US Physician Blasts 'Lucrative System of For-Profit Medicine' | Hacker News Reader

US Physician Blasts 'Lucrative System of For-Profit Medicine'

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90 pointsgardenfelder78 comments

This is the part that gets me every time this topic comes up:

> "the U.S.... spends far more on healthcare than comparable nations both on a per-person basis and as a share of gross domestic product.

And it's not just "on a per-person basis." We spend more public funds per person; there are countries doing socialized medicine spend less public funds. And then of course we additionally spend our private funds on insurance premiums and out-of-pocket costs.

And we don't have better outcomes.

There are some ways I'm glad medicine is a way for people to build wealth. It seems more reasonable to reward good physicians and health-related product creators than, say, pro athletes and maybe even SaaS providers. But on the other hand, if financial incentives were all it took to build an exceptional healthcare system, we'd have one.

Most countries with universal healthcare don't have "socialized medicine." The UK has a socialized system, with public insurance and public healthcare providers. But only a third of hospitals are publicly owned/managed, and even there most doctors are private practitioners. And in the Netherlands and Switzerland, both the insurance and hospitals are private.

Changing "who pays" won't solve anything in the U.S. system, which is obvious because if that mattered Medicare and Medicaid would be a dramatically better system than private insurance. What's different in all those countries is higher supply of medical providers, lower compensation for medical providers,[1] and aggressive price controls not just for drugs, but for all procedures.

[1] It's notable that in the U.S., being a nurse or even a nursing assistant is a great middle class job for non-college educated people. In the U.K., where nurses are public employees, nurses are literally on strike right now because of their extremely low wages.

Many countries don't have price controls, but do have purchasing controls. The two are very different. Price controls you say you can't sell something for more than x. Purchasing controls is saying we won't pay double for something that works 1% better.

My opinion is that in the US there's basically no purchasing controls.

> if that mattered Medicare and Medicaid would be a dramatically better system than private insurance

They are in the most important respect, that being they negotiate pricing with health care providers.

Medicare pays significantly less for any procedure or product than consumers do via private insurance companies.

That negotiated pricing expanded to the entire country will lower the cost of care for everyone.

The US is moving towards requiring a bachelors degree to maintain an RN license, and the majority of US nurses have one already.

More of elite America’s war on the working class.

In the main I agree with this sentiment, but you're being reflexive here, which gets you into trouble. The movement towards BSN degrees follows a significant amount of research showing that BSN degrees correlate with superior patient outcomes. You wouldn't call a degree credentialing requirement for an MD "an elite war on the working class", nor would you visit a doctor without a degree. You're happy to throw a little culture war barb at nursing credentials because: you don't respect the profession. It is much, much harder than it looks. Its biggest problem is that it has a stupid name; they should be called "associate physicians".

You can reasonably disagree with state statutes requiring BSNs for RN licensure! But you can't pretend that the notion is risible, the way you have here. It is not.

You’ve whiffed it. Lots of people in my extended family are nurses or nursing-adjacent. Some have degrees and some don’t. I think it’s a really important job and it’s really good that elite gatekeepers haven’t gotten to nursing yet. I also think you shouldn’t need a college degree to be a programmer or a lawyer and probably not a doctor either. All of those jobs could be done by people with focused applied education, rather than theoretical academic education.

My view is pretty much exactly the opposite of what you suggest: I think few jobs including mine, justify the time and expense of a theoretical university education. Cancer researchers and civil or nuclear engineers, sure. But we shouldn’t use college degrees as barriers to keep “the proles” out of large segments of the workforce.

Lots of people in most extended families are nurses or nursing-adjacent, Rayiner. It's an extremely popular career. I'm Irish Catholic, which is the "my father is from a village in Bangladesh"-equivalent mic drop of "being related to lots of nurses".

As I said, that's not what we're doing: we have empirical data that says that additional training improves patient outcomes. If you truly believe that doctors shouldn't require degree credentialing, there's not much more for us to discuss.

At any rate, I just jumped in here to point out that nursing is not in fact a reliable pathway to a solid middle class career that doesn't require a college degree. All nurses have some kind of degree, most have 4-year college degrees, and in 10 years it's likely that all of them will.

