[stopadvertising]

The healthcare system seems to be optimized towards extracting as much money from older people as possible. I just hope we can move the ball forward and try to make it good at healthcare instead by the time I get old.

[colechristensen]

This assumes widespread bad faith, when I think the situation is much different.

The healthcare system is biased towards doing something . Patients want there to always be some action taken, and actions are found. Doing nothing seems like giving up.

[prepend]

Patients do want to do something. And the fact that doctors and surgeons and lots of other individuals in healthcare make much more money by doing something means there’s lots of inertia to action, even if it’s not the best or even useful.

I think the healthcare provider incentive is a more important factor since there is such a power imbalance. I’ve had numerous elective surgical procedures recommended. When I asked for non-surgical therapies I was told there are none. When I researched I found them and found other healthcare providers.

I’m pretty young and healthy so the bias for surgeons to recommend surgery seems really strong. Maybe it’s not sinister and it’s just a coincidence that a surgery costs $10-30k and physical therapy costs $1k to someone other than the person who is recommending.

[hestipod]

I was advised to have surgery I didn't need and it ruined my life. I will be ending it soon because of all the pain and loss and abandonment and not one of them will care or help prevent that outcome because they got paid. Nobody said "do nothing". They all advised surgery. They advised surgery multiple European doctors later said was never needed and wasn't appropriate. Every one of those doctors attacked when confronted about the outcome and necessity...called me a liar and mental and that the pain and disability was not real. They said I was just trying to get a big payday from them. Everything was about protecting their profits. From the moment I was victimized people started blaming me and trying to discredit me. Doctors, staff, their lawyers, administrators. They never admit fault and will cover each other's back. I have met many people like me...victims of this system. American hospitals and doctors operate for profits not as a public service. They don't get their big houses and fancy cars and status without that precious surgery income. It's very much about bad faith in the American Healthcare Business. People don't want to believe it and think because they haven't had their life taken from them that it's great and people like me are extreme outliers. The number THREE cause of death in America is doctors and hospitals killing people. But nobody cares until it's them. Bad faith is part and parcel with for profit anything and healthcare is one of the biggest for profit cabals on them all in America. Anyone who believes otherwise is just preserving their own income stream or sanity because they need to believe the system will be there for them. As long as "other people" are the victims then for most people it's all fine. I had a life...I had a future...I deserve to live safely and without pain...and I am denied this because they stole my health and means to earn. They made my value zero. Bad faith is their mission statement.

[ip26]

I will be ending it soon

I had a life...I had a future

Yes, but now you have a cause.

Ever thought about attending law school? Or some other related course of action? You can stand up for the other people like you. You could be for them, what wasn't there for you.

[hestipod]

I am not just playing emo and choosing not to go on because life is a drag. I have lost everything and everyone and live in severe pain and just existing takes all my energy. I have tried over and over again to work enough to have some sort of life but my body fails and that takes the mind with it. I was denied social assistance. Abandoned by family. Nothing has gone right since this was done to me. While I would love to help others again as I once did...I cannot manage myself and there is not sufficient help here. I want out of this country back to the only place I have ever really enjoyed living in Europe but I have not been able to realize that either. The last thing I have the energy for is something like law school. I'd need a lot more of Maslow's lower rungs secured before I could attempt something like that and I'd never be able to do it on a normal schedule. I am old and broken and on a thread. I have reached my mental coping limit after many years of pain and decline and abandonment.I need consistent help and stability in a healthy environment to survive. That has been denied and I have had nothing but the opposite. So there will be no survival.

[ip26]

I believe you, and I'm sorry. As a young father, it's hard to imagine how your family could abandon you. Yet of course they did, all the same. I offered purpose, as purpose is sustaining for some. But you are of course right- Maslow, after all, knew what he was talking about. I would help if I knew how. I hope you do not give up- there are people who care, even if finding them is difficult.

[djohnston]

Im sorry you're going thru this. If I may ask, what was the procedure?

