Comment by bdesimone | Hacker News Reader

Comment by bdesimone | Hacker News Reader

I haven't read the whole site yet but I jumped to the topic I know fairly well, medical malpractice. Just some additional notes to consider:

* 9 out of 10 physicians would discourage their children from becoming doctors.[3] There are many reasons for this. Malpractice insurance premiums are a factor. Not the only factor.

* California physicians have the lowest insurance premiums in the country. This is directly the result of tort reform, and caps on pain and suffering payouts. His survey of physicians he knows in the area is subject to this sampling bias. Malpractice is a big issue in other states.[0] California is the model for tort reform for this reason, by not acknowledging this fact, he's missing a big aspect of the national (not just Californian) issues regarding healthcare.

* California physicians also have some of the lowest reimbursement rates in the country.

* As he indicated, internal medicine docs pay far less in premiums (as he noted) than other specialties. Surgeons pay much higher premiums. [1]

* The California Department of Insurance does a good job of keeping most premium information public. It's not a secret what your average doctor pays in insurance.[2]

[0] : https://en.wikipedia.org/wiki/Medical_Injury_Compensation_Re...

[1] : http://cl.ly/image/0m390m1F2D2D

[2] : http://www.insurance.ca.gov/0250-insurers/0800-rate-filings/

[3] : http://www.thedoctors.com/ecm/groups/public/@tdc/@web/docume...

Do you happen to have more digestible numbers? Something like: "In California, malpractice insurance is ~X% of cost, in the rest of the country, it is around Y% of cost."

My understanding is that for all the attention it gets, malpractice insurance isn't that big a deal. But I haven't researched it very much.

Not at my fingertips, because I dealt almost exclusively with physicians in California. I'm basing this on almost every out of state physician remarking on how much lower premiums are when the move to California. NY and FL seem to be some of the worst states to work in for doctors paying their own premiums.

Malpractice rates are a factor, not the only factor in physicians deciding where and if to practice. Just like reimbursement rates.

Richard Thaler just had this op-ed in the NYT on ways to reduce costs, talking some about tort reform: http://www.nytimes.com/2013/02/24/business/overcoming-obstac...;

I'm skeptical about tort reform as a panacea. However, lawsuits are incredibly expensive, and so doctors take steps that we would otherwise call economically unreasonable to avoid them.

The amount of tort reform I think is really necessary is whatever would allow me to set up a private equivalent to the UK's NHS here. If someone thinks they are getting denied care that they deserve to have, the decision needs to be very cheap to adjudicate.

It's not a panacea. It's a part of the very complicated system that is providing and paying for healthcare. How important are insurance premiums relative to other factors? It depends. But there are costs to having uncapped settlements, and lack of tort reform.

Also, insurance premiums effect practices of different sizes differently. I personally think you can attribute the shift away from smaller private practice groups towards larger groups and hospitals are for other reasons. Insurance premiums are somewhat to blame, but I think the bigger driver is that many of the government mandates are too expensive (n.b. this doesn't mean it shouldn't be done) to take on for most smaller private practice groups.

I'm not sure how to respond to your comment about tort form if it get's us to an NHS like system, because I disagree that's the best way forward. But that's a topic for another day.

Most opposition to tort reform comes from the left, and fans of European-style health care also come from the left, so saying that we couldn't set up a European style because of the legal climate is intended to cause cognitive dissonance.

(I'm not advocating putting everyone into a government system run NHS-style system. Surely, though, me and a few thousand of my friends ought to be able to get together and attempt to emulate it if we wish.)

Yes. Malpractice insurance isn't super costly, but knowing many doctors (my father was a doctor as well), the adversarial relationship that malpractice suits sets up is a heavy burden. We know that overtreatment is a huge source of the cost overages we have in the US relative to other countries with the same health outcomes, and malpractice threats are a significant contributor to that, although it is obviously very hard to measure.

Personally, I think there could be some advantages in making a more patient-responsible system. The most expensive healthcare we have is ongoing (chronic) stuff, and most people with issues like that end up being experts on their own conditions. Why not allow them to get their own medicine and equipment directly rather than be forced to visit the doctor every N weeks to refill a prescription? Or be severely inconvenienced by being somewhere where it is difficult to obtain the right prescription for the medication they know, any sensible person knows, they need? That's silly and inefficient.

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