[eldavido]

This is completely a story of industry structure and bad incentives, and how people react to them.

Currently, in the United States, we believe all of the following things: (1) Human physicians, are the only qualified parties to diagnose, treat, and/or recommend courses of action related to health (not nurses, physician's assistants, computer programs, etc.), (2) everyone has a fundamental right to healthcare, (3) health professionals must undergo expensive, lengthy, difficult courses of study and training, and (4) we reimburse for procedures, not pay for outcomes.

Given these incentives, it's not hard to see why doctors are some of the most overworked, stressed-out, and generally miserable professionals out there. They're at the nexus of a crushing conflict between keeping people healthy, a management system that demands more revenue (and remember that revenue=procedures, because we reimburse for procedures, so the only way to increase "productivity" is to do more, faster, with fewer breaks and longer shifts), and a legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study.

I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. I believe this outcome is inevitable, but will take a decade or more to surface, because it requires major shifts in how doctors and insurance companies think about billing, greater human trust in computers and recommendation systems, and a collective realization that the current state of healthcare is untenable.

[idiot900]

> greater human trust in computers and recommendation systems

I am an MD and have a degree in CS. Expert systems are not remotely there yet for this purpose. On no planet would I trust care of my patients to a computer. Far too many subtleties involved in accurate diagnosis and treatment that are not encoded in a machine-readable format.

> legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study

Good reasons for this - it actually takes that lengthy course of study to safely perform many procedures, and, more importantly, to fix things when they go wrong.

NPs and PAs are helpful but based on the quality of care that I personally observe they should not function without physician oversight.

There is no escaping that medicine is an extremely complex field, and it is only getting more so. Not long ago, many of the people who today are restored to their usual state of health would simply have died. The sicker a patient is, the more complex and difficult to manage they are. By definition a doctor is the one who is able to do so.

I am still waiting to meet a patient who comes to the hospital and prefers to have their care rendered by non-physician providers over physicians, or would even settle if there were an option.

[HIbachikabuki]

It's not that simple. A society cannot afford the triple-A gold standard of everything for everybody. Not everybody can live in a McMansion and not everybody can afford to have an MD/CS for their every single health need, no matter how minor or how routine. Tradeoffs have to be made.

US medicine has been very successful at creating a guild system that's prevented lower-cost provision of care for decades, all under the concern of "it'll lower the standards of patient care." End result has been millions of people who can't afford medical care at all.

One anecdote: for a time I was splitting living in the UK and the US and had health care experiences in both places. It was fascinating to see the differences in treating my (very ordinary) health issues. One time I came down with a mild rash that rebounded a few times before it finally went away. In the UK, the GP looked at the rash, punctured the pustules with little pokey thing so they'd drain, and they cleared up in a few days. In the US, the dermatologist wheeled in a big machine filled with liquid nitrogen and froze the pustules; they went away in a few days after that too. End result the same; cost to administer - orders of magnitude different. In the US, it seems like there's no medical treatment that we can't make more expensive by requiring more specialists with more years of training, using ever more expensive machines and medications.

I love modern medicine. My dad's a retired doctor and I almost became an MD myself. But the system we've created has costs out of control while simultaneously creating worse societal health outcomes than other countries.

[idiot900]

> It's not that simple. A society cannot afford the triple-A gold standard of everything for everybody.

The society in question has not realized it.

> US medicine has been very successful at creating a guild system that's prevented lower-cost provision of care for decades, all under the concern of "it'll lower the standards of patient care." End result has been millions of people who can't afford medical care at all.

Even the bottom rungs of the doctors in the "guild system" are not very good - lowering standards even more is very hard to agree with when push comes to shove. Especially there is no guarantee that this will actually lower costs to society.

But I guess this is what will have to happen, at least in primary care, because that is a miserable field that I am incredibly glad I didn't go into. I hope that at least some kind of care turns out to be better than none at all.

[nathanvanfleet]

I like people from the US who want to cut out people poorer from being helped by an MD because it's "impossible"; when so many other developed countries seem to manage with it just fine.

[throwwit]

I'm still amazed some want to go back to a system that charged them more for marketing it to themselves than actual care-- boggles the mind.

[eldavido]

> I am still waiting to meet a patient who comes to the hospital and prefers to have their care rendered by non-physician providers over physicians, or would even settle if there were an option.

Attach a price tag to each and find out. Maybe someone who couldn't afford a $500 consultation with an MD could settle for a $250 or $100 consultation with a PA, or an expert system. You really don't know until you experiment, and find out.

[idiot900]

True, that is the experiment to do.

It is not without ethical concern though. Unfortunately, most patients are not sufficiently informed about medicine to make a rational market choice. (Indeed, outside my specialty, I am not really either, and would seek the advice of a trusted physician friend, which is a luxury most don't have.)

For example, the PA and expert system would not reliably know when they are in over their heads and require an MD. Some subset of people would suffer serious injury or death through no fault of their own other than not having had the information necessary to allocate their funds in a manner most benefiting their interests.

[hershel]

There's some research that at least some expert systems("decision support system") implemented in the right culture do improve medical services[1].

But still due to huge resistance by doctors, who like the autonomy of the job, such systems are rarely used.

I could only imagine