Medical Anarchy
chrispacia.wordpress.com
chrispacia.wordpress.com
That's like saying that Comcast/Time Warner are a "union for Internet users".
If the AMA were "little more than a union for doctors", doctors would have a lot more respect for it, instead of the great contempt that they currently do.
If anything, you could argue that, because power follows the money, the AMA is an advocate for the insurance companies that the doctors are beholden to (essentially every doctor in the country must pay their fees to the AMA in order to process billing, because the AMA has a monpoly on that[0]). One of the big disadvantages of dissociating with the AMA (yes, a provider can do this) is losing the ability to use these insurance codes.
I don't think that that characterization is quite fair either, but it's a lot more correct than saying that the AMA is a union for doctors.
If you want to know more about CPT codes and billing, my startup[1] works with hospitals and outpatient providers to handle the billing process - I am happy to tell you far more about CPT codes than you ever wanted to know. :)
[0] The AMA owns and controls the CPT codes - the billing codes that payers use. The providers don't always pay them directly (especially if they're not independent practitioners), but they do end up paying them in the end.
[1] https://www.boardrounds.com/ (plugging shamelessly because it's relevant).
Comcast and Time Warner are most comparable to hospital chains in the medical context (or perhaps insurers, depending on what parameters you choose for the comparison).
>"If the AMA were "little more than a union for doctors", doctors would have a lot more respect for it, instead of the great contempt that they currently do."
Many rank-and-file union members hold their organizations in contempt.
>"If anything, the AMA is an advocate for the insurance companies that the doctors are beholden to"
The AMA's members are physicians, and other medical personnel; you may look at the AMA as a union, lobbying group, or a professional association, but it is certainly not advocating for the interests of the insurers.[1]
Explicitly, certainly not. But in some ways they do end up empowering insurers (whether intentionally or corruption of their original intent).
(And by the way, I didn't mean that this was the case either; just that it was a slightly less ludicrous interpretation than the original statement.)
[1] http://www.policymic.com/articles/41531/union-of-the-snake-h...
I think it's important to distinguish here between "screw experts they don't know anything" and "I've taken your professional opinion into account, and will be making my decision." The second has a long, long history in anarchist thought:
> Does it follow that I reject all authority? Far from me such a thought. In
> the matter of boots, I refer to the authority of the bootmaker; concerning
> houses, canals, or railroads, I consult that of the architect or the
> engineer. For such or such special knowledge I apply to such or such a
> savant. But I allow neither the bootmaker nor the architect nor the savant to
> impose his authority upon me. I listen to them freely and with all the
> respect merited by their intelligence, their character, their knowledge,
> reserving always my incontestable right of criticism and censure. I do not
> content myself with consulting a single authority in any special branch; I
> consult several; I compare their opinions, and choose that which seems to me
> the soundest. But I recognise no infallible authority, even in special
> questions; consequently, whatever respect I may have for the honesty and the
> sincerity of such or such an individual, I have no absolute faith in any
> person. Such a faith would be fatal to my reason, to my liberty, and even to
> the success of my undertakings; it would immediately transform me into a
> stupid slave, an instrument of the will and interests of others.
>
> - Bakunin, "What is Authority" http://www.panarchy.org/bakunin/authority.1871.htmlOkay, so I like the idea of CoinMD. It's a nice way for people with medical knowledge to get paid for their tips, but so far that's really about it. It's just yet another forum for medical advice, but with a gimmick. It's not even an original gimmick. The whole "integrate Bitcoin into everything" appears to be motivated by more of a cargo cult to appear modern and countercultural than anything rational.
However, it does offer an alternative payment system and in this case it works, so I won't complain about that.
But can we please let go of these childish fantasies that Bitcoin will overthrow all government and usher us into an anarchist utopia of voluntaryism and global human liberation? Those kinds of libertarian/anarchist pipe dreams were excusable during the very beginning of Bitcoin, when the protocol was still being sharpened and everyone was enthusiastic about this new idea.