[hestipod]

Orthopedic surgeries on lower limbs that was never needed...made even worse by another round of surgery meant to "fix" the first wrong one. The second was done incorrectly as well and was something different than I even consented to. This all created a lot of problems, new damage, and pain. Then the rest of the dominoes fell. Every system meant to protect and assist failed to do so. The doctors lied and their lawyers were more powerful. The disability system was adversarial and cherry picked the doctors lies whilst ignoring evidence I provided. The appeal went to the same judge who was hostile and denied me the first time. There was never any help throughout this. Nothing but failures and blame. After all if someone loses so often it must be them right? Then when you get depressed they retcon THAT as the cause of everything. That's what my family decided as they turned their backs. That I should have known and was somehow at fault. I would never trust an American doctor again, and hate this country and it's hatred for social systems, but I am trapped here now.

[neuro_image2]

Physician here. Really sorry to hear about your situation.

I can't comment on what happened before but there may be ways out of your pain. Have you explored all options in terms of pain management.

Spinal cord stimulators? Baclofen pumps?

There are several options for treating 'neurogenic' pain including MR guided focused ultrasound (for which there is a clinical trial going on now at the University of Maryland). Where are you based?

[hestipod]

I have tried multiple radiothermal sympathectomies in Europe to some effect, ruled out spinal cord stimulators years ago after talking to docs in Europe I trusted and patients who were unsatisfied with them (plus the cost is insane). Every procedure done in this country has made me worse or just cost me for nothing. I have no insurance. Fall in all the gaps for things. Honestly a low stress lifestyle with control of environment and temps etc is the best pain management I have ever had. Last time I was able to move to Europe and have a small flat in a place amenable to me and away from the assholes here I felt a lot better and managed without strong meds...meds which cause other problems, cost too much, and are increasingly difficult to access.

But my living situation now is very unstable and hostile and stress worsens pain and hopelessness. You can't solve that with pills and procedures. On top of that it's not as simple as "solving pain". I have lost all forms of security, have no family or social reliability, have obviously severe depression and anxiety because of all of this, keep taking more hits in all regards, and you can't just plug one hole while there are 7 others in the boat and an 8th about to blow etc. I will never have a full and good life, but a survivable one is possible just not accessible. I don't want to disclose my location online since I have been very candid about my situation as all I need is someone calling the authorities and causing me more loss of agency and massive medical debt. They won't help with what I really need but will 100% "help" by locking me up and feeling good about themselves.

I don't want more surgery or devices or procedures. I don't need more doctors. I have (actual not dramatized) PTSD about doctors and hospitals now. I don't trust them with the exception of two in Europe who actually helped me. Here the have never helped and have literally ruined my life. I need my basic needs secured and a peaceful and stable environment away from hostile people, in a place where I am not one emergency or major problem away from complete and permanent debt losing the tiny bit I have left.

[dennis_jeeves]

About 2 decades back when I was naive, I would have agreed with you. I have since then looked critically at the healthcare system.

>This assumes widespread bad faith, when I think the situation is much different.

There is really widespread bad faith and there is widespread incompetence. A near complete lack of integrity. ( there are always the physician/practitioner who is the exception, but they are rare.)

>Doing nothing seems like giving up.

This point to the competence aspect. In many situations doing nothing is precisely what is needed. In many types of cancer this is what is to be done. (I cannot be certain but this seems to be the case). Aggressive early treatment appears to endanger the patient more than inaction. No treatment is also 'doing something' and not to be confused with 'we-do-not-care' type of inaction.

[SuoDuanDao]

I think the American healthcare system has a particular issue as well - doctors are required to be salespeople. The skill sets needed to be a doctor and to be a salesperson seem immiscible in some ways.

[stopadvertising]

Why wouldn't you assume bad faith? In every interaction I've had with the healthcare system nobody has seemed to have good outcomes as the goal. It's never even discussed as a possible goal, much less implemented as a priority.

