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Comment by jmward01 | Hacker News Reader

The question is will this lead to better care or a reduction in resources? Technology allows companies to become 'just good enough'. Any better than 'just good enough' and resources are withdrawn. If there is a 26% improvement in x and x was 'just good enough' before then the only 'rational' move by administration is to reduce other resources until x hits 'just good enough' again. That being said, I think the improvements are coming so rapidly in healthcare that we have a real chance of causing the entire system to shift into a new dynamic so maybe we will actually capture some of these gains for patients.

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This takes place in Canada. There are no for-profit hospital complexes like the USA. All of our major hospitals are non-profit, reimbursed by the single-payer healthcare system and philanthropists getting stuff named after them. The profit-motive isn't as significant of a factor here.

That being said, I'm fine with a reduction of resources if additional resources don't increase the quality of my care. In Canada, doctors don't really like to prescribe antibiotics for minor infections.

Americans find this bizarre, but for a minor infection antibiotics are going to screw up your stomach bacteria and long-term health to maybe treat a disease that your body can easily handle on its own.

There's no magic value that comes from allocating resources to a problem. Oftentimes spending money has zero or negative impact beyond virtue-signalling that you care about the problem.

Canadian hospitals have largely the same cost cutting and "efficiency" measures as their US equivalents. Departments have budgets that they have to fight for, feifdoms compete for scraps, and there is an enormous and perpetually growing admin/executive side that is taking more and more of the budget. Couple this with governments such as Ontario that "starve the beast", so to speak, forcing hospitals to squeeze further.

I don't think we should ever take any sort of superior position on this. The same motivations and outcomes occur.

Having said that, efficiency is good, especially with an aging population that will require more and more care. Resources are limited, so applying them in the most effective, efficient way possible is always a win.

American healthcare spending 80% more than Canada on a per-capita basis for worse or equal outcomes.[1]

Our system has major problems, but we spend less money and have a healthier population. That definitionally means we're more efficient.

> The same motivations and outcomes occur.

Our hospitals don't have shareholders that capture excess revenue as profit. Efficiency gains in a non-profit hospital typically get reinvested into the mission of providing healthcare. Efficiency gains in a for-profit hospital often go to the owners.

"Efficiency" is also measured differently in a non-profit context. A business measures monetary return on investment. A non-profit organization measures the monetary cost of achieving its mission.

Many for-profit hospitals in the United States offer free mental health clinics. These clinics have been accused of baiting patients into saying something suicidal as a tactic to involuntarily commit said patients.[2] Because appeals of an emergency mental health order are difficult, this is an extremely efficient way of making money (the hospital gets to bill the patient for their stay).

I don't believe this could happen in Canada. The goal is to get people out of the hospital because there aren't enough beds.

[1] https://en.wikipedia.org/wiki/Comparison_of_the_healthcare_s...

[2] https://www.buzzfeednews.com/article/rosalindadams/intake

I will always choose properly funded universal healthcare over the US model, and my disagreement was with the claim that somehow the Canadian system wouldn't yield a reduction in resources because of some unique quality of universal/non-profit healthcare. Of course resources would be rebalanced if some part of healthcare could be done with less, and if the administration could cut budgets because a model lets them hit the same benchmarks with less, they absolutely, unequivocally will. And then they'll give themselves a fat bonus.

As to the mental health holds, here in Canada we have a problem with social workers encouraging difficult cases to consider medically assisted suicides, which is pretty disgusting. We have people dying on waiting lists. We have people having to go to the US to get basic imagining of probable cancer cases.

Universal healthcare is superior -- again assuming proper funding, which jurisdictions like Ontario are far, far short of -- but in the current state of the Canadian system, I would never imagine bragging about it online.

> Our hospitals don't have shareholders that capture excess revenue as profit

Aren’t most hospitals in the US technically non-profit, though?

I totally agree. The tie to whole patient outcome is stronger in that system. Still not perfect, but a lot more direct for sure. It may be an odd thing to say, but because of that there is an argument that the Canadian system is closer to a true free market healthcare system with the patient as the consumer than the US system.

I think you're missing an important part of the equation: it's outcome quality per amount paid. If you could have gotten 20% better results but it would mean tripling the costs of healthcare because we'd need to hire a lot more staff, perhaps we felt that was a bad deal.

If you can get 20% by paying... what, presumably <5% more for some ML tool that double-checks stuff and flags risky stuff... perhaps it's something we want to do.

