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Comment by nickysielicki | Hacker News Reader

Lots of cheap takes in here. I think it’s a solid bet. Healthcare makes no sense.

Example: I fractured my elbow 2 weeks ago snowboarding (sticky down-flat-down). In order to see an orthopedic, I need to see a primary care physician for a referral. But I don’t have a doctor in the area and haven’t had a checkup in a long time. So in order to get an xray of my elbow I need to get a new primary care physician to write me a referral for an orthopedic specialist. It would take like 6 hours of my time to go through this process.

So what am I doing? I’m hoping and praying that it doesn’t require surgery and letting it heal on its own. I still can’t fully extend or retract my arm.

You might think this is dumb on my part, but I don’t want to miss work. Millions of people think the way I think. Telemedicine changes everything.

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I just want to walk into a place, ask for a price, pay with cash and get a xray (or anything else I want or need).

The clusterfuck US healthcare is just show how deeply dysfunctional the political system is.

Health insurances should be banned. Everything should be paid in cash, prices posted at the door, and government should maybe co-pay to help low income and/or unfortunate (cancer and such), possibly funding most effective preventing healthcare to make sure everyone gets, all paid from normal taxes.

National government run health insurance provided to everyone, along with a flat deductible for everyone scaled to income, would be an interesting model.

You pay 100% up to deductible (out of pre-tax HSA), government insurance covers everything after that.

It would be interesting to see how many people stay under the deductible, and not cost the government program anything. Along with publicly posting prices for most services, so people can spend their deductible most efficiently.

This isn't very well thought through. But I'm trying to imagine a system that combines market forces for everyday health care expenses, paired with government health insurance for the truly massive expenses of traumatic health events.

Spending any money is a bigger deal to people with less (or no) money than people above a certain threshold.

So one problem you end up with is people that won't go to the doctor for preventative care or before issues become worse (and thus more expensive to fix) to save money now.

It's why the ACA specifically says preventive care, immunizations, medical screenings, etc. cannot be subject to copay or deductible or coinsurance.[1]

[1] https://www.healthcare.gov/preventive-care-adults/

Once people realize they can vote to lower the deductible the system will quickly turn into just government run healthcare.

I’ve had the same thought, but keep it private. Mandate everyone is on a high deductible plan with government support to make the deductibles lower for the truly poor.

Make health insurance actual insurance again - instead of health plans.

It’s the same basic idea but a little less vulnerable to the whims of politics. Of course, your idea is more palatable for democrats (though not very) and mine is more palatable for republicans, meaning neither will happen.

Also, tie drug prices to the prices other countries pay damnit. The only reason something so obvious hasn’t happened can only be because of lobbying.

Interesting you advocate for free market insurance plans, but price controls for drugs.

> I just want to walk into a place, ask for a price, pay with cash and get a xray (or anything else I want or need).

One small edit is how it actually works in much of the rest of the world:

You just walk into a place, hand them your health card, and get an xray (or anything else you want or need).

See how the NHS is currently doing.

There are more possible health care systems than the NHS and the worst of all worlds disaster that is US healthcare. I know British people love the NHS but I don't think the US should copy it given its bad outcomes and constant issues with Tories underfunding it (as if the "deficit hawk" wing of the Republicans that is currently blocking the debt ceiling increase wouldn't do the same thing to an American NHS).

I think any kind of reform to US health care is going to require a substantial role for the market (ideally without coverage networks, deductibles or those insurance company death panels that refuse to pay for care that a doctor considers medically necessary) and probably an expanded role for Medicare, Medicaid and CHIP. There should probably also be a single payer malpractice insurance program so that doctors can start private practices again, a federal law requiring safe staffing ratios for nurses (maybe tying this to Medicare funds?) and antitrust action to break up hospital monopolies. Addressing college costs and cancelling all student loan debt would also help as many doctors are still repaying their med school loans decades after graduation.

> I know British people love the NHS but I don't think the US should copy it given its bad outcomes

keep in mind that for the vast majority of Americans the bad outcomes of the NHS would still be a massive improvement from what they have now which is basically no care at all. I know people who are solidly middle class but are putting off needed healthcare because of costs that wouldn't be any issue whatsoever if they were UK citizens and for lower income US families there's no NHS waiting list as long as "You will never be able to afford what you need"

I agree that, if we were to look to implement some version of the NHS here, we should learn from their mistakes and shortcomings, but if we took it "as is" today it'd still be a net win for Americans.

Not a good example. At the moment it's being criminally mismanaged by the conservative government. The NHS has seen better days.