I don't know what kind of world the author lives in where he thinks people posting textual descriptions of their conditions on the Internet, backed by a digital currency, will revamp the healthcare system into an anarcho-capitalist institution and turn government irrelevant? What bullshit. Do I seriously need to explain that writing about your condition isn't enough to get diagnosed with anything beyond the most rudimentary of advice ("This might be that, but I'm not sure. Go see a doctor and try this herb in the meantime to see if it stops.")?
Bitcoin will not render government irrelevant. You see, the thing is that even if the concept of Bitcoin theoretically can allow financial independence from the state, it's completely meaningless when your ecosystem is a mess. The Bitcoin ecosystem, as we have witnessed so many times, is absolute chaotic mayhem that can ironically only be controlled through state regulation, which many hardcore Bitcoiners are advocating for.
Homeschooling is opting out of the state? Uh, last I checked, homeschooling requires one to be registered with the state, as well as offer vigorous and regular checks with it to ensure you're in line.
The Silk Road isn't any different from your standard drug dealing market, only it's online and just as volatile and unreliable as the physical thing.
Look, Bitcoin is certainly capable of great things, but these here are just naive pipe dreams.
In the United States, we fought an entire war over the question of whether or not a state had the authority to secede from the federal government (the Union). The seceding states lost that fight.
It would be very hard to argue that individuals have that right when the states do not.
You may wish that it were different, but the fact is that individuals do not have this right, according to virtually any constitutional interpretation since the mid-19th century.
So wars decide what is right and what is wrong?
Philosphers may claim you have a natural right to buy and consume drugs the US government considers illegal, since you aren't harming others; you can then scream about your natrual rights from prison all you want.
You can give us the script for explaining rights and the state of nature. I'll tell you guys which of urandom, random, and arc4random to use. 'gruseom can give us a cheat sheet on what Albert Einstein and Pablo Picasso did and didn't say. Patrick can give us each a laptop sticker that says "raise your rates and never work for free". 'tzs will explain the secret trick for rolling the score over on the 1982 stand-up Galaga, and also the difference between first-to-invent and first-to-file.
Then we can all sub for each other. Maybe we can use a single account: 'tptzseominer11.
The point is you are going to be forced to live under the rules of another no matter where you live (I'm sure there are some Crimeans that would rather not be part of Russia or any other country). Bitcoin has the potential to disrupt the economy, but it cannot provide freedom of movement or freedom from taxation.
No, I'm hardly a statist. I'm just saying Bitcoin will not solve the problem.
tl;dr He probably got flagged for being a day old account (and being argumentative). I try not to say anything too controversial on here since I do not want to meet the same fate.
It seems incredibly irresponsible for a doctor to prescribe things based on an internet conversation without a physical exam. You can't auscultate (listen to with a stethoscope), visually inspect, run labs, do basic imaging, etc. over an anonymous internet forum, which are basic facilities that anybody should expect a doctor in the US to utilize. It is plainly evident, once you become involved in clinical encounters, that you discover things on exam that the patient didn't know about, forgot to tell you, or wouldn't be able to find themselves. These findings are often critical for diagnosis. Telling the patient to take a certain drug without that data is dangerous and irresponsible.
You could certainly offer general "advice", but this will never be a substitute for seeing a doctor. Perhaps interfaces with video and sound are able to up the bandwidth of internet medicine but currently there is still too wide of a gap between that and actually laying hands on the patient.
I was not surprised to find that this is exactly what the linked document of related policies by state medical boards states for New York (http://www.fsmb.org/pdf/InternetPrescribing-law&policylangua...):
Section 80.63 of the controlled substance regulations requires a practitioner to physically examine a patient prior to initially prescribing a controlled substance. Issuing a prescription for a controlled substance solely on the basis of a questionnaire or other medical history submitted to a practitioner over the Internet does not meet the requirement of a physical examination or establish a legitimate practitioner-patient relationship and is not a valid prescription.
