic medical conditions. Depending on how you count, something like 1/7 of all healthcare spending now goes to type-2 diabetes and related conditions, and nearly 100% of those cases are caused by lifestyle issues.

But it's unfair to blame doctors. In a typical office visit they only have a few minutes with the patient which isn't enough time for useful lifestyle counseling. And it isn't even really their job anyway; diet counseling should be provided by Registered Dieticians who are specifically trained in that field. Any real improvements will require major national political policy changes to better align incentives and shift resources away from treatment and towards prevention.

Thank you for your sane reply.

Your solution to the healthcare crisis is just make everybody lose weight and all the problems of our system go away. You ever try to lose 10 pounds? 100? Spend some time in a general medicine clinic and come back to me.

No, all the problems wouldn't go away. But a healthy-weight population would cost roughly 64% less to treat, which implies a 64% reduced hospital congestion and workload. This could get offset somewhat as people die later in life of "old age" rather than chronic conditions or CVD events, but those costs would be much lower. So let's say a 50% reduction over the long run.

Yes, I am a former fatty who has kept it off for well over a decade now. It's really quite trivial to do.

serious question - you think overweight people do not know they are overweight? And they don’t know it’s bad for them? They are probably overweight because they physically have trouble losing the weight (disability, hormonal issues, etc), or they have no self-control, or they are poor and don’t have the means or time to focus on their health.

if you are already fat and prediabetic, you have a lifestyle problem, not a medical problem a doctor can fix.

My point is that the medical industry prioritizes treatment of expedient consequences over treatment of root causes, and then they bitch that they're so overworked and overwhelmed.

If they were truly interested in un-clogging their hospitals and clearing their dockets, they'd be actively engaged in treating root causes. Sure, maybe alongside the pharmaceutical interventions, but the focus ought to be on the cause.

To your points:

- Most moderately overweight people do not, in fact, know they are. Humans operate on the basis of visual comparison, not medically significant measurements like BMI or visceral fat measurements. If you look approximately like your other overweight coworkers, friends, etc, then you'll assume you're fine (in the genpop case, HN denizens and other data-driven folks likely excluded).

- Many of those who are morbidly obese to the point it's obvious they're much larger than their peers, are likely blind to the actual health consequences of their behavior. The general population is vaguely aware that being fat is not super healthy, but they have no idea of HOW devastatingly unhealthy the actual medical literature indicates. On top of this, you have HAES/fat-acceptance nutcases convincing huge swathes of the obese population that they are perfectly healthy.

The medical industry prioritizes treatment of current problems instead of prevention because that's how incentives are set up in the system. Most treatments are delivered under under a fee-for-service model. Insurers and government generally won't pay to prevent a patient who isn't obese yet from becoming obese.

Any major changes will have to come at the state and federal government level. The medical industry can't do much to change that on it's own.

I used to work with a brilliant software engineer who weighed at least 400lbs when we worked together. Incredibly smart, kind, and thoughtful, and funny. But there was this one puzzling thing about her.

She was vocally critical of the mere concept of "fat" and would find any excuse to pick fights about it. During a company-wide meeting of about 1200 people it was announced that we'd be inviting employees and their families to a theme park for the day, all to ourselves. She stood up during the Q&A portion and asked if the company would be, in her words "giving people who didn't fit on the rides a sum of money equal to the cost of admission, travel expenses, and meals." The HR rep asked for clarification, to which she said "those of us who were born too big to go on rides shouldn't be denied benefits other people get because they fit. That's discriminatory."

She would also frequently and passionately argue about how the idea of "overweight" or "underweight" is an invention of capitalism - a tool to get people to spend money on books, gyms, diet programs. No amount of rational debate would alter her stance. She'd cite supposed medical journals from memory disputing the concept of obesity if anyone asked "aren't there health risks?"

Denial is a crazy, sometimes heart breaking, thing. There are people who don't believe that being fat is unhealthy.

She was one of them. I say "was" because she died of cardiac arrest at the age of 27 while at work, 20 feet away from where I was sitting. Even now, I still have a hard to reconciling who she was (smart, rational, kind) with what she believed and how she died. Utterly tragic.