Of course it's a good example. The whole point of nationalizing things is to make them subject to politics, and an important consideration in nationalizing important services is that they will only run as well as your country's politics.

While the NHS is subject to the whims of Tory politicians, it can still be kept trudging along through a period of incapable government thanks to the legion of civil servants running in the background. I don't think the US has any equivalent answer for the UK Civil service.

How's it doing?

I imagine it's still a lot better than the high cost and poor outcomes we have here in the US.

Being increasingly gutted by Tories.

Just as good as the US system, at less than 1/2 the cost?

You do not need referrals to go to an ER, and they will perform initial care, including x-rays and surgery if needed.

If you don’t need immediate surgery they will patch you up and send you away, and that’s when you have to go see a specialist with a referral (if your plan requires it).

Did you go to the ER?

Also, don’t mess with joints, go see a Dr.

If you have insurance, an urgent care center is typically much cheaper and faster than an ER visit, for non-life-threatening injuries.

Urgent cares don’t do surgery. My preference is always ER if there’s a major injury that might require surgery.

A lot of urgent cares don't do much at all. Many don't even do X-Rays. Most are basically just there to treat very-minor, clean, uncomplicated, superficial injuries, and to tell you "yep, that thing you already knew is a sinus infection is a sinus infection, here's a prescription for antibiotics" when it's a weekend and you can't see a normal doctor, or the normal doctor's wait time is too long.

ER's have separate deductibles. $500-$2K is pretty typical just to walk in the door.

HMO's usually require referrals. PPO's usually need no referrals and you can go many more places.

No, I didn’t go to the ER. That sounds expensive, and I am a cheap bastard.

I suggest reading this reddit post about hospital billing [1]. You certainly have options other than paying a shitload or leaving your arm untreated. Money can be negotiated, but you only get one body.

Edit: I see elsewhere in the thread you have health insurance. If you're paying for it, utilize it. You're in a better position to deal with this than uninsured people.

[1] https://www.reddit.com/r/TrueOffMyChest/comments/x9b7vm/im_p...

Joints are critical. I can't judge without knowing a situation, but I wouldn't want to live my life with a fucked up elbow because I didn't go to the doctor.

When I was briefly without insurance between jobs, I went on a desert hike and was scared about getting injured, so I get it.

Your untreated joint injury has a strong chance of winding up much more expensive later, especially if you develop chronic symptoms that make it difficult to work.

I’ve never had insurance that doesn’t let me directly make an appointment with specialists. Never once have I been asked for a referral.

Last year I thought I fractured my heel or something. I called an orthopedist, did X-rays with him, and he went through them on the spot. No break but he told me about a bunch of stretches to prevent my heel pain from coming back. Same deal with an ENT for an ear problem after a lake swim and another issue.

I updated my regular doctor on my next visit.

Well maybe this is more to my point: I don’t know how my insurance plan maps to what I’m required to do in terms of seeking care. But I do know that if I guess wrong I’m looking at paying my entire deductible, so what I end up doing is avoiding the medical system as much as possible.

My point is just that if it’s an app on my phone, it’s a lot different. I’m probably going to sign up for this.

My healthcare plan has a website and you can put in a zip to see who is around you. They should list in network doctors, if there are only out of network doctors you can call the insurance and get an authorization.

United Healthcare dropped a large provider in my state for a few months and I had to do the authorization thing to see my regular doc. No out of network changes.

Have you never known anyone in your life for whom this was a requirement? This is a pretty common occurrence for the less well-off folks I've known as the risk profile for lower-income insurance markets puts the cost analysis toward requiring referrals to "prevent excessive utilization."

The inevitable outcome when you have such segregated risk pools.

I have family members who qualify for subsidized Obama healthcare on my state’s marketplace based on income. Their kid has another special state provided insurance.

It’s an interesting question I will ask them.

What does Medicade and Medicare do? I’d imaging there are more hoops to jump through with government plans.

I hope you recover fast.

I was wondering, shouldn't you go to an emergency care for an accident like this one?

Urgent care would be more appropriate, I think, but yes, it doesn't seem like a PCP is necessarily required.

(But now might be a decent time to think about it anyways?)

Most of the urgent care I've used don't have the equipment to handle this. I've been twice in the last 6 months to 2 seperate urgent cares. In both cases I had to go to the ER anyway for X-rays. The doctor in one urgent care gave me a referal since she has surgical rights (I think?). I was sent straight to the X-ray tech rather than waiting it out in triage.

You'll miss way more work when you have constant pains. Go to the doctor if you can afford it, what the heck are you doing?

