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Comment by vsskanth | Hacker News Reader

One thing I don't see mentioned here is unnecessary surgeries being performed on elder patients. My wife was a home health OT for a small rural county. She was primarily doing post-op rehab at home. Recently, she noticed a lot of old patients on Medicare had shoulder replacement surgeries done on them, even though looking at their medical records it was clear it's either not necessary (won't improve their QOL) or simply shouldn't be done since it introduces other complications.

Every time she encountered a similar case, she noticed it all traced back to a single doctor in the area.

It was extremely sad to see old people end up in a much worse situation because of complications from their surgery, or pass away because they got sick in the hospital. All because some greedy doctor wanted to make more money.

These old people place a lot of trust on their doctor and simply do what they ask without a second opinion.

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Both of my in-laws are in their early 70s have been recommended to have shoulder surgeries by their doctors because of shoulder pain. There was no recommendation of seeing a PT or introducing any sort of strength and mobility work into their lives. My wife and I keep trying to convince them that they should be using surgery as a last resort, not as a first attempt at addressing their pain. They've lived the typical sedentary lives most Americans live and it seems impossible to get them to believe that doing physical activity would help their pain.

If they get the surgeries they're going to have to do months of PT anyway, so why not at least try it first? But surgery is what their doctor recommended and they're of the generation that doesn't believe a doctor would be wrong about something or would be doing the thing that makes them the most money.

My father-in-laws doctors are kinda like this. He’s definitely had real damage in younger years but I think a lot of recent pain is because of a lack of any physical exertion, he’s allergic to stairs and takes the shortest path anywhere.

Spot on about the PT, it was probably the most regular physical exertion he’s done since the last surgery.

My docs are always like you need PT, stretches, and more movement for your upper back/shoulders/heel etc. Also stop doing these X things that bother it. In no way were they going to give me surgery or even pain killers.

an old surgeon here in California (now deceased) used to complain bitterly about the PTs making more money than he did ! So many stories about that guy.. big game hunting in Africa was a status symbol, his daughter had a $200k wedding.. etc

Good PTs are worth all their fees. Truly underrated profession. I wish they all made more money cause then more people would be motivated to get better at it.

It's true. The problem is hard it's hard to separate the wheat from the chaff.

The amount of money insurance will pay PTs is nonsense too. Last time my wife went it was like $40 or $50 an hour or perhaps less?

I don't think it's common, but it isn't uncommon either.

I'd encourage her to try to reach out to HHS. https://www.medicare.gov/basics/reporting-medicare-fraud-and...

It may take a bit of effort, but a huge part of Medicare abuse is that HHS can't know all the details of all procedures.

But if they're alerted to "you may want to look at shoulder replacements by this provider" then they can definitely put it under more scrutiny.

It'd be great if they had proactive systems to alert... but my guess is the size of the healthcare market at Medicare scale somewhat preclude open-ended, continuous queries.

I had a herniated disc that took me down the rabbit hole of over-operated spines. It was astonishing the number of doctors who would straightaway recommend surgery, even though most spinal surgeries have complications, my case wasn’t particularly bad, and there is plenty of evidence that most spinal injuries heal on their own over time.

I could research and consult friends and family in the medical field, but good God there has to be some oversight.

For the record, conservative physiotherapy healed my back and I’m back to normal again.

Old people vote the most and "death panel" rhetoric works really well. This is the result unfortunately. Overprescription is generally a huge problem in medicine because of asymmetric information and the incentive structure that fee for service creates. That's why medicare is trying to move to a capitated system in which health care providers get paid per patient they cover per year, not per service they provide.

A significant amount of healthcare spending is in the last year of life due to an unhealthy relationship with death at a cultural level. Until that changes, people will commit to exhausting healthcare and medical resources to cling on to the last part of life (note: I am not advocating for withholding care when a positive outcome is possible, and I have had to make end of life care decisions for loved ones). There is also evidence the system is incentivized to consume resources versus allowing someone to choose to die at home.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610551/ (Medicare Cost at End of Life)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2708119/ (Place of Death Among Older Americans)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5326787/ (Thanatophobia (Death Anxiety) in the Elderly: The Problem of the Child’s Inability to Assess Their Own Parent’s Death Anxiety State)

Good luck changing people's fear of death in this country. Properly disincentivizing interventions that don't work or aren't cost effective is the only solution.