I have to say, at least if you're tied to employer healthcare plans, there are bad Aetna and United contracts out there. I've had better runs (on the west coast at least) with Anthem Blue Cross, in terms of engaging with the system. I've been lucky enough in my life to have high quality plans that the employer subsidies (100% paid for me, 80% for my partner) with very low deductibles, and they're PPO to boot (no HMO hoops), which helps when you want to completely by pass getting a recommendation to see a specific doctor (useful when you know what you're doing)

Agreed. If your employer is trying to skimp on cost you can end up with some really poor options. Lesson there is to find an employer that offers generous benefits. Easier said than done, I know.

Have had both employer provided Kaiser and Aetna. Aetna was awful while Kaiser was great. Aetna made us jump through all kinds of hoops to get a simple prescription (not pain meds) while it was only a quick phone call with Kaiser. In fact, while in great pain we had to wait for over 8 hours with Aetna to even talk with someone before we gave up and went to GoodRx and got the help we needed nearly instantly. I don't really know where I'm going with this, but I have to say there's a wide discrepancy between employer provided health insurance. I had ACA and it was actually really good! No or low copay (less than $10) and was always able to get ahold of someone when I needed it.

Aetna is known to be low quality, especially after CVS bought them. CVS has a ton of debt and I do not see CVS management to have a culture of investing in employees. They are known for their retail business, where it is typical to ride employees to the limit until they burnout.

I like sticking to BCBS insurers, such as Elevance, Regence, Independence, Horizon, etc.

Except BCBS Premera here in Texas. They're having a bitch fight with Ascension/Seton healthcare, which includes Dell Children's Center and the majority of the good hospitals and ERs in the area, as well as many doctors practices. But Open Season ended in November, so now people can't switch insurance companies so that they can actually go to their healthcare provider of choice.

And BCBS desperately wants to force you to use only their approved pharmacies, but as of late last year there is a new law here in Texas that makes that illegal. So, what BCBS does is make their preferred pharmacy "optional", but what is not optional is that you can't get any drugs from any other pharmacy until you call up their preferred pharmacy on the phone and speak to a human being to get them to opt you out of the "optional" preferred pharmacy. And imagine how hard that process is these days.

Fuck BCBS.

Aetna used to be good here in Texas. That was a few years back. I had them when I worked at Whole Foods, and that was probably what you'd call a "Cadillac Plan".

Now, as bad as BCBS Premera is, it's still better than Aetna. Maybe it's because CVS bought Aetna, or some other reason, but they've definitely taken a major nosedive here in the last few years.

Kaiser is legendarily great healthcare, so I hear you.

Not familiar with Kaiser being in NYC, but I can say that Aetna is probably the best insurer here (again, depending on your plan).

Having had Kaiser, it really, really really depends on what care you seek.

Broken arm? great. Straightforward / well known ailment? Check check check. Psychiatric care? Hit or miss, but was not good in our experience (I can attest to some close friends and family who did receive quality care). Need an uncommon specialist or research doctor? Horrible.

My partner has a relatively rare thoracic spinal herniation issues, and Kaiser just wanted to put her on drugs and tell her "too bad, its all we can do". No physical therapist specializations, only 1 standard MRI and was looked at by a doctor who was not a specialist in thoracic spinal issues. When we balked at that, they then tried to turn around say it was "all in her head". We had to go out of pocket to see a physical therapist who specialized in this sort of thing to get any real help, and we have as of yet to meet a doctor who's willing to take on her case and advocate for specialized care, who then recommended us a chronic pain psychiatric specialist who's job is, to tl;dr, to help train the mind to lessen the daily chronic pain. That combined with a pretty strict diet & regiment of physical activities are the only thing giving her quality of life. Kaiser blew it. I can only imagine how much worse off we'd be had I not have a good job to cover the costs out of pocket.

Aetna seems to be hit or miss here in California. My brother had it and it was great for him. For me, it doesn't compare to Kaiser

I’ve been on paperwork side of health a small bit.

1) cash pay / direct / concierge

Agreed - especially if employer plan not great. Some of these folks do house calls. I did this for a while

2) high income area

Sadly agreed. Even in a city if a hospital is more accessible etc that can be tough. I did a walk in to sf general once a long while back - took me 20 minutes to walk out. Great hospital, but waiting room was nuts. Had a finger burned being an idiot and got seen very quickly at a different sf hospital - night and day difference in waiting room

3) mixed view on this. Kaiser brings some peace of mind - grandfathered hsa plans w 2k deductible and some free base car not a bad experience - key for me is not coordinating/ dealing w multiple bills. Their issue resolution team is terrible though on billing

#3 - Kaiser is great, no question. Just not familiar with them since they don't have a presence in NYC. Honestly, if we had to emulate one model in the country it would definitely be the Kaiser model.