The doctors I know claim that they are good people and will treat anyone regardless of means, but they have also sent many patients into bankruptcy and suicide with five, six figure debts for minor procedures. That's not ethical. That is doing harm. It's either bad faith or sociopathy to ignore the fact that our life expectancy is going down every year, I'm not sure which.

[wwweston]

On one hand, incentives matter (reward improving care). On the other hand, incentives matter (markets are not known for keeping away from extractive practices).

Reward outcomes rather than fee-for-service?

[Gatsky]

This is on the money, it’s all about incentives. In Australia there is a public and a private health system. In public, the surgeons are paid a salary which is the same whether they do 1000 or zero operations. In private they are paid per procedure, with zero salary. The probability of getting an operation is very different for the same condition in public and private.

[refurb]

If you’re paid the same whether you do surgeries or not, wouldn’t that incentivizing not doing surgeries?

Less stress and less risk for the doctor.

[ineedasername]

Except they aren't necessarily paid more for surgery. That is a common misconception. Surgeries take time. Not just for the surgery, but the prep time before and then the aftermath.

-For example, a bit of searching shows an appendectomy takes about an hour. Lets add 1/2 hour onto that for prep & cleanup.

-Searching indicated about $900 to $1200 is the typical insurance payment to the surgeon. That's $600 to $800 an hour.

-Based on my own insurance claims, specialist visits are reimbursed from $200-$300. Average 10 minutes per visit and that works out to $1200 to $1800 and hour. (Non specialist annual "wellness" checkup/physical was reimbursed around $180 for $1080 an hour)

Certainly not all surgeries are necessarily the same, so rates may vary and there could be more or less $/hour, although the same goes for office visits. As such, doctors already are paid roughly similar, or close enough that concerns of pushing surgeries for the $$$ probably don't need to be a huge worry.

[Gatsky]

No. Doctors are not bureaucrats. They have a 1 on 1 relationship with a patient and they do want to help them (this fact seems lost on many people). You don’t need to incentivize them to do the right thing, it is more that perverse incentives interfere with how things should be, for example performing pointless revascularizations.

[tootie]

I think that's not a valid conclusion to draw from this. The stent procedure has been considered the gold standard for quite a while and doctors have not had reason to question it until right now.

[astura]

They had a reason to question it, the evidence of stent overuse has been piling up for at least a decade.

https://www.vox.com/science-and-health/2017/11/3/16599072/st...

[Merrill]

IIRC about half of medical expenses are incurred in the last 18 months of life. That would be around $1.6 trillion annually.

[prepend]

That seems normal since so many people die at the end of their life. You wouldn’t expect expensive, life saving procedures to take place in the middle of people’s lives.

Since many don’t succeed those costs pile up and count in your stat. But many do succeed do people’s lives are extended.

[ip26]

Google suggests it's about 10% (for the last 12 months)

[Gustomaximus]

A quick google and a few articles seemed to agree E.g.

"Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan"

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017....

[mgarfias]

I’m checking out before I get there

[ineedasername]

You can't: As long as you live past 1.5 years, you'll always have a "last 18 months" of your life ;)

[mgarfias]

I meant before I get there as in before the costs to keep me alive go eat the hell up

[ineedasername]

But how would you know? You could be a healthy 74-year old and think, "well now is the time, before I go down hill". But you could be cutting off 10 or even 20 years of life in decent health.

Or you could wait until you start to get sick, but how would you know it's not just short-term? You could have a case of pneumonia but recover in a month, and again go on for another 10 years. I've seen a fair number of elderly be sick for most of a year and still come out of it: A relative recently passed at 94, but around 86 she had some serious health issues, and her fate was very uncertain. But she beat them, and had another 8 years where she took great joy in seeing multiple great-grand nieces & nephews born, swim in her pool, listen to her read them stories, etc. They were some of her happiest times, but would have never happened if she'd been trying to beat the 18-month decline.

[mgarfias]

Because dementia runs in mom's family. Shes getting it and is aware of it, so if I get it I should be aware of it also. At some point its time to pull the plug.