[amsilprotag]

I guess McKinsey erred in accepting the work from Purdue, but it seems like the consulting provided was obvious and likely overpriced. More at fault, in my estimation, is the AMA and other physician standards bodies. Propublica released a search tool [0] last year based on Open Payments Data [1] and the numbers are ridiculous. My small state shows 10s of physicians receiving over $100k over the recorded 2013-2016 period and a very long tail. Many on the list are orthopedic surgeons and psychiatrists.

[0] https://projects.propublica.org/docdollars/

[1] https://openpaymentsdata.cms.gov/

[arkades]

Know that Gell-Mann amnesia effect that comes up all over Hn?

As a physician, former health insurance exec, and guy with a graduate degree in health policy: propublica deserves deep skepticism.

[dhbradshaw]

This is worth drilling down on. What types of errors should one expect and what are their causes?

[arkades]

Largely they lack context to interpret what they’re seeing. One that jumped out at me a while back:

They were showing physician payouts from Medicare and presenting them as though they were salaries. Problem: some specialties carry overhead in their Medicare payout.

When your cardiologist prescribes you a blood pressure medication, that money goes to a pharmacy, not to the doctor. So your physician payout is X (cost of visit.)

An oncologist prescribing you a chemo infusion, however, has to buy that infusion from the pharmacy. Medicare then reimbursed doc Z (cost of the drug plus a couple of percentage points). Docs Medicare payout looks like Z; his take-home salary is actually about 0.03*Z.

The failure to distinguish between these meant that PP’s data massively over-inflates these specialties’ salaries. PP just presents them at face value.

Or another: hospitals rarely charge their publicly posted prices. The vast majority of their pay comes via rates negotiated with insurers. PP loves to post their public numbers and go on about high variance numbers without any recognition that those numbers are in no way pegged to the actual negotiated rates. PP presents them at face value.

Largely, PP just doesn’t ever seem to dig deeply enough to find the nuances and caveats in their data, to find how they relate to the actual underlying questions that they -superficially- seem to answer, like “how much are hospitals charging people for this procedure?” or “what kind of money are doctors taking home?”

[klenwell]

Here's the introduction at the top of the ProPublica page cited by the GP:

Pharmaceutical and medical device companies are required by law to release details of their payments to a variety of doctors and U.S. teaching hospitals for promotional talks, research and consulting, among other categories. Use this tool to search for general payments (excluding research and ownership interests) made from August 2013 to December 2016.

https://projects.propublica.org/docdollars/

That seems like pretty fair context. You seem to be referencing a different article about Medicare reimbursement without actually citing it. That's a dodge.

If the medical industry requires reams of context to understand its practices and pricing, it's largely because pharma, insurers, medical groups, and individual providers often go to obscene lengths to obscure their practices and pricing.

I'm not going to waste skepticism on ProPublica that could better directed at the American medical-industrial complex.

[arkades]

> That seems like pretty fair context. You seem to be referencing a different article about Medicare reimbursement without actually citing it. That's a dodge.

I'm not dodging anything. I'm pointing out that when I bother to read their articles, they repeatedly get things wrong. The whole point of the Gell-Man effect is: "I read things I'm an expert on. They get those things really wrong. I am skeptical when they continue to write (on that topic) and (other topics), because why would they get other things any more right?"

I'm not an expert on the nuances of the pharma payout reporting. I am an expert on health care policy, health insurance, and clinical practice. Everything they write related to that, that I have read, tends to be off-base. If they regularly get healthcare stuff wrong, then yes, I apply skepticism to them writing about closely related topics which I may not have the same expertise in.

> If the medical industry requires reams of context to understand its practices and pricing, it's largely because pharma, insurers, medical groups, and individual providers often go to obscene lengths to obscure their practices and pricing.

(a) Any data of any complex, multi-component system requires reams of context to understand. This is why "domain expertise" is considered one of the key components of a competent data scientist.

(b) Our system is complex in part because >60% of our healthcare dollars derive from either federal programs, state programs, or an intersection of the two, which means they come with piles of regulatory things that complicate the issue.

(c) Our system is complex in part because we have a free market system, which is a fractured, multi-actor system (as opposed to a single-party-system). This means cash-flow gets complicated by the fact that reimbursement flows to lots of different interacting groups with dis-aligned interests.

(d) Our system is complex because we have a privatized insurance system, which puts a for-profit actor between the consumer and the physician - and one who, in partnering with certain provider groups, specialty pharmacies, etc. effectively channels the demands of the consumers into preferred paths - preferences determined by negotiated rates.

(e) Pricing tends to lack transparency because the vast majority of healthcare dollars are via these third-party insurers, who each negotiate separate rates with providers. Everyone involved in these negotiations has an incentive to not let their negotiated rates become widely public.