I cannot find anything controversial about that. I am all for forums linking doctors to talk to more patients, even for payment, but keep the "MD" out of the name because this is not a true substitute for seeing a doctor.
Come to think of it, it's both!
I am not meaning this as a particularly anti-capitalist view, but I think there are areas of human existence where profit making should be excluded. For certain things, like fire departments, that battle was won long ago, and thankfully we are not in the days of ancient Rome where you would have to argue prices with Marcus Crassus before your house fire was put out. http://en.wikipedia.org/wiki/History_of_firefighting#Rome
No, and I don't think anyone is arguing that. But surely its better than doing nothing, which is the alternative for people who can't afford to visit a doctor?
As a commenter below put it so well, all of these responses are "a symptom of how we think about these kinds of problems being badly broken..."
Furthermore, I disagree that something is necessarily better than nothing. Wrong or incomplete advice can be much worse than no advice. Telling somebody it sounds like they have the common cold while missing out on the possibility of tuberculosis because the doc can't do a chest XRay, a PPD (skin test), run cultures, or listen to the lungs, is downright dangerous to that person and the people that they come in contact with. If a doctor then recommends the wrong drug to somebody based on incomplete information, the long term outcome can reduce or end a life.
This is why (1) medicine is already so heavily regulated (2) malpractice is such a prevalent concern among doctors and (3) it would only confuse healthcare consumers to endorse a second tier of medical care where the advice they receive might be "less right" than that of the first tier.
Here are some reasonable parallels to the dilemma you bring up:
- Plenty of people in the US can't afford to buy a car. Is it surely better to let them all buy cheaper used cars from foreign countries with crappy brakes, no seatbelts and no airbags?
- Plenty of people can't afford to buy meat as often as they'd like. Is it surely better to let them buy cheaper meat from unknown sources which hasn't been USDA approved?
It is this kind of thinking, the fear of missing that 0.01% chance of something serious, the fear of colleagues low opinions, the fear of lawyers and persecution- that perpetuates the current culture of doing as much as possible regardless of probability, adverse events or complications of those actions. You can't cough in an ER these days without getting radiated. You can't be a little short of breath without getting a chest CT. Surely there is a line to draw.
I agree with your overall premise that there should be a minimum quality level and regulations on any service. But I am not convinced that an online doctor (or even Watson) would be any more of a 'quack' than seeing a nurse practitioner/PA in a tiny clinic in suburbia.
How many old farmers have you seen drag themselves into clinic with their 2-year bone pain that turns out to be multiple myeloma? Would they have come to attention sooner if a virtual visit took 10 mins on their computer, rather than a full day in the city?
Hard to quantify, but I do believe there is a role for a "drive thru" option here. Not every symptom needs the full weight of an academic medical center. Every day in the community there are doctors prescribing based on only a conversation, and there's ample conditions when this is fully appropriate. When a simple answer isn't possible, referrals will undoubtedly be made. The biggest issue is establishing trust.
Now, this idea may be far from perfect. But comparing it to the existing system while having a blind faith in it is wrong. In our existing system patients don't have many options of checking what their doctor tells them; they are referred to doctors by other doctors and very often have no way of checking on the reputation (% of successful operations this doctor conducted, for instance). The current system is very inflexible and not consumer oriented at all. Consumer interests are sacrificed in the name of their supposed safety, without first giving said consumers options to decide what they actually want and consider safe.
"Imagine a future where renegade doctors shun licensing laws and practice medicine over the internet. They build up a reputation around an anonymous identity. Use public key cryptography to sign their diagnosis, reassuring the patient that it really came from them. It’s not hard to imagine this would create a demand for anonymous accreditation agencies. These agencies could issue exams and then use their digital signature to sign the credentials of doctors who pass the exam. Patients pay for these services in anonymous currency ― Bitcoin ― and pay fraction of the price they would pay to the government enforced monopoly."
