Incentives matter: America's for-profit medical industry thrives on massive wastage, unnecessary procedures, overbilling and overtreating

boing
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I agree with much of the article, but I will say that many of these expensive procedures have small positive benefits. (Every so often, those expensive tests do discover something life threatening.)

From what I’ve seen, most Americans aren’t prepared to see their health jeopardized in order to save health care costs. HSA’s that don’t cover procedures that eventually result in preventable deaths are pilloried.

Single payer is the obviously sane alternative, but I’m not at all certain that the majority of insurance-owning Americans are willing to accept even the minor sacrifices in health outcomes that such a decision would entail, especially since the much of the savings would (should?) go to covering the uninsured before dropping what healthcare costs them.

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You seem not to be aware that the US system delivers clearly worse outcomes. Moving to single payer would be an unmitigated good.

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From an average perspective, yes. But for the reasonably well-insured? They have marginally better outcomes than their Canadian counterparts. (At least from a few years ago when I did my research.)

Perhaps my attitudes are informed by the Americans outrage against HSAs, which I considered to a step towards sanity. After all, what is single payer, if not a giant HSA from which there is no appeal, short of leaving the country?

I’m not certain unmitigated is the right word. It would be a welfare-improving change. There are lots of Americans who would have slightly worse outcomes, and a few who would have significantly worse outcomes. (Of course, there would be huge numbers who would have better outcomes, but unmitigated implies no exceptions.)

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So what?

Your concern for the wealthy is touching, but do you really not think that insurance - private medical insurance - is a thing in the rest of the world? News flash: it is. I have it. It’s kind of pointless, but has been marginally useful in one niche area for me. There are also these things called “planes”. They’re like magic carpet rides, which convey you any where you want to go. Like, say, Thailand. Or America.

There are lots of Americans who would have slightly worse outcomes, and a few who would have significantly worse outcomes. (Of course, there would be huge numbers who would have better outcomes, but unmitigated implies no exceptions.)

This is straight up Bull. Shit.

lifeexpectancygraphic.jpg3748×4252 2.89 MB

Stop looking for the cloud in the silver lining. And, seriously, get out of that fucking bubble you’re in.

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So what? You used the term unmitigated, which means unqualified or absolute. And then you dismiss the fact that there’s a qualification! English, man!

It’s also indicative of a far more dangerous malaise, which is if a policy is favoured, then it can have no trade-offs. Every single individual must be better off, or, anyone who is not better off is a non-person.

That poison is plentiful on the right, which frankly, I don’t care about. But it’s becoming more plentiful on the left, and that is a big problem, because there has to be somewhere that actually looks at policies and is willing to acknowledge all the realities, including, inevitably, the costs to that policy.

It’s gotten to the point that there are people (or at least posts) who don’t seem to be able to conceive of the fact that one could acknowledge costs to one’s favoured policies, and therefor must be supporting some other policy on the sly.

I do NOT support the availability of private medical insurance as a supplement for universal coverage, except in areas where the universal coverage does not apply (travel insurance, for example). I think the availability is corrosive, and leads to decreased population support for the base medical system (which it turn becomes even less attractive) until you basically have the American system lite.

However, that does lead to a universal HSA with no appeal. I support that. Why? Because the long-term benefits of such a system are much higher than the costs.

But that doesn’t mean that there are no costs.

I personally am doing well enough that the portion of my taxes that go to healthcare would support a fairly reasonable American style health insurance (if purchased through an employer) and would avoid things like a 3 month wait for non-life-threatening MRI, longer waits for doctors, etc. Why? Because the taxes I pay cover a lot of my fellow Canadians healthcare that they could not otherwise afford.

But that doesn’t mean that personally I wouldn’t be financially better off under an American system.

Honestly, if you can’t find anything to learn from systems you don’t favour, then you are probably more in love with the concept of your system than the actual outcomes. And that’s a terrible place for the left to be. Leave the mindless tribalism to the right.

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Actually, talking people into getting their five-year-old’s ears pierced so you can charge $1,877 is an individual doing the wrong thing, not just an effect of the system. The effect of the system is creating individuals who see this as normal.

Actually this is a relatively inexpensive procedure (in Canada it’s billed at between $350 and $450) that can be done while you are awake or with mild sedation. The fact that it’s extremely expensive and require general anesthesia in the United States is a product of the system this post is describing. Going for a colonoscopy when only a sigmoidoscopy is required is another.

Well, unless their insurance companies decide to stiff them and they go bankrupt. Unless they go to an emergency room and get directed to another and another because of network rules. Healthcare in the US is precarious even for the insured. When you average the outcomes of cases when everything went well in the US and compare that to the average outcome of all cases in Canada, of course the US does better. But life expectancy in the US is falling and infant mortality is rising. The idea that the average american has something to lose is unsupportable.