It makes a lot of sense to me that nurses would generally have degrees. It does not make sense to me that sales account managers, HR professionals (the fastest growing white collar profession in the US), marketing communications specialists, bookkeepers, and project managers are required to have degrees. You saw the newly-elected Democratic governor of Pennsylvania run on the issue of eliminating degree requirements for public positions in his state; I'm optimistic we'll see a movement pressuring corporations to adopt similar rules, since they're fundamentally unjust and also serve to increase prices.

>I'm Irish Catholic, which is the "my father is from a village in Bangladesh"-equivalent mic drop of "being related to lots of nurses".

I thought that was Filipino. I have yet to meet one whose parents or aunts were not nurses.

https://time.com/6051754/history-filipino-nurses-us/

I believe it. Anyways: lots of nurses aunts and cousins.

Is it just correlational data?

I assume in almost all professions more education correlates with better employees but I imagine most of that value is selection bias as opposed to causative.

I think you're going to have to go find and read it before you attempt to pick it apart axiomatically.

Here’s a hub of links, though TBF there’s so much money at stake that my starting position is skeptical, even discounting rayiner’s concerns about elite institutional capture. Especially without a corresponding analysis of costs (maybe that’s here?)

https://ldi.upenn.edu/our-work/research-updates/hospital-nur...

I found a bunch of different studies some showed an effect some didn't. But all the ones I found linked the % of nurses with BSNs to outcomes which has two sources of possible confounds, the nurse level and the hospital level.

Maybe you've seen better studies than I could find that convinced you of this but all the studies I could find looked like bad science.

Everything positive in the world correlates with increased education level. Even lifespan. People with a BA live 3-4 years longer than without. But I'm under no impression that if we extended mandatory schooling to the age of 22 the average lifespan in the US would shoot up 3 years.

This is the problem in a nutshell. Sure, BSN provide better care. However, they don't provide better care than the number of regular nurses you could pay with the same money.

The US has an obsession with maximizing outcomes per clinician or per drug. It gives no or very little thought to outcomes per Healthcare dollars spent.

Also of interest is that R&D costs are often used to justify exorbitant drug costs, but it's been pretty widely reported that pharma spends much more on marketing drugs than developing them. Don't forget that these drugs are funded in large part by tax dollars.

https://www.washingtonpost.com/news/wonk/wp/2015/02/11/big-p...

The problem is that there are no incentives to optimize benefit versus price.

Socialized systems, the state looks at each new drug and decides if the benefit is worth the additional cost. They will either agree to Buy it, not buy it, or negotiate the price.

When private individuals purchase Healthcare out of pocket, they do the same.

It is only in an insurance Market with mandatory treatment coverage where drugs and Medicine get purchased no matter what the cost is.

If you asked a private individual or socialized system to pay 500K to extend someone's life 2 months, both would refuse.

Someone with insurance that they've been paying for has no reason to put the brakes on

> Someone with insurance that they've been paying for has no reason to put the brakes on

Especially when the insurance company itself can just pass the costs along in the form of higher premiums because people are legally required to buy insurance.

The 2017 TCJA repealed all federal penalties for not having health insurance, making the individual mandate to have health insurance moot since 2019.

https://www.commonwealthfund.org/publications/fund-reports/2...

These people still get indirectly subsidized when they receive healthcare they can’t pay for and providers have to collectively eat the cost. Removing the penalty simply enables inefficient freeloading on the system (as these folks are likely to be stuck with medical debt or have to declare bankruptcy from medical bills they will never be able to repay).

I don’t understand the idea of freeloading here. Insurance companies charge rates the market will bear. They are still going to charge these rates if insurance payouts to the freeloaders go away. This is not a perfect market where competitors will spring up overnight to provide insurance at lower rates if the cost of doing so goes down.

Health insurance rates are highly regulated. Everyone pays higher rates due to people who don’t pay, because providers build their uninsured costs into what they charge insurance payers. They’d go insolvent otherwise.

https://www.healthcare.gov/how-plans-set-your-premiums

https://www.healthcare.gov/health-care-law-protections/rate-...

Additionally, "legally required" was a dubious way to describe the state of affairs even before then: you could continue to live freely your entire life without ever enrolling in an health insurance plan either by demonstrating participation in some other communitarian health share program or by paying a tax.

Protections of the ACA include the requirement to submit premium increases for state and federal review, and limits on how much of premiums can be used for anything other than medical costs. This means that they cannot legally "just" pass costs along, and that even when they can those costs are effectively a representation of the limited power anybody has to negotiate with healthcare providers, which is hardly something one can pin on insurance companies.