Medical services are the place where in-person attention is pretty much generally needed, where consumers tend to be bad judges of their needs and so-forth. It's pretty much the point where the "disruption" paradigm breaks down.
Unfortunately, this paradigm seems to be the hammer that everyone applies to every problem today. Every scheme to make medical more efficient today, not just those of "crypto-anarchists", seems to hinge on giving consumer more choice when medical care is exactly where consumers are incompetent to make choices alone.
Assuming good , mostly automated process and a good expert system - this could be a way to offer highly accurate second opinion.
And it would be a perfectly legal service from the provider side.
[1]This could be used locally in the country, which is a nice way to augment/start a country medical system
As far as I'm concerned, students have a right to a high quality education because without one their future will be a trainwreck. Just because they're largely minors doesn't, to me, mean that their parents have the right to deny them a future in favor of whatever their personal reasons may be. Yes, this is an infringement on the 'rights' of parents, but I don't think parents have the right to treat children like property in the first place.
And yes, there are some parents who do a great job homeschooling; I'm sure of it. I've just never met them, and I was extensively involved in local homeschooling programs back in my home town, so I interacted with dozens of homeschooling families, hundreds of homeschooled kids, and visited some of the organized conventions and programs that involved thousands more. Too many of these people simply aren't qualified to teach a child from the beginning up to college age, even if they may have the legal freedom to do it.
As it relates to the article's premise: I also think individuals have a right to reasonable health because it is integral to their future. A nation full of sick people is going to be a nation with low productivity and a high tax burden from running things like emergency rooms. It is in our best interest to offer everyone affordable access to some basic minimum level of health care, and to do so in the cheapest possible manner. The author seems to believe that a comparison shopping website for doctors will deliver affordable health care to everyone, but I think he ignores a few essential issues that could make it impossible for such a website to deliver good results:
a) Even now, many people who need health care do not have regular access to the internet. This is in part due to the huge stretches of rural America, but it is also due to the fact that we have a huge homeless population and a huge low-income population, both of whom may not even be able to afford the equipment necessary to get on the internet. You certainly aren't going to propose giving them free equipment and internet access so they can go buy health care on a website.
b) It is arguably impossible to comparison shop for essential health care. You don't have the time to waste on it and you are emotionally/mentally compromised by the stress of your impending doom. To a degree, this is correct - you should be prioritizing your own well-being. It should be the responsibility of everyone else in the system to try and keep costs for this essential care to a minimum; instead, a profit-driven health system tries to maximize profit off this essential care, and deny claims to as many dying people as possible. Introducing more profit motive into this system does not seem like it will fix anything.
c) Medical practice over the internet without licenses is simply a recipe for disaster. I am willing to accept that a licensed doctor could perhaps perform a subset of their duties over the internet; I occasionally email my doctor instead of visiting them in person when I need minor adjustments to medicine doses, and that is fine - both sides are fully informed and no corners are being cut. However, if you're not even going to license them to verify that they meet the basest standards of medical competence, you'd be mad to also let them practice without ever seeing a patient in person. It's just a bad idea. We have enough issues with malpractice and patients being sold treatments they don't need as things are; removing licensing and medical standards will make this worse as both of those problems can be increased by a profit motive.
d) Comparison shopping for long-term health care seems nearly impossible since in many cases, if you discover the care you are getting is suboptimal, it is too late to switch - whether because of pre-existing conditions, or because the care is ongoing and transferring to another provider would put you at risk. You can't trivially ask to have your dying father moved to an intensive care unit across town just to save a couple thousand dollars, even if you CAN do it.
So the issue is that the parents are forcing a decision on the child, in violation of the child's rights? What if the child wants to be homeschooled?
I know a couple kids who preferred homeschooling, but mostly because it was easier than going to school. That was to their detriment later on when they started college. I don't know if that makes it wrong, though. Education is definitely not one-size-fits-all.