Haven't most plans moved to PPO since Obamacare. They usually allow you to just skip primary care nowadays.

That sounds tough, sorry you have to go through that.

I do want to share that up here in BC, we have both, publicly funded health care AND telemedicine offered by private companies but charging MSP (Medical Services Plan). So it's not an either or. We don't need Amazon to bring health care to people.

That's not a very complete story. The proliferation of telemedicine services by private sector services in BC, and Telus in particular has actively reduced the availability of healthcare professionals in rural communities.

While telemedicine is a suitable replacement for some medical services, the cannibalization of public health services for privately owned, less capable service delivery models is actively harming folks who need in person care. This isn't theoretical, there have been numerous cases across BC, Alberta, Manitoba and Saskatchewan where medical offices in rural communities have simply closed to in-person visits and the doctors have shifted to deliver telehealth services exclusively. This increases access for prescription refills, or low-to-moderate risk, non-acute diagnosis that can be done, but lowers access to in-person care, or the established doctor/patient relationship for prescriptions for high risk medications.

I am not opposed to private participation in publicly funded health care programs, but the increased push across Canada from business and some political parties for increased private care options appears to be directly undermining the public health care system. We should have a true single payer system, with mandated pricing for medical procedures, and drive private sector competition to allow them to compete with publicly delivered options in a way that increases, not decreases access.

I'm not sure how to do that because I am an application security specialist, not a medical policy specialist, but it's obvious to many Canadians that the current approach is not working, and is probably not a model to promote.

Have you called a local urgent care facility? I don’t think I’ve ever paid more than $150 for a visit out of pocket (no insurance) even when I got X-rays for broken ribs. You can charge it to a credit card if you need to and figure out reimbursement from your insurance later.

>In order to see an orthopedic, I need to see a primary care physician for a referral

I've never had insurance that requires a PCP. But if I did, i'd be sure to have a PCP. It's not that complicated.

Even if you wanted to go the One Medical route, that means you pay Amazon $200, and choose a PCP. So essentially nothing in your circumstances have changed. I don't believe One Medical, or any other virtual doctor service will give you referrals that will be accepted by your insurance.

Your insurance will still require a PCP. Your PCP might or might not be accepting virtual appointments. In One Medical they do not. The virtual appointments are done by nurses who don't work in the One Medical offices

> But if I did, i'd be sure to have a PCP. It's not that complicated.

In all fairness, this isn't possible everywhere. There's such a shortage of doctors in my part of the US (a medium-large metro area) that there are literally none accepting new patients. I know four people who have been actively looking for a PCP for more than two years now.

> Your PCP might or might not be accepting virtual appointments. In One Medical they do not.

Not true, and thanks for the reminder -- I just booked a remote followup with my PCP (the very same Dr, not a NP or anyone else) to discuss some test results.

I'm sorry that happened to you but you could go to the ER if you could afford it? I fractured my elbow on a bike and went to the ER who scheduled me an ortho the next day. Ended up with surgery two days after the accident and paying my high deductible health plan for the year.

This was my first major health problem. It solidified to me how much of a clusterf the healthcare system was and how fortunate I was to be able to take off work for a week afterwards and be able to pay my high deductible.

wouldn't you walk into an urgentcare for exactly this? I had an ache, havent had a PCP for a while, walked into an urgentcare, they xrayed me and everything...

You can't go to the ER for this?

Take care of yourself. 6 hours is a very small price for your health.

And an ER trip is a very big price for something that shouldn't need that level of treatment.

Most insurances cover ERs well - also, a fractured elbow definitely seems to me like something that warrants a trip to the ER.

Primary care doctors can order xray's and many primary care offices have their own machine. You dont need an ortho referral to check for a fracture or apply a basic cast

> I fractured my elbow

> In order to see an orthopedic

Why does even a simple thing like fracture need a specialist in USA.

Elbow fractures aren’t simple, it’s not just about identifying the presence of a fracture and putting it in a cast. They send you home in a sling for elbow fractures in adults, either with surgery or without it. PCPs aren’t qualified to make the determination about how it’s going to heal and whether surgery is needed.

Just go to urgent care or walk in and get a referral not that hard

When I broke my collarbone a few years back, urgent care turned me away. Maybe others have had better luck there, but in my experience they're not good for much more than maybe stitches and dispensing over-the-counter pain medication.

>sticky down-flat-down

This is exactly how I broke my collarbone.

Park crew doesn’t do their job in terms of removing rust with a wire brush, and we pay the price. If I wasn’t concerned about getting my pass pulled, I’d buy one of those small cans of WD-40 to spray on the rail on my first lap.

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