And of course on top of that, it's inaccurate to say that people are legally required to buy insurance. It's wholly without basis for the last 3 years or so, and even before 3 years ago it's a dubious representation of the options available to people.

I think it's the exact opposite actually. Insurance is incentivized to go along with Healthcare cost increases because it lets them increase their premium and profit. If you have a 10% profit margin and need approval to raise cost, higher healthcare costs overall is the best way to increase your net revenue while keeping the same profit percent.

It is the classic problem of Cost Plus contracts

>incentive

The incentive should be: the people want it, the corporations should figure out how to deal or fail, and the government should be held accountable until the people get the healthcare they want.

As with any “slow turning ship” sometimes it takes a bit of a push.

Seeing other nations do it better is not enough push.

When people start to protest over this, momentum will build.

The problem is: sick people make terrible protestors.

I would argue that most people don't want to optimize benefit for dollar spent. This is why you get rhetoric about death panels and garbage like that.

Almost nobody's going to turn down ludicrously expensive cancer treatment because the money could be better spent on preventative medicine

Sick people make terrible protesters. They also make terrible decisions about how Healthcare should be rationed.

Prices will continue to rise until somebody in the system decides they are unwilling to pay more. Right now there's no one in the US taking on that role.

I posit that part of the reason we (in the US) are in this current climate is because of active actual choice by the capital owning class toward profit over people, because sick and in-debt people will work for a little as possible.

I think prices will rise until corporations find it’s too expensive to find new labor when a lot of it can no longer work. Like a paperclip bending over and over.

WE may be saying the same thing.

Humans will pick profit over people every time. The problem is that we have made it so the most profitable option is not the best at helping people.

I propose we change the laws and spending so the most profitable business is one that helps people the most.

You propose what exactly?

It’s nothing exact, as it’s anecdotal and incipient thought, at best. We may be indeed saying similar things.

I think, though, that a nation state’s job, if it wants to exist at the gunpoint they all exist at, it should enforce a rule that corporations within critical for life industries (healthcare, housing, power, food, education, utility, etc), are not to provide profit, shareholder return (dividend/buyback), or other similar during times when they raise consumer prices greater than inflation or layoff any employees for financial reasons or have over a certain amount of employees on public funded support programs. (Welfare, etc.)

The corporation and its profit to the owners should come second to the consumer and the corporations labor force.

The medical systems of other countries definitely deliver better results on average. It's plainly obvious if you look at a top-level metric like life expectancy. However, from personal experience in the U.K., Germany, and the U.S., the U.S. system unquestionably delivers better outcomes to wealthy people with health insurance. It's not surprising that the U.S. policy remains in place: it benefits the elites. Also, healthcare makes up something insane like 20% of GDP. The amount of people employed by the healthcare sector is staggering. Spending less means putting people out of work. It's going to be hard to sell that idea.

One is there is a supply problem. There are lots of people who would like to be doctors, that are capable of being doctors, that won't become doctors because there are only so many seats available at medical schools. So fixed supply of new grads every year. Next is there is no market pressure on prices, even though theoretically that's what should happen. People NEED medical care so there isn't much to haggle about. Insurance companies don't care about prices so much, they just raise their rates if prices go up and take a bigger cut. In countries with socialized medicine, the government is THE buyer and can negotiate prices for things. But here, a drug company just raises the prices by 10^3 percent and everyone just pays it.

US does have an exceptional health care system if you are moderately rich or moderately powerful.

There is a reason an Indian communist leader that hates the US came to the US flying halfway around the world on tax payer money for medical treatment.

https://swarajyamag.com/amp/story/insta%2Fkerala-chief-minis...

I just read this article earlier today about NYU Langone ER prioritizing treatment of VIP patients (politicians, celebrities, donors, trustees of the hospital):

https://www.nytimes.com/2022/12/22/health/nyu-langone-emerge...

JS-free archive link:

https://archive.today/eds69

That is plainly disgusting.

Doctors are typically very status-hungry creatures, thus when someone quantitatively more influential than them comes along, they are extra impressed and pay more attention to them. But simply having an 8 digit net worth won't do much for you, except to allow you to buy expensive concierge medicine services that can use their medical community connections to pull strings for you.