You could make the libertarian/capitalist argument that if a child is really lazy and wants to do highly relaxed homeschooling that won't prepare them for college, that's fine, and they can just accept never having a good job or lifestyle, I guess? I don't really like that.
If the parent prefers homeschooling but doesn't have the time/energy to do it right, is that similarly fine? Or do they have an obligation to deliver their children an adequate education, just like they have an obligation to feed and care for them (otherwise the kids will be taken away)?
I got very into programming, and when I was 18, I launched a Web site which succeeded wildly, and has been paying my bills ever since. I did fine on the SAT, and I had a 4.0 GPA during the year I spent in college. (I left after that to run my company.)
My feelings on unschooling are complicated. Knowing how it turned out, there is no way I would go back in time and make my parents send me to school. But I can easily imagine alternative outcomes where I end up dying in a ditch instead of starting a company. I don't think I would ever unschool a child myself.
But since I'm happy with how unschooling turned out for me, how can I support a law denying those potential benefits to everyone else? That's essentially a law against what caused me to be who I am. I'm fairly certain that if I'd been sent to school, I wouldn't have started my company. It was the result of endless hours of tinkering -- time I wouldn't have had if I'd been busy with homework.
It's a bit like doing a startup versus working a normal job. If you do the startup, you might lose all your cash and fail; but you also have a small chance of winning big. High risk, high reward. The job will give you consistent pay, with no chance of losing your hat; but also with no chance of a big win. Low risk, low reward.
High risk certainly isn't for everyone, but imagine a world where no one ever took risks.
Generally, that duty falls upon the parents and/or upon the state. The state attempts to fulfill its duty by attempting to provide high-quality public education for all children. Parents attempt to fulfill their duties by (1) providing their children with access to high-quality, public education; (2) providing their children with access to high-quality, private education; or (3) providing their children with high-quality education at home.
Many people disagree with the priorities of these duties (for example, whether the primary duty is on the parents or on the state) and many people disagree with whether any particular example of education counts as "high-quality" (for example, whether a particular teacher is doing a good or bad job at teaching a particular child).
Some people don't believe that children have a claim-right to high-quality education.
My opinion is that a child's claim-right to high-quality education is only violated when neither the state nor the parents provide this high-quality education. States generally provide public education in order to relieve parents from having to fulfill this duty themselves (because of cost or incompetence), while some parents choose to provide this education themselves or privately because they believe that the state fails to fulfill the duty because the education is not "high-quality".
There are people who fall outside of all of these groups as well, and I don't intend to dismiss them. Most people, however, fall into these groups.
With this interpretation of the claim-right of children to high-quality education, it is irrelevant whether the child wants to be homeschooled.
Here's a question: do children have a power-right to waive their claim-right to high-quality education?
I would really love to see tokenadult respond to this, because I know he has very strong (and informed) opinions on homeschooling.
Sounds like the solution is to: 1) Define what a "high quality education" means in terms that it is objectively measurable whether one is being provided to a child, 2) Assure that children, regardless of education venue (home, private, or public school) are receiving it.
Assuming that certain venues do provide a "high quality education" and that other venues do not -- in any direction -- doesn't seem particularly useful if that is a genuine concern rather than a superficial rationalization.
To me, the amount of criticism public schools receive is an indicator of their worthiness - people are able to inspect the education and intervene directly if they feel it is inadequate, and the government has the ability to provide useful oversight and assist in setting standards. I'm sure there are many cases where this centralization is to children's detriment, but at least it is a largely transparent system.
In comparison, the only real transparency provided into a homeschooled child's education is when they start college and have to find out whether they really learned enough essential skills and information to be able to compete in a real educational environment. If the answer is 'no', it's too late to do anything.
Objective measurements would be great, and so would more rigorous enforcement. Historically, homeschooling groups are against both.
But still, you're assuming that unqualified (according to whose qualifications?) people using unverified (by whom?) techniques are worse on average than public schools.
