Hacker News Reader

I worked in healthcare start-ups for many years and the main problem is mis-aligned incentives.

The #1 thing we need to do is make it illegal for your healthcare to be tied to your employment. We can still have your employer provide a X% or $Y to an HSA account that the employee can buy health coverage wherever they like. (I'm not optimistic that this will ever happen politically)

The issue today is that NOT healing you makes everyone more money, like a LOT more. There is no incentive for anyone to help people get healthy just to have a different insurance company benefit from the decreased claims.

This is also the only way forward to value based care (for primary) where doctors (providers et al) can take on the risk/reward. They get some amount (say $1K ??) per year and they keep it and submit no claims. However, if there costs go above, they eat it loss. Now the doctor and the insurance company (payer) are all incentivized to get and keep people healthy.

> I worked in healthcare start-ups for many years

I learned a while back that there are two industries you should never ever touch as a startup:

- Healthcare

- Education

Both systems are so broken (for different reasons) that it's a fool's errand.

> We can still have your employer provide a X% or $Y to an HSA account that the employee can buy health coverage wherever they like. (I'm not optimistic that this will ever happen politically)

Doesn't this already partly exist? My (US) employer offers an HDHP (high-deductible health plan) that comes with an HSA.

(It's not quite what you described, because you have to use the insurer that the company picked. I think you're describing something more like the Singaporean system with Medisave.)

I think the mechanic they're trying to speak to is that due to insurance being tied to employer, no insurance plan (besides Medicare/Medicaid) is truly motivated to ensure good health outcomes beyond a ~4 year horizon. You'll switch jobs and get a different plan.

FEHB plans would also have this incentive. I think at least historically Federal employees didn't switch employers as much (though job-hopping between agencies happens), but more importantly if you retire from the Federal government you keep your health insurance.

Yeah, what I'm suggesting is that your premiums are funded through your HSA, not just your deductible and medicines. Obviously, the max HSA funding amounts would have to change.

The main difference there is that with an HDHP your employer is still the one choosing the insurance provider, and the insurance provider views your employer as the customer. There's no risk that you as an individual will switch to another provider as long as the employer remains with this one.

Removing that layer of indirection would make it your own choice to pick a provider, and the provider is then incentivized, at least a little bit, to provide you with a good outcome or else you may freely switch to another provider.

There's also the component that, right now, you lose the discounted group rate insurance premium as soon as you lose or leave a particular job. Putting the purchasing power with the end consumer means that you can keep your provider at the same premiums even if you switch jobs. All that might change is your employer contribution.

The #1 thing we need to do is make it illegal for your healthcare to be tied to your employment

Yes. Or at the very least, stop making it mandatory. Health insurance should work like literally everything else: your employer pays you money, and you use that money to buy it.

> Health insurance should work like literally everything else

Eh, everything else varies significantly by company. Tradesmen have to buy their own tools. FANG provides free lunches.

I've yet to see an argument for why a singular person is going to be able to do a better job making healthcare more efficient than a company that shells out millions of dollars for that line item. Like why doesn't HR drop the health insurer that just keeps lock-step increasing prices? And why doesn't that reason apply to an individual?

Lots of people without a lot of assets would gamble.

The current system exists because yours is even worse.

Why make this so complicated when we can just have medicare for all? You're right that healthcare shouldn't be tied to your employment, but what you're proposing is something that only the rich + affluent can achieve independently.

All you're doing is playing musical chairs with different capitalists, just stop playing the game. A large part of the electorate wants to stop playing the game.

I think politically it is an easier sell than medicare for all or government only healthcare.

You need to do some actual canvassing and get out of your SV bubble, M4A polls at a consistent 60% support where both independents and democrats are at nearly 80% support.

What you're advocating is more corporate welfare that I don't see happening but it's the only playbook those with money seem to advocate for.

Weird.

No offense, but that is meaningless.

60% support abortion but he we are with no Roe. 70% support gay marriage but the small percentage in charge want to outlaw it.

It takes more than polling to become legislation. Weird indeed.

The reason you tell several different people why you are there is because that is important. if a system doesn't they need to start!

people often remember things when asked latter. this gives more opportunity to ask about everything you care about even if you forget the first time.

people sonetimes grab the wrong chart. This helps ensure that they check for things that matter to you and not someone else - your history is on the chart if they are watching you for something weird in you history this is important.

Or the patient makes the mistake. I've seen it happen:

My wife has a foreign name--an English speaker coming at it cold is going to butcher it. Someone gets it right--either they've been told or they speak some Chinese. (It's not hard to say, but you have to know the Chinese Pinyin rules to get it right.) Over the decades we have grown used to responding to anything in the ballpark and then sitting back down if someone else responds. Oops--L shaped waiting room, we didn't see the somebody else. She ended up in back, the check caught it there.

Or look at my own name. That's the male spelling--but most people don't realize there is a male spelling. It's caused confusion over the years.

I mean isn't that why they ask for name and DoB each time? I get that they want to ensure they're working with the correct patient. I just don't love trying to recall on command the litany of symptoms I've experienced and remedies I've tried before seeing a physician.

I am less interested in the quantitative analysis, but the qualitative analysis. Why, culturally, has the US shot itself in the foot in this way?

> And I think part of the answer is that in most cases, individuals and families themselves must allocate resources they control to make this happen.

Assuming uniquely American selfishness got us in this mess, I don't buy that rugged individualism is the route out. You'll just get that classic pattern of those with enough resources to manage criticizing the resource management of those with too few resources to learn to manage. That just further corrodes solidarity.

The unfortunate answer is that the US seems to be very bad at fighting regulatory corruption which allows small parts of the market to buy laws which give them a moat. Rinse and repeat over the last half century and you get to the situation we're in.

But that's not rugged individualism. It's just letting the market actually do its job, and let consumers and producers actually communicate a price

> Assuming uniquely American selfishness got us in this mess, I don't buy that rugged individualism is the route out. You'll just get that classic pattern of those with enough resources to manage criticizing the resource management of those with too few resources to learn to manage. That just further corrodes solidarity.

I chose my words carefully so as not to imply "rugged individualism" was the solution. I mean I even explicitly invoked "families" as an institution greater than the individual. And I used the word "control" rather than "earned" or something.

Weirdly, "rugged individualism" is kind of why American healthcare is so bad: we tie it to employment for those under age 65. Before the ACA, this was simply because healthcare is exempt from income tax; with the ACA, it's literally mandated. In order to get health insurance, you need to pull yourself up by the bootstraps and get a job OR pull yourself up by the bootstraps and pay extremely high premiums.

Disentangling healthcare from employment and allowing for other institutions like churches or schools to play a part in helping fund it would do a lot. And for the truly catastrophic conditions like cancer, we should just have a universal policy that kicks in.

One key problem appears as misaligned ("perverse") incentives. But it has to be that because its essentially impossible for an average person to purchase health care in the moderately informed and choice-filled fashion that I can purchase a vacuum cleaner.

Of course, another key problem is trying to divide distinct parts of health care into distinct costs. Everyone benefits from having a good quality hospital in their area and so assigning a health care provider's cost to just a given patient and then trying to reduce the patient's cost is quite irrational.

Essentially, you have a public good that the state and private interests are trying to make into a public good. A lot of profit comes from this but little good for the patients.

Why do you think we can??

We already have mandated covering the things where spending now saves more down the road. And the medical community has standards of proper care. If there was a way to reduce costs by improving patient health it would already have been done!

Think we haven't learned a fair bit about our own health issues? If there was some magic answer a lot of people would have found it.

And yet it is still vastly more inaccessible and inefficient than other countries where the same holds. There is a lot that could be learned from other countries. So it's good to see that this repo does so.

I notice the repo has no data on supply of doctors per person in different countries. It's well known that the US residency system with its limited slots constrains the supply of doctors who can practice in the US.

There exist similar systems in pretty much any other western nation. The problem is that teaching doctors is expensive and isn't something you can ramp up quickly because you need other doctors to teach the new doctors. The supply of doctors is a problem that is universal to essentially all western nations especially if you move away from metropolitan areas. It's largely due to aging populations and failure to increase spending on medical education over decades. I think the US is actually better off than many other countries, because they pay disproportionately high salaries so get more immigrants.

That said I don't think there's evidence that lack of doctors is what is driving up cost in the US. Just an example, growth in hospital administrators has significantly outpaced medical staff over the last decades, which will directly increase cost.

Clarification because people get this wrong a lot:

There is no imposed limit on the number of residency slots.

There is a limit to the amount of money the US government is willing to spend on slots.

Why does the government need to spend money on slots at all? Do other countries do it like that?

Because it makes pretty much no economic sense for anyone else to do it

One of many failure modes of the glorious and totally perfect Free Market

Yes most other countries use public money to educate their doctors

> Because it makes pretty much no economic sense for anyone else to do it

I think other funding models simply haven't been explored. I'll pull one out of my ass. The hospital does it themselves. In exchange the doctor works at the hospital for the next N years, or pays a contract break penalty. The hospital can pay the doctor somewhat less than market rate and doesn't have to deal with staff turnover.

It should be obvious that other funding models will be invented if government funding goes away. Because the alternative is no new doctors and people start dying without treatment.

Residency training costs like $750,000 to $1.5MM per physician

Primary care doctors would have to work 12-15 years while giving up 25% of their gross salary just to pay for the residency program. They'd also have to pay x% of their salary to pay for their debt from med school training before the residency.

People just wouldn't go into the field, which is already happening even in a world where the residency is funded. The economics of being a doctor are simply not that great anymore, especially relative to other things you could do.

> It should be obvious that other funding models will be invented if government funding goes away. Because the alternative is no new doctors and people start dying without treatment.

There is an infinite number of jobs that would be great to have but we can't reasonably fund and so don't exist.

We currently live in a timeline where there are no new personal one-to-one tutors for middle schoolers and therefore every single middle schooler in the country receives subpar education, causing vast amounts of economics losses as compared to if they could be trained more thoroughly.

But that's just the way it is!

> Residency training costs like $750,000 to $1.5MM per physician

And how much do residents generate in billings?

Your numbers may also be off by a lot. It'd be great to see some sources. https://news.ycombinator.com/item?id=45507076

I find it completely unbelievable that residencies are not a profit center for most teaching hospitals. The residents do almost all the day to day work with a half dozen of them reporting to a single attending physician.

It’s not like you get a discount if you’re seen by a resident vs attending either. Sure the first year or maybe two a resident needs a lot of close supervision, but not nearly as much as people think happens.

I would bet dollars to donuts that the vast majority of patients seen by a resident have no clue. They simply call them doctor.

My bet is it’s all accounting tricks. You’d be utterly incompetent not to somehow make a profit on 60-80hrs/week of basically free doctor labor even if those are junior doctors. They generate massive amounts of billable services. Plus they are basically guaranteed to work for you for 4+ years, aside from the few that wash out.

> The question we ought to ask is how we can buy better health outcomes for people

spend more money. you DO live in the greatest country on the planet, surely if an american citizen cannot raise the funds for healthcare, in what country can you expect to?

We spend a ton of money per capita and get bad outcomes.