>And we don't have better outcomes.

It's apples and oranges though, yeah? Do we have worse health outcomes after controlling for the health-related demographics of our population?

That's like saying I live a ten minute walk from my job in Manhattan's financial district and you live a ten minute walk from your job in New Jersey; I pay more in rent but have the same commuting outcome! Therefore it's the fault of the overpriced sidewalks in Manhattan??

If you ignore those pesky poor people and those that died, the stats look amazing.

You realise that comparing countries and the amount they paid is as good as it gets? It’s a direct comparison.

> Do we have worse health outcomes after controlling for the health-related demographics of our population?

Health outcomes in the U.S. do track socioeconomic and regional factors. But should the system not meet the needs of whomever walks through the clinic door? I mean, some of the difference is not just the direct effects of poverty or social disadvantage on physiologic parameters but also on access to healthcare itself. We can control for socioeconomic factors and make the data look better but it doesn’t entirely exculpate the system which makes it incredibly difficult to get state-of-the-art care if you haven’t got ample resources to gain access.

We're talking about other industrialized mixed market democratic nation states. At that level, demographics fade into the background, to the point where it's not even clear that we're talking Granny Smith vs Red Delicious, it's more like Fuji vs Pink Lady.

If there's citrus in the basket of fruit under examination, it's policy.

>> there are countries doing socialized medicine spend less public funds. And then of course we additionally spend our private funds on insurance premiums and out-of-pocket costs.

To tie some things together, don't forget the doctors have to earn very high pay to cover the (insane) cost of medical school and insurance.

>have to earn very high pay to cover the (insane) cost of medical school and insurance.

Also opportunity cost for people capable to become physicians in the US have other options with competitive pay to quality of life at work ratio. Lots of ways to not spend one’s 20s memorizing stuff for step exams and then spend 26 to 30 being a slave during residency, and then maybe a fellowship or getting board certified, and at the end, you still have to deal with patients.

Alternatively, they could go for a job where they sit behind a computer and not deal with the general public and get to work from home when shit hits the fan.

But at least we don’t have death panels!

Instead we have the idiot herd...

Did you not read the part about 10,000+ unnecessary deaths per year due to financial inaccessability?

And there are even what are, effectively, “death panels”! Doctor prescribes potentially lifesaving (or life extending, or quality of life improving) medicine. Drug maker sets outrageous price. Patient and doctor argue with the insurer (the death panel!) over whether the patient actually gets to buy the medicine.

Meanwhile, the drug seller engages in the utterly corrupt practice of offering a kickback (sorry, I mean coupon) to help give the patient an incentive to win the argument with the insurer.

I read the comment you’re replying to as intensely sarcastic.

People in the US tend to ignore systemic issues while hyper focusing on individual cases. Talk about missing the forest for the trees

You won’t get very far in the Ayn Rand club with that redistributive attitude.

In every healthcare system rationing has to occur since there aren’t enough resources to 100% cover everything. The U.S. rations its care in one of the most unethical ways amongst the industrialized nations. The whole system needs a reboot. Anyone who says, “The reason that it is bad is because…”, is delusional. The system is so complex that there are multiple causes and many things need to be changed. Simplistic analysis leads to tweaks that end up contributing to the mess. A full reboot is needed but won’t happen until things get unbearably bad.

What would be a more ethical way?

Death panels of government appointed employees "ethicists" deciding who lives and who dies?

Other countries provide universal care and access to the system is not determined by how generous your employer is or how much money you have. A lot of people in the U.S. put off care due to upfront costs at the point of usage. This is particularly true for people on high deductible plans. Every other country has a more ethical way of providing care as far as I can tell.

Personally I think a "death panel" made up of government employee "ethicists" is more likely to make ethical choices than a death panel made up of private company employees trying to optimize their profits. The government employees are, after all, at least making an attempt at being ethical.

Government-run death panels would be anti-American. We privatized them and delegate our death panel decisions to for-profit insurance companies.

My immediate question for this physician: when discussing care with patients, is he able to readily answer questions about how much various services he provides/recommends will cost? Or if he is like every doctor I've asked, equivocating and generally acting like the financial damage shouldn't be important - effectively forcing people further into the arms of the same "insurance" protection racket hellhole that he's bemoaning.