No, my argument isn't that this wouldn't be used, it is that by using it there will be overage in quality of care above 'good enough' for the same or similar cost. That will result in the most expensive resources being reduced until quality of care is back to 'good enough' at less cost. It isn't a stretch to imagine that a tool like this would lead to a reduction in nursing staff since they can make rounds more effective and now don't need as many people to get the same level of quality job done.

But I think that's a wrong way to look at it. Or rather, it posits that we're at a point we truly consider good enough independent of cost.

It's entirely possible that we want better healthcare outcomes - all the historical trends point to that - but that we're more or less out of ideas how to get there on the cheap. This might be a new possibility.

In your model, why do we get improved, costlier insulin if the old thing was good enough? Because we actually want to pay more if it works better, and it doesn't mean we cut something else to make up for it. You just pay more in taxes in a subsidized model, or pay more at the pharmacy with private healthcare. There's a drug manufacturer profit motive in there, but it holds true in the added-cost ML scenario too.

I can agree that good enough is not tied to cost and that is likely unfortunate for the patient. It is instead tied to profit, for the company. If increasing the standard of care leads to more profit a rational company will do that. If it means lowering then they will do that. Unfortunately there aren't many actual direct ties between patient outcome and profit and often when they do exist they are negative for the patient. The classic example of this is the question of is it more profitable to cure or to manage a disease? I'd love it if whole life outcome was actually tied to profit in a way that was beneficial to the patient. That would mean a free market driven by the patient as the consumer could exist. But healthcare systems, especially in the US, generally aren't structured that way.

So, to answer your question about 'why do we get improved, costlier insulin if the old thing was good enough' it is because the healthcare system will make more money on it. If they take a % then they are incentivized to use a more expensive version and they can justify it with the word 'better' even if the person is actually worse off as their financial situation deteriorates and they and their families are forced to cut quality of life everywhere else. They put their line for good enough at the point that makes the most value for them, not the point that is best for the patient.

it's outcome quality per amount paid

Outcome is not one thing. The patient wants better health. The provider has an interest in profits. The government has an interest in optics…well anyone using “AI” does.

I think in this case it's unlikely because I don't think the problems the tool solves correspond 1-1 with reduced staffing or other resources. The tool mostly seems to provide ongoing diagnosis at a level of detail the clinical team doesn't have regular bandwidth for (they might make one diagnosis of the patient per time they visit the patient rather than on an ongoing basis). It doesn't really reduce the amount of time staff can spend with patients. They can't get rid of doctor diagnosis entirely so they can't really reduce time per patient in any effective way.

Starving the beast is an ongoing program, the budget will be cut (or fixed, hence silently cut through inflation) either way. My hope is that improvements like this will stave off the harmful effects of the budget cuts.

You realistically can’t starve the beast that is healthcare. The costs will go up disproportionately, and they do, in basically every advanced economy: https://en.m.wikipedia.org/wiki/Baumol_effect

You can reduce the spend per person by replacing more qualified workers with less qualified (cheaper) workers, and adding friction to the process of obtaining healthcare.

Increasing prior authorizations, increasing paperwork complexity, increasing hold times on the phone, obfuscation for who is responsible for what, constantly changing coverage so people have to change providers, and otherwise discourage them from seeking care.

While I agree that you shouldn't, and that the end goal (privatized health care) is at the same time more costly and less efficient, that doesn't mean people can't or don't.

The Baumol effect you link to only shows that wage demands from health care workers go up in proportion to the wages of other workers. This means (roughly speaking), that reducing the health care budget will reduce the effectiveness of your health care system, because you're able to afford fewer people (I think this is the point you're making, please correct me if I'm wrong).

But that's entirely the point of starving the beast! By cutting funding to some federal department, that department becomes less effective, which makes people think that the government is incapable of running said department, and makes them open to the idea of privatizing the department. Et voila, you've opened up a whole new market that can be exploited for profits! The holy grail is opening up a market with inelastic demand such as health care, where people, no matter what you charge, will be forced to buy your product. This program has been incredibly successful in the US, which can be seen by comparing their health care system to that of other wealthy nations.

This question has an implicit assumption that you're talking about a US-style health system and the incentives that exist in a system of that structure.

This is exactly why a structure like the UK NHS which is going for "what's the most healthcare I can get for the country with a fixed pot of money" is a better setup.

For instance, in the UK the female contraceptive pill is free to whoever wants it. Because that is a whole lot cheaper than extra (unwanted) pregnancies. Similarly the NHS has spent money on reducing smoking because that's cheaper than dealing with the health effects.