The American government pays more per capita for healthcare than any other nation. Under the American system you would be paying more taxes to provide healthcare to those unfortunate people who couldn’t afford it, despite the fact that it wasn’t being provided, and despite the fact that you would also be paying privately for your own healthcare either directly, through your employer or both. It’s worse outcomes at higher costs.

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Hate to break it to you, but 3 month waits for non-critical MRIs is a pretty typical wait time in the US. And I can guarantee that you would be worse off financially if you had to buy insurance through your employer. We pay about the same in overall taxation as Canadians, but then pay on top of that for health insurance. Dog forbid you actually have need to use that insurance. Between co-pays, deductibles, yearly coverage limits, caps on what the insurance company will pay and over-billing by physicians, you could spend thousands of dollars out-of-pocket each year over and above what you have paid into insurance premiums. If you get cancer, you will most likely have to file for bankruptcy at some point during your treatment course. Then the cherry on this shit cake is the quality of care you receive for all this money is far too often worse than mediocre.

I have to agree with @JonS that single-payer would be an unqualified good for US citizens. If you’re at all interested in how bad health care really is in the US, just ask any of the hundreds of Americans commenting on the BBS instead of arguing with a guy from New Zealand.

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I have recently been thinking about evil after reading M Scott Peck’s People of the Lie.

I actually do believe that there is an evil component of our healthcare system. That evil stems from the fundamental dishonesty and incompatibility with medicine’s purported aim of healing people.

The death and destruction brought about by profit seeking and the viewing patients as revenue streams is undeniable. Because it is so spread out, hard to understand and abstract it can continue.

I especially feel for the healthcare providers who are trying to work in good faith in this system.

In Going Postal, by Terry Pratchett, Mr Pump points out that Von Lipwig has essentially murdered people by defrauding them.

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I remember reading the essay by Kevin A Carson regarding how US healthcare has all kinds of waste. For example, hospitals will buy various machines to do scans and tests because they incentivize doctors to use defensive rather than empirical medical diagnosis (the former basically does a scattershot method of tests to understand what’s actually going on and the latter takes what’s established in the presented symptoms to decide the course of treatment). And this is despite the fact a neighboring hospital or clinic might have the same machine and charge a similar or lower price for the scans as well. They basically keep as much as possible under their control. Conversely, hospital management will try to undercut labor in the form of staff every time because it’s hard to bill in the value of their labor whereas people seem to be more compliant with bills loaded to the brim with tests and medicines. Basically, they take the old GM business model and bolt it onto healthcare (I think he has the essay on his blog somewhere that explains this better than I could). So obviously the the business model is doomed to failure unless governments come in to bail the hospitals out.

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Von Lipwig, thankfully, grew a bit of a conscience eventually. I don’t expect the players behind our healthcare system will any time soon, unfortunately.

As an interesting aside, looks like BB’s comment system blanks out Von Lipwig’s first name if you try to type it. Funny. And kinda weird.

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■■■■■? Meowist? Maoist?

So it does. Is it that new? What other words does it work on? Hmm, doesn’t seem to work the first five common swear words I thought of, or even on “Santorum” or “Belgium”. How about “moîst”?

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It is a travesty that you can say “Belgium” when it blocks more innocuous words like the one in question.

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Tying up Emergency Department resources to address a minor sore throat is not a sane response. Emergency Departments are for, you know, emergencies.

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Why “Medicare for all” gives me the screaming heebie jeebies. (NB: none of the hospitals mentioned are for-profit)

http://www.modernhealthcare.com/article/20171125/NEWS/171129969

THE TAKEAWAY
Payment shifts and regulatory mandates are putting hospital Medicare margins on a slippery slope.
While Medicare has never totally covered the cost of care, hospital executives say the chasm between the two has widened in recent years due to a number of factors: federal mandates to deploy expensive health information technology systems under the meaningful use program, a 2% across-the-board cut to provider Medicare payments under the Budget Control Act of 2011, reductions in Medicare disproportionate-share hospital payments and the move to alternative-payment models. Layoffs and reductions in services have been common coping mechanisms to avoid the income drop.

David Ramsey is in a dark place. Despite running West Virginia’s largest hospital, a sense of dread has grown about the facility’s future.

“There is no light at the end of the tunnel other than another train,” said Ramsey, CEO of Charleston Area Medical Center. “There no reason to feel optimistic.”

Ramsey, and many of his C-suite peers, are grappling with that fact that Medicare margins are in a free fall. In 2015, the aggregate margin hit a negative 7.1% across hospitals, according to the Medicare Payment Advisory Commission; margins are expected sink to a negative 10% this year.

Charleston Area Medical Center has been hit particularly hard, especially since 20% of West Virginia’s population is on Medicare, one of the highest rates in the country.

The hospital plans to cut 300 jobs by year-end. On top of that, there are plans to close a wellness program, one of its community-based pharmacies and a pulmonary rehabilitation program.