I don't think you have to deal with incentives at all. We can simply stop paying for low or negative Roi treatments

This is where the death panel rhetoric comes in. As soon as medicare recipients realize their doctor is recommending stuff that some panel has decided they won't pay for politicians are in big, big trouble. "How dare the government claim they know better than my doctor" type of stuff works really well

You're not wrong, progress here is going to be governed by the velocity at which younger voters become a larger voting bloc than the elderly.

https://thehill.com/changing-america/respect/diversity-inclu...

https://www.pewresearch.org/fact-tank/2018/04/03/millennials...

https://www.pewresearch.org/wp-content/uploads/2018/04/FT_16...

Edit: https://www.populationpyramid.net/united-states-of-america/2...

Aren't demographics heading in the wrong direction for that?

https://www.morningstar.com/news/marketwatch/20230314284/bab...

https://www.pewresearch.org/fact-tank/2020/04/28/millennials...

https://www.brookings.edu/blog/the-avenue/2020/07/30/now-mor...

Yeah, I agree, but I think a "we dont cover that but you can pay for it" is a suitable answer.

In fact, it has to be an option if we ever want cost efficient state coverage.

No one asked, and not exactly on topic, but I'd like to throw in my $0.02 towards our culture having a slightly less unhealthy relationship with death.

The essence of it is this: No one suffers over how they don't exist on, say, the top of Mount Everest right now, or the bottom of the Marianas trench. They also don't worry about how they didn't exist in the 12th century in Madagascar, or on the surface of Mars one million years ago. No one worries that they don't exist in the center of the Sun, or on the surface of some star in some other part of the universe. There is an almost infinite number of places and times that I currently don't exist at. I think that death is like that. There is no one to worry about anything, just like you weren't there to worry about anything before you were born.

I went to a junior college that I spent time at years ago, and, being in the physical location made it easy to place myself in the mental space I was at then... The person I was then, the things that were important then, everything, all of it, are now gone. I have memories of that time... some sad, some happy, some bittersweet. But the person I was then is gone, no longer exists in any real way. It's easy to get swept up in those memories and the emotions, but, if I focus on what's going on in the present moment, then it's clear that none of that exists any longer (at least not outside my memories). And that's a good thing! It frees up the present moment for doing new things, for becoming someone else.

I'm not trying to get all nihilistic "nothing matters", and I'm also not all New Age "everything is going to be perfect". There are real problems in the world, and some seriously f*cked things happen. But working on real problems is hard enough without dragging a bunch of anxiety over fantasies into it.

The joke, of course, is that we have death panels already. They're even less accountable than the government. What I don't understand is how so many people think it would be worse with the government running the show, given we already know exactly how terrible the private insurance companies are.

It's worse with government because of the scale. The math of Medicare is that if it is not restrained, it will consume the economy.

> It's worse with government because of the scale.

Can you explain what you mean by this? Why would the cost per-person be greater? Are there not opportunities to take advantage of economies of scale? And to benefit from not needing to achieve profits for the shareholders of insurance companies?

Are you assuming that Medicare gets no additional funding?

My assumption is that every dollar which currently goes to insurance companies as premium ends up going to Medicare[0]. Medicaid would have no reason to exist any more either, it would become part of the same program.

The only way this ends up being more expensive than what we have now is if we must cover a bunch of people who are currently doing without health care. There's a really obvious moral question that comes up right about then, we can skip that. The actual number of truly uninsured people (no private insurance, no medicaid) is relatively small. That would be offset by all the money we don't spend on medical billing and insurance company bureaucracy.

[0] or whatever it would be called, Medicare is a nice name but I'm talking single payer

While this is an incredibly serious issue, the fraud the article focuses on is billing for services that don't really get provided, which is very different than pushing unnecessary procedures.

The latter seems like fraud also.

I'd guess that in a similar situation of knowingly performing unnecessary surgical procedures would constitute assault in the uk. Among other things.

I'm a medical student and I have actually been working on some research to re-evaluate how we decide when to do/not do large bone/joint surgeries. Currently, whether to do surgery or not is based on unvalidated questionnaires that basically ask how much pain they are in and how much it affects their daily activities. We basically don't know when to do these large surgeries or not and the few randomized controlled trials have many issues and report data completely different, limiting the usefulness of meta-analyses. Pretty disconcerting, but I hope that this starts to change in the future as the newest group of surgeons realizes that the current standard of care isn't very evidence based at all.

Does she know there are whistleblower rewards for Medicare fraud? She can make a report and possibly earn 15% of any money collected by the government.

1. It's not clear this is fraud, more like over utilization of reimbursed services

2. We're on H1B, can't complain without risking losing job tied to visa and having to leave the country.

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