Because ultimately the only way we've found to orchestrate large scale distributed behavior is through price signals, no matter who is paying. The main reason that healthcare has become so screwed up is the utter destruction of price signals through cartel behavior by "insurance" companies and healthcare providers. So it's a bit disingenuous to focus on one type of miscreant in the industry while sidestepping your own part in the symbiosis.

Having said that, I'm not against single payer because it will at least put some of the garbage into a bag and tie it off, rather than the current system continuing to dump it into everyone's lives. But it's important to keep it in context - single payer is nowhere near a full solution to the real problems of the healthcare industry. If you've ever been party to someone needing significant healthcare, it's quite apparent that affordability is merely the tip of the iceberg.

Why link to the common dreams review of the article, instead of the NYT article?

https://www.nytimes.com/2023/02/05/opinion/doctors-universal...

Sometimes I wonder what the end game is for US healthcare. Costs for private (even employer subsidized) insurance keeps going up every year, and then you have Medicare, Medicaid and ACA on the other hand for a separate set of individuals who have their own spiralling costs.

My own prediction is that we all end up with very high deductible HSA plans, basically catastrophic insurance, paying out of pocket for everything else. Probably will need to work till 65 just to avoid healthcare costs bankrupting you.

>My own prediction is that we all end up with very high deductible HSA plans, basically catastrophic insurance, paying out of pocket for everything else.

How is this a bad thing? The insurance model breaks down when you try and use it for routine stuff because it creates perverse incentives since the person services are being rendered to isn't paying.

On some level every average person's lifetime cost has to be paid for by them if populations are stable? Why should we pay a 3rd party to administrate that stuff.

I would say that about capitalism, AI, etc. The way it’s going it feels like there will be only 1 company after all M&A, and then eventually only 1 person running it.

We will finally have the thing we've been wanting for, the King of America.

The biggest challenge of changing the health system now is the entrenched interests. If we reduced our spending health care just to the average of the OECD nations, it would remove $1 Trillion of annual revenue from the US Health Care system. Even if you assume that the average health care worker makes $100k, and that labor makes up less than 50% of the cost of health care, that's still over 5 million people no longer employed in the industry. Those people, and the organizations that employ them, are understandably going to fight tooth and nail to keep their jobs and their livelihoods.

I think you underestimate how much money is absorbed by insurance companies, and the bureaucracies hospitals/doctors offices need to maintain to deal with all the different insurance companies.

I don't think so, I'm including those people in the 5 million that would lose their jobs or see pay cuts. They are exactly the ones who will fight to keep the system as it is.

We absolutely should get rid of those expenses, it will take quite a while, or be a significant disruption.

IMO This is a deep-seated cultural problem. Specifically the overtly litigious corporate culture that exists in the US creates systems that are inherently flawed and tend to be abused. The idea that every misfortune is subject to multi-million dollar lawsuit settlements led to such modern 'innovations' as the 700$ epinephrine auto-injector.

There is also a rash of arrogant cretins impersonating doctors across the US. Midlevels (NP, PA, DO) are a serious danger to patient safety in the US healthcare system. This is basically McDonald's medicine and relegates the MD to a manager of nitwits. Essentially, going to an ER with an emergent problem today is rolling the dice.

Imagine going to a hospital or clinic, only to never be seen by a doctor. Many times the patient will not know they are seeing a midlevel because they use vague terms like 'provider' to refer to themselves.

Few procedures in medicine are both diagnostic and therapeutic. Endoscopy is one such procedure. A GI surgeon will have all the knowledge to deal with any implication or complication should it arise. Today, in many places, mid-levels are allowed to perform endoscopic biopsies (without treatment) resulting in repeat surgeries($$$) to the patient.

https://www.midlevel.wtf/ This site is made by dissident American physicians

Iirc, nearly half of the people in the US are receiving medical cost insurance through government sources (Medicare, Medicaid, Tricare, CHIPs, various Indian/indigenous organizations, etc).

It's a sad joke ...

IMHO this is necessary reading about one of the largest hospital systems in the country--

https://www.nytimes.com/2023/02/05/opinion/doctors-universal...

It's not just the healthcare system, also the pharma. Trials for more precise targeting of cancer medicines don't get sponsorship from the maker of the medicine because if it succeeds they would sell less. Trials for new uses of medicines don't go through if the medicine is close to patent expiry. It makes sense as they are for profit corps but it sucks

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