>Number one recommendation: spend $$$ on a concierge primary care doc.

Fuck the country I was born in if this is the solution I need to keep myself healthy in a place I pay more than my fair share of taxes and rent to scumbag landlords just to live. Fuck this world.

Exactly this - life in the USA has felt like an unfamiliar board game, run by a rules lawyer who has a grudge against you (personally), my entire life. No wonder we have a shorter life expectancy than _Cuba_!

Cuba is definitely an outlier specifically for that among developing countries and therefore not a great comparison.

I hate the US healthcare experience and try to avoid it, but somehow after all the craziness you hear about half the country uninsured and $500k medical bills, the life expectancy numbers are actually not that terrible. I'm not sure why.

Anyone who has medical insurance regulated under the Affordable Care Act (Obamacare) will not receive a $500k bill. The individual out-of-pocket maximum is only $9k.

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

what about the dodge where when you to an emergency room, there are multiple providers who bill separately (doc x was not on the emergency room bill, he's some other provider).

I suspect Cuba is an outlier because they have a reasonably functional healthcare system, but at the same time most people are too poor to overeat or indulge in substance abuse. They literally can't afford to sit around and get fat.

If you're in the category of paying more than your fair share of taxes you probably can afford to buy instead of rent. But if you want to keep renting, find a non-scumbag landlord. They exist, I've rented from them.

Don't blame the rest of the world for your own country's fuck-ups.

That’s not what you need to keep yourself healthy. Statistically, you need to not overeat, exercise, walk a lot, and not do too much risky shit (i.e., ride a motorcycle). Obviously there are exceptions, but in a system where people are actually taking care of themselves the resources are there for it. The sooner people realize they alone are responsible for most of their health, the better off we’ll be.

Health insurers (payers) don't deliver different levels of service based on a plan’s deductible or copay. That's literally just a field in the database. All of your claims and prior authorization requests still flow through the same systems.

In general high deductible health plans can be good option for consumers who are in good health and have the financial means to absorb an occasional large medical bill. There are also tax incentives for such plans.

https://www.healthcare.gov/glossary/high-deductible-health-p...

>Number three recommendation: pay up for/seek out a cadillac insurance plan from a high quality insurer like Aetna or United with a low deductible (not high) and low copays. Why? Makes the patient experience much better on the back end with much less paperwork if you do engage the system.

Why would the size of the deductible/copay affect the amount of paperwork? My naive assumption would be that the amount of paperwork would be O(1) with respect to the amount of money changing hands -- same way you will always be asked if you want a receipt in a store, regardless of how much stuff you bought.

Also, how do I know if an insurer is "high quality"? Neither Aetna nor United is available in my state.

(Thanks in advance for any replies -- I still have about 3 days during which I can switch my insurance for 2023; was thinking of switching to a high-deductible plan since I don't anticipate using my plan much in 2023)

If you have a zero copay plan and your provider is in-network, for example, you're not going to be getting a bill in the mail later saying you owe XYZ dollars.

If, however, if you have a situation where you are using co-insurance (you pay x% and the insurance pays 1-x%) the backend bills and related paperwork can be a nightmare.

In terms of quality I'm really talking about the plan design moreso than the insurer and I'm really talking about a benefit rich plan, which is always going to cost more (and a lot more upfront).

A high deductible plan can save you money on the front end, but if you start using that plan you should prepare for rain - a deluge of bills from providers who have no idea what the insurance owes and what you owe.

And God-forbid you use a narrow network plan like an EPO because it's hard to figure out ahead of time what services are covered by the network and what's not. I went to see a doc who was in-network and only paid a $25 copay, which was great, but the lab where my routine blood work was sent was NOT in network and now I'm looking at $1,000 in lab bills for a test I didn't ask for.

>a deluge of bills from providers who have no idea what the insurance owes and what you owe.

But if the provider can't communicate with the insurance in order to figure that out, why would a different deductible/coinsurance change that?

I was actually told that I met my deductible in 2022, and then I got another big bill in the mail. So that made me think deductibles are a scam and I should just pick the plan with the lowest premium.

(Thanks a lot for answering my questions by the way!)

The deductible is one of two thresholds that are typical on insurance plans. The second, higher threshold is the out of pocket maximum.

So some aspect of the coverage might be a 20% coinsurance, where you pay the full cost up to the deductible and then pay 20% of the cost after that until you have reached the out of pocket maximum.