It’s a similar story in Iowa where Todd Linden is CEO of Grinnell Regional Medical Center.

Last year, Grinnell Regional closed its outpatient mental health clinic. The system has reduced its workforce during the past five years by nearly 20% in an effort to stay afloat. For decades, hospitals could rely on rising commercial reimbursement, but those raises have stopped as insurance companies struggle with their own thin margins.

“There is no silver lining from other payers,” Linden said.

Having a payer mix where 40% of patients are covered commercially has been a lifesaver for New York-Presbyterian Healthcare System, according to CEO Dr. Steven Corwin. It’s why he gets nervous whenever the idea of a Medicare-for-all single-payer program gets bandied about.

“The 150 million or 160 million people with employer insurance support the entire healthcare system,” Corwin said.

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Recently went in with abdominal pain, got put under more than once but ended up not cut open. When all was said and done, the hospital submitted and resubmitted one of the earlier prcedures for payment, and my insurance decided it wasn’t worth doing, and I’m the one who got stuck with the bill.

So we lose out as individuals (situations like mine) and as a society. (highest costs and worst bang for buck)

I wish conservatives weren’t so worried about spiting others, or that they really cared about long term costs so that we could just get to single payer and reap all the collective benefits. As I veer further off the immediate topic, it really irks me that they’re trying to pass a tax plan that skyrockets debt right before the now yearly looming shutdown where they traditionally say that the debt ceiling is too high and the sky is falling.

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I am not a medical professional, so I don’t feel qualified to comment on the seriousness or otherwise of anyone’s symptoms. However, it does appear that the US health system is uniquely geared towards encouraging patients to ignore symptoms as long as possible until minor ailments do become medical emergencies, at which point health facilities are obliged to treat them as such.

There is a difference between hating the game (which you absolutely should) and hating the players who game the system they’re forced to be a part of (which you should not do).

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You used the term unmitigated, which means unqualified or absolute. And then you dismiss the fact that there’s a qualification! English, man!

I used the term "unmitigated good’ which is semantically distinct from “unmitigated perfection”. Don’t let perfect be the enemy of good. Reading, man!

It’s gotten to the point that there are people (or at least posts) who don’t seem to be able to conceive of the fact that one could acknowledge costs to one’s favoured policies, and therefor must be supporting some other policy on the sly.

To paraphrase your position, as it applies to US healthcare, it seems that you’re saying that providing poor people with adequate nutrition is a bad idea because they’ll have to spend more on toilet paper. Which, spoiler alert, is an absurd thing to worry about.

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You are not at all wrong with this comment. Did you know most of our insurance plans either don’t cover or barely cover preventative medicine?

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Given the wide variety of treatment in the US, “typical” is almost meaningless. However, Corey’s thesis here was that a large amount of US healthcare spending is spent on overtreatment, which I agree with. Your claim is that there’s under-treatment even at the well-insured level.

My view of US health-care at the upper-middle range (programmers, etc.) is coloured by my peers working in the States, whose health-care was what I’d call ‘Lexus’ to my ‘Corolla’. In other words, about the same outcomes, but it was a somewhat nicer ride for a hell of a lot more money. Now most of my investigation was in the ACA-fight era, so maybe things have gotten much worse for them recently.

Many Americans have a very different utility function than I do. Health outcomes per dollar of expenditure are definitely higher in Canada, but many Americans value things like choice, being a world leader in medical advances, etc and are not as concerned that everyone is covered.

As expressed by voting results (and not just presidential results), Americans have a different culture than the rest of the world. Thus I’m loath to tell Americans that they have nothing to lose. I would have nothing to lose, but I don’t believe in cultural imperialism in any direction.

I will say that universal medical care is an ethical imperative, but that’s totally different from what people would consider good. After all, there’s almost certainly an ethical imperative for me to distribute my wealth to the truly poor across the planet, but I wouldn’t consider it “good” if it was forced upon me.

I’d agree that the average American would have better health outcomes under single payer. However, I’m not certain where the cut-over is. Maybe 60th-70th percentile? While its fun to blame evil cabals, the reason why ACA was the best that the Democrats could come up with was Americans. I think single payer will come, but it’ll come over decades of engaging and shaping American attitudes, not by assuming that huge numbers of Americans are stupid, or even worse, the enemy.

Unmitigated perfection? What’s next? “Most unique”? :slight_smile:

Anyway, my argument wasn’t so much about English as the attitude that because I see it as a good (and I would see it as a good), there can be no cost or argument against it. If I cannot understand people who stand against my policy, then I am no longer of any use to promulgate that policy.

And for some policies (kicking kittens is bad), that’s fine. I’m uninterested in persuading people that its bad if they think so. But for health-care, where things can only change if millions change their mind, if I’m going to offer even my trivial help, I’ve got to understand the benefits they’re getting from the wrong policy.