The early death of smokers tends to save a long, expensive period of end-of-life care. I believe smoking deaths reduce health care costs, ironically enough.

It does, there is even a study on it. https://pubmed.ncbi.nlm.nih.gov/9321534/

Smokers also help keep pension/social security costs down since they pay into it but don't collect out of it or do for much shorter period.

That study is almost 30 year old, has there been more current research? I also wonder if externalities like trauma on friends/family are factored in, I could imagine there are some transitive effects?

> Because that is a whole lot cheaper than extra (unwanted) pregnancies.

From a nation which should know better after being so very thoroughly roasted by Mr. Swift some few years ago: https://www.gutenberg.org/files/1080/1080-h/1080-h.htm

> the female contraceptive pill is free to whoever wants it. Because that is a whole lot cheaper than extra (unwanted) pregnancies.

Abundant contraception encourages and promotes promiscuity

> the NHS has spent money on reducing smoking because that's cheaper than dealing with the health effects.

Reducing tobacco usage makes more room for nicotine OTC and vaping to replace it. Among other stimulants.

What do you recommend? Just letting people die of cancer and ignore teenage pregnancies?

I don't think data supports your claim that tobacco use was merely redirected to other forms of nicotine. But even if it did, that's a success since they're less harmful.

I recommend that kids who go to the Bodega and pick up a pack of smokes, a tub of ice cream, and a packet of condoms, check Wikipedia for terms like "Helen of Troy", "Trojan Horse", and the eponymous war, lest their Y chromosomes combine with something in a way they thought was impossible.

> Reducing tobacco usage makes more room for nicotine OTC and vaping to replace it. Among other stimulants.

And? Nicotine itself is not particularly dangerous and might be even neuroprotective if consumed in moderation. Vaping as a consumption method might be problematic of course, but I don’t think there is any research showing it to be even as remotely as harmful?

Why are you putting ‘just good enough’ in quotation marks?

Even declaring that is the case doesn’t change that it’s still clearly a personal judgement depending on the individual.

Its not a personal judgement to say private equity buying up hospitals has shifted the priorities of the hospitals from care to profit.

"Depending on the individual" here means, depending if you're a share holder, or the patient dying on the cot.

Huh? How does this relate to value judgements made by individuals?

This scenario exists only in progressive and HNers heads. Companies make money and Capitalism works by offering more services not fewer. Are there companies that does short-term thinking? Yes. But overall, our standard of living and quality of services has always improved

That was a rational capitalist argument. If a company has an opportunity to make money, they will. Any better than 'good enough' isn't rational and the people running that company should be fired. In the long term the entire industry will slowly adopt this and the standard of care may rise slightly as these gains are used for competitive advantage instead of pure profit but that will take a while at best and relies on a true free market, which healthcare definitely isn't.

> relies on a true free market, which healthcare definitely isn't.

I think this is the part that people miss the most. When a purchasing decision is made based on something like "who has the best quality shoes in price range X", competition can occur.

When the buying decision is "will I live or die", there's not really any choice made there. Couple that with the complete lack of transparency for how much a give procedure will cost, and you've strayed so far away from a free market that it's not even recognizable.

I mean, even the hospital can't even remotely accurately tell you how much something will cost before you actually get a bill...

It’s not only about living or dying. Care work is fundamentally about treating humans with dignity and respect, and just shouldn’t be regarded as a free market playfield.

Right, my point was more that healthcare isn't optional.

Folks think that removing the "profit motive" will somehow cripple the whole system, or hospitals will try to save any penny they can (spoiler alert: they already do)

>Any better than 'good enough' isn't rational and the people running that company should be fired.

This is kind of the reason the Japanese economy is stagnant and continues to fail in winning global marketshare. Businesses that are too good will fail or at least not compete with businesses that settle for being good enough.

> If a company has an opportunity to make money, they will. Any better than 'good enough' isn't rational and the people running that company should be fired.

...where "good enough" is relative to a particular level of quality and price point, of course. Otherwise there wouldn't be different markets for rich and poor people. And this mechanic helps avoid a "collapse into mediocrity" that you'd otherwise get if all goods and services were offered at a single price point.

The real problem is what you identified at the end, that healthcare isn't anything like a free market. There's no buyer mobility, no transparency as to the level of the service you're getting - heck, you don't even know how much you're going to pay in advance, unlike almost every other industry.

IME anything that looks vaguely like a cost center often has something vaguely resembling an acceptable service/quality level and people typically aim to achieve that with the lowest cost. It’s not at all uncommon to cut budgets/headcount when that goal is exceeded noticeably.

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