If your need to point a finger of blame undermines your willingness to understand the complexity of the system, you only do a disservice to yourself. The system doesn't get simpler just because you don't like its outcomes - and attempting to modify it without understanding the interacting components is doomed to massive unintended consequences. Or, in short, don't tear down the fence until you understand why it was built.

>I'm not going to waste skepticism on ProPublica that could better directed at the American medical-industrial complex.

That's a false dichotomy.

People providing inaccurate reporting that is critical of an industry don't become more accurate because you are also critical of that industry. That's just rationalization: "these guys must be above criticism because they validate beliefs I already hold."

You could be skeptical of both parties. You could be skeptical of the medical industry and shitty reporting on the medical industry. You could be skeptical of FB and NYT's recent obsession with it. You could be skeptical of etc. etc.

[amsilprotag]

Looking closer at the data, almost everyone is receiving small travel, lunch payments. Many of the higher earners are receiving large sums for "Promotional Speaker/Other", "Consulting Fee" or "Current or prospective ownership or investment interest".

Comparing 10 or so names in the source data with the Propublica data, often Propublica has identical amounts and trasactions as the Open data, a few times Propublica's dollar amounts and transactions are higher. This might be evidence to support arkades's claim, but I can't be sure since I don't know the exact methodology.

[yeahitslikethat]

They also get paid to speak about drugs. Thousands of dollars per lecture and interestingly the only people in attendance at said lectures are the physician and a drug rep and the venue is a restaurant.

[JumpCrisscross]

> propublica deserves deep skepticism

Seconded. One of their journalists, Jesse Eisinger, quoted a paper to back a particular claim. I found the paper and discovered it said the opposite. Figuring a skimming mistake, I e-mailed Mr. Eisinger. The response was a brief dismissal, nothing more.

[whyisthewhat]

Very often "Gell-Mann amnesia effect" is invoked to mean "this story is complete rubbish" when what is actually meant is "I have a different, not necessarily correct, and very possibly self-interested interpretation of the facts"

[arkades]

In the interest of not getting unnecessarily combative:

I can't tell whether your comment was stated in a tone of "I generally think Gell-Man amnesia effect is misused on HN," or whether you meant it to directly criticize my comment.

Please clarify, if you don't mind.

[yeahitslikethat]

Also deserving of skepticism: doctors who accept money from big Pharma.

It motivates over prescription. That's a scientifically proven fact.

[bitL]

One of my doctors refused to give me a prescription for a 25mg version of a medication over a 5mg version (pill could be cut in pieces and still as efficient), as the lower dosage was classified as "cosmetic", commanding 50x higher prices/mg, whereas the higher dosage was "life-saving", therefore cheap. Then I went to another doctor and experienced the same. The same doctor was recommending me to buy the higher dosage and split it into pieces just 2 years ago.

[arkades]

He probably got burned at some point and got scared. We get reviewed a lot more these days.

"You prescribed a 5x higher dose than he needed!"

"But I told him to cut it in five."

"That's not what you wrote in your documentation?"

"Well, if I wrote that in the documentation, it would have been documenting my own insurance fraud. I had to write that it was for (condition that requires 25 mg)."

"Did he have (condition that requires 25 mg)?"

"No, he had (condition that requires 5 mg)."

"So, which is it? Did you commit insurance fraud, or did you write him the wrong dosage?"

One is insurance fraud, the other is malpractice.

Why is it the doctor's fault that we're stuck in the middle of this shit system? Do people not understand that we aren't in control? The insurers, the federal regulators, the combination of the two, (Medicare), the state regulators, the combination of those two (Medicaid), congress, etc. They're in control. It's a happy day when our hands aren't bound from the start of our day to the finish. Don't blame us because we're the face you interact with.

[yeahitslikethat]

Are doctors doing anything to end the requirement that patients get prescriptions for drugs? What are you doing to change the system? The AMA lobbies congress to keep it broken in the favor of doctors and detriment of patients.

Doctors control our right to live. It's contrary to life, liberty, and the pursuit of happiness, because we must get your permission to live.

[arkades]

> Are doctors doing anything to end the requirement that patients get prescriptions for drugs?

(A) Physicians are not some monolithic block. Whatever ones stance on the AMA, they are a single lobbying group. They are not the collective noun for “doctor.”

(B) I, personally, do plenty. I left health insurance for clinical work because I saw how few healthcare leaders understood how to forge more effective care models in the current landscape, and I wanted to do better for people.

(C) I am unaware of any movement among physicians to give people unfettered access to prescription medications (not to say that I’m omniscient - such a movement may exist outside my knowledge.) I would not support such a movement if it existed; it would do massive harm to the public.

[bitL]

The explanation I've received was that they don't get any money from the higher dosage from insurance company and as I use it for "cosmetic" reason, I won't get the cheaper one.

[arkades]

Doctors don’t get money from insurers for drugs one way or the other, barring infusions (think: chemo.) An explanation that involves the doc not getting more money from the insurance company sounds like it may have lost something in translation.