Most of the fees you pay count against both of them, so like if you pay $35 to visit your primary care doctor, you are $35 closer to meeting your deductible, and then also $35 closer to reaching your out of pocket maximum. Lots of frequently used services are covered as a fee based co-pay rather than as coinsurance.

If you have a major expense for something that is covered as 20% coinsurance, the amount up to the deductible would be 100% out of your pocket, and then the coverage would kick in and pay for 80% of the rest (until your 20% exceeds the out of pocket maximum).

I kind of wonder if disallowing insurance companies to negotiate deals with providers would actually end up improving things a lot (because it would create pressure to normalize prices vs fucking around to save a little bit).

@ShredKazoo

Most providers do communicate with the payor and have a decent idea of what you owe, so I was being a bit snarky there. If they know you have a zero copay, you make no payment on site with no follow up bill afterwards.

>I still have about 3 days during which I can switch my insurance for 2023; was thinking of switching to a high-deductible plan since I don't anticipate using my plan much in 2023)

If you have sufficient cash flow and savings to afford out of pocket maximum (usually $10k or so for a family), and you can max out contributions to an HSA, it is always advantageous to opt for an HSA eligible plan (which are legally defined as High Deductible Health Plans, but they will say “HSA” in the name of the plan).

This is due to the triple tax advantages of an HSA, which surpass any other type of investment vehicle.

You can put pre tax money in an HSA, all investment earnings are tax free, and withdraw all of that free of tax to reimburse yourself for healthcare expenses you incur at any time during your life.

So you keep a spreadsheet of all your healthcare expenses, pdfs of receipts, and do not touch it until you absolutely need to. Use a free Fidelity HSA to have access to all investment options (you can continuously transfer from any HSA your employer uses to fidelity HSA).

In the absolute worst (best?) case that you simply do not have healthcare expenses, the HSA functions as an IRA, and you pay regular income tax when you withdraw after age 65.

Hi, I apologize if my comment is not relevant to the conversation, but this specific comment seems very useful to my personal situation and I desperately need some further insight on the matter.

I am an US expat living in a country with free universal healthcare. It is also affected by a war that started a year ago. I could not leave then because I had a life threatening health emergency and had to spend 2 month in a hospital. Luckily, it was finally resolved, but i need to stay on heavy meds to remain in remission.

And they just discovered that I have a tumor in my kidney that requires major surgery. To have surgery here is almost certain death from complications/infections/neglect (i've seen it happen)

So I have to go back to US.

My plan is to move back, buy a "cadillac" health plan on ACA market place. I understand that one can enroll after enrollment period if moving from overseas. Then try to get a treatment.

What is the best approach to get the treatment as fast as possible? Is concierge thing only way to go? I checked major cancer centers in an area where I plan to settle, they are all accepting new patients. Does it mean I can go directly to them and expect them to treat me right away?

Most important question. What if I denied insurance or it is delayed and I end up uninsured? Is there a way to get a treatment first and pay later/negotiate price, payment plan, etc

Any advice is appreciated

Thank you

Go to Slovakia. Relative cheap and relative good health care. At least some years ago. Language may be a problem.

May be some years ago. Now Slovakia is also affected by a nearby war and packed with refugees from Ukraine.

>concierge doc

Can you please elaborate? I need something like this and I'm willing and able to pay for it.

How would I get started finding one?

Basically, like a doctor with a membership club. Generally doesn't take your insurance, although some services might covered by your insurance.

Good example is MDVIP - https://www.mdvip.com/. I have no relation to the company other than being a customer. I pay $1,600 a year for my Mom to be a member and it's the best money I've ever spent.

Thank you. My local practioners are terrible and border on being unethical.

Would it still be good to have insurance in addition to this, in case of disaster?

Yes, you definitely should have a health insurance plan of some type. Your concierge doc fee will not pay for a visit to the ER, which can bankrupt the average person who doesn't have coverage.

Another term for this is direct primary care.

https://www.forbes.com/health/healthy-aging/concierge-medici...

Or do what I did and get on an A320 with a one-way ticket.

I haven't set foot anywhere in North America in almost ten years, and frankly I don't miss it.

The food is better, the transport is far better, the weather is better, and my health care costs are literally a rounding error.

Where do I live, you ask?

Not in the US.

Why do you define United as a cadillac plan? I've only had awful experiences with them thus far.

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