[gjem97]

It's a question of fundamental incentives. Doctors and hospitals are paid for procedures, treatments, and appointments. Is it any surprise that there's incentive to undertake these activities? You don't even need to believe that your doctor is greedy to understand that if there's a borderline case, they might order the test or treatment "to be safe", or "because there's no downside", or because "we have the available capacity". Even if they aren't explicitly considering payment as part of the equation, it's not unreasonable to think that subconsciously the monetary incentive will tip some of these cases in the direction of overtreatment.

IMO, the only way this is going to change is a movement away from the "pay for services" model that is dominant in US healthcare today.

[novalis78]

I slightly disagree - what's missing is price transparency inviting competition. Through competition the payment and cost side of things will be added to the equation and shift incentives to cut waste and increase quality of service. That includes all aspects of the healthcare services.

[shawndimantha]

It is probably both. The primary reason for healthcare cost growth is price not utilization (refer to work from IHME, others), but there also have to be appropriate incentives in place such as exist in ACOs to ensure quality care is delivered cost effectively. Agree that value based care by itself may not be the answer, just look at the way drug companies claim to price medications based on value such as Gilead’s Sovaldi curing Hepatitis C.

[lr4444lr]

Also that for the majority of people, a third party pays. The receiver of care only indirectly affected by slowly rising premiums, deductibles, co-pays, caps.

[merpnderp]

For most people it is actually a forth party pays. There's the traditional three party insurance system, but for most people there's also the forth, their employer. So not only is the receiver of medical care removed from any price sensitivity by their insurer, they're removed from much of the insurance price sensitivity by their employer.

Removing the ridiculous system of employers paying for health care and instead just paying people the money (come on, FDR's WWII salary fixing has been over for 70 years, yet its harm continues).

[shimon]

Patients also often want more stuff to be done. Humans evaluate treatment decisions as "let's keep trying vs. give up" not "I'd take on a 5% risk of complications for a 20% better chance of living another 3 months".

The complexity of these tradeoffs means that unusual choices are really hard to make well. This is most obvious in the expensive treatments that are sometimes applied before a patient's death -- expensive both in cost to deliver and harm to the patient's remaining days.