It's not easy to agree on what objective measurements comprise "good schooling," but I think most people will agree that homeschooling and public schooling both vary wildly in quality if we were to agree upon some objective measurements. It's not fair to implement policies for either type of schooling based solely on the worst examples of that type of schooling.
Many arguments in favor of homeschooling are about parents' religious freedom or about how the public school system has failed the children, and in both cases this does nothing to demonstrate that the parents are going to do a better job.
I do agree that objective measurements would allow this stuff to be considered rationally, but historically it's really hard to come up with useful objective measurements due to all of the different pressures involved.
I disagree. I think it could go either way, as I have no real scientifically valid evidence either way, but I think the burden of proof is on the party advocating using violence to prevent the other party from doing what it wants.
> Many arguments in favor of homeschooling are about parents' religious freedom or about how the public school system has failed the children, and in both cases this does nothing to demonstrate that the parents are going to do a better job.
True, but it also does nothing to demonstrate that the parents are going to do a worse job.
Sometimes.
Othertimes, its being done by highly qualified professional educators who are intimately familiar with their students and who spend a lot of energy on researching educational methods specific to their student(s), with far greater focus than when they are having 150 students passed by them each day on a conveyer belt.
Would I like to guarantee that no child is subjected to the former? Certainly. Would I accept the cost of preventing children from benefitting from the latter to do it? No.
> while public schooling is at least largely done by people who got teaching certifications and their methods get public scrutiny.
Yeah, and restaurants are at least subject to inspections for compliance with requirements of facilities and methods, whereas home cooking is done by unqualified people using unverified, quickly considered techniques.
But what I cook at home is consistently better than McDonald's, still.
Industrial mass production -- whether its of food, or education, or anything else -- is rarely of the highest attainable quality.
Um, good luck with that.
My post didn't actually say that the average homeschooling education is worse for children than a public school, but I do happen to believe that it is :) This is, however, not based on scientifically-gathered data, so I would welcome data to the contrary.
I can understand the desire to do the complete opposite of the public school system if you believe it is the source of all your woes, but it kind of defies rational logic to abandon things like objective measurements, professional training, etc.
No, that's exactly what being a minor means. One's parents have the right to teach one whatever values, facts and fictions they wish, while one is a minor.
But don't worry too hard about it: teaching is _not_ hard. Almost any parent who cares enough to homeschool is capable of teaching his or her children better than a public school would (which is not a very high bar to clear).
As for your anecdotal belief that the homeschooling families you encountered were incapable, I wonder if it was really your belief that they would not teach what _you_ think is true and correct.
You seem to think teaching is easy, which makes me wonder if you've ever even tried to do it. My time tutoring students in college definitely makes me skeptical of anyone who says teaching is easy, and none of the schoolteachers/college instructors I know say teaching is easy. It is hard work.
If you have interacted with this many homeschoolers and never met any you thought were doing a great job, this might indicate something about homeschooling. Or, it might indicate something about you.
We're not talking about perfection here either; if someone decides to apply a different teaching style, or is okay with being relaxed and letting their kids take a slow approach to education, that's totally fine! I'm talking about parents utterly failing to prepare their children for college and for adult life, and I've watched that happen dozens of times. It inflicts tremendous emotional and mental harm on the kids and can destroy a decade or more of their life as they struggle to make up for it.
I do apologize to HN for helping hijack the thread.
What about liability in case they're wrong? A coworker lost a relative last year because the doctor missed an obvious case of septic infection. How do you take an anonymous physician to court for a mistake like this? Hard to pay restitution when the injured party dies.
Now, for a price $10 I don't think anyone should expect any kind of liability. It's advice. If someone gives you a $10 take it as such and go see another doctor for $100 if you're unsure. To my understanding CoinMD simply provides what market needs: cheap accessible advice of reasonable quality. If you could sue doctors there, prices wouldn't be as low.