Comment by colonCapitalDee | Hacker News Reader

Comment by colonCapitalDee | Hacker News Reader

Parent Full thread

colonCapitalDee

There is absolutely a middle ground? The healthcare system, like any system, has an incentive structure. Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice. Doctors are not angels sent from heaven, they're people like you and me, and they respond to incentives like you and me. It's also well known that people strongly prefer receiving treatment over not receiving treatment, even when the cost to their health of receiving that treatment outweighs the expected benefit! Given that people push their doctors into prescribing treatments, and doctors are incentivized to go along with it... you would obviously expect some proportion of prescribed treatments to not be medically necessary. 5% sounds about right. And the kicker is that denying these treatments improves health outcomes for the general population, because those medical resources can get routed to the people who actually need them. Every successful public health system has an opposing force built in to it to limit the spurious consumption of scare medical resources, because without such a force costs balloon and the system becomes unsustainable. Not to defend the US healthcare system of course, our cost problem is worse than anywhere else...

> Doctors are incentivized to prescribe treatments, because that's how they make money for themselves and their practice.

This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in.

What is perverse is that, while we have the Stark Law to constrain physician behavior, we've decided that it's okay if a diffuse group like a non-physician-owned hospital chain enforces rules to this effect.

> This is literally illegal! Physicians cannot refer patients to entities they own or have an interest in.

There has to be a done of exceptions to this.

You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it.

You see a doctor, and they refer you for a test. They have a share portfolio that contains shares in the facility they referred to.

Medicine is riddled with potential conflicts of interest. Managing them is what professionals are supposed to do and what regulators are supposed to enforce.

I don’t live in the US, I’m a n Mew Zealand. Sadly, I am aware of behaviour that looks like corruption in our system.

> You see a cardiologist and they recommend a stent. They aren’t going to recommend a different cardiologist does it.

Things must be different in NZ.

First, it's true that you're going to want to go to who your doctor knows/recommends. The law in the US is just that they can't refer you to a group they own/their spouse owns, or for which they get a financial benefit.

Next, you're speaking about the doctor doing a consult visit before doing a procedure. That is not the same thing as ordering a treatment for you to go get the treatment elsewhere—which describes what happens you go to the pharmacist to get drugs.

Finally, the cardiologist you see in the office is almost certainly not doing stents for you as those are very distinct skillsets (in the US).

>Finally, the cardiologist you see in the office is almost certainly not doing stents for you as those are very distinct skillsets (in the US).

Umm, what? No. It's exceedingly rare for an interventional cardiologist in the US not to do office work. The average number of PCI/yr is like 50 or something. Plus if one spent all one's time in the cath lab, they'd have a spinal fusion, knee replacement, thyroid cancer, and cataracts.

But what you are trying to get at is that there is law about self-referral ("Stark law") but in reality there are exceptions that render it fairly useless

> But what you are trying to get at is that there is law about self-referral ("Stark law") but in reality there are exceptions that render it fairly useless

What are the exceptions that render it useless? I have never heard of them in my 10+ years of hearing about it.

I did not know that I-cards do office work, not my area of medicine.

IR is in the angio lab daily without cataracts, thyroid cancer, etc., so that part of your statement is clearly not true.

I also don't understand what you mean about knee replacements... humans are generally capable of standing without requiring surgical intervention.

> What are the exceptions that render it useless? I have never heard of them in my 10+ years of hearing about it.

It sounds so unlikely that there is a blanket rule that you can’t refer to something you have a shareholding in. If you own a shareholding in a hospital you work at, you can’t refer internally for a test?

I just don’t believe that.

Edit: I did some hunting. ‘Per click’ payments or bonus payments based on volume are illegal. Rents must be fair market etc.

It looks like owning a chunk of the place you refer to is fine. https://www.healthcarecompliancepros.com/stark-law-explained...

> It looks like owning a chunk of the place you refer to is fine

The article you link to says that anyone can be liable even if she didn't realize her referral violates the law.

I cannot imagine any reasonable physician risking this after the decades of training required to get a doctor. I would not, for sure.

From the article you sent:

Some of the most widely used regulatory exceptions are longstanding and foundational across healthcare organizations. These include:

    In-office ancillary services exception: Allows physicians in the same practice to refer patients internally for DHS such as lab work or therapy, as long as certain supervision, location, and billing criteria are met.

    Rental of office space exception: Permits lease agreements between a physician and an entity, but only if the space is used exclusively for legitimate business purposes, rent is fair market value, and the agreement is in writing for at least one year.

    Employment exception: Protects compensation arrangements between hospitals and employed physicians, as long as compensation is consistent with fair market value and is not based on referral volume.

    Personal service arrangements exception: Covers contracts where a physician provides services (like medical directorships) to a DHS entity. The agreement must outline duties, last at least one year, and pay a fixed, fair-market-value fee unrelated to referrals.

Each of these exceptions includes detailed requirements, and missing even one element, like failing to document the arrangement in writing, can render the exception invalid. This is especially important when physicians have investment interests in joint ventures or ancillary service providers.

It’s exactly those points that allow referral to entities in which physicians have a financial interest. That’s why I provided the link.

Otherwise they’d be breaking the law with investment funds that hold stocks in large healthcare companies etc.

I remind you that we began this with the idea that doctors are prescribing treatments for their own financial benefit: https://news.ycombinator.com/item?id=48621445

At the diffuse 401k ownership level, individual actions are not relevant - the Stark law is clearly dealing with the first case and that was how this whole discussion began.

Diagnostic imaging companies - each of the big ones (Siemens, GE, Philips) all offer in-house financing on very favorable terms for MRI, CT, etc., that they specifically advertise to physicians. They also all offer specialist consulting help to facilitate you getting a CoN (Certificate of Need) for your facility. Hell, they also will help you find other physicians in your area who'd like to go in with you on setting up a DI facility, and they will assist with spinning up the practice.

We then find that physicians who own a DI practice (or a share in one) refer their patients to diagnostic imaging at rates several standard deviations above other physicians and at rates that are "statistically improbable" when correlated to underlying ICD-10 diagnostic codes.

Everything above is fair, if true. I don't see a reference in your answer so I can't assess the quality of evidence.

The point is that they cannot refer you to one of their companies. Of course, there may not be a meaningfully-competitive local market, so patients may end up needing to go to the physician-owned imaging facility. I do not thing this is a large issue for most of the US population though it's probably an issue on a spatial basis.

> Of course, there may not be a meaningfully-competitive local market, so patients may end up needing to go to the physician-owned imaging facility.

Certificates of Need. A legal requirement in most states for creating a new healthcare facility. Ostensibly to make sure that the population in that area has adequate healthcare options. But lobbied for by healthcare facility and hospital owners, it actually surveys other providers (your competitors) in the area and asks if their revenue would be adversely affected by you opening up. Too much of this, and no CoN for you.

Reply on news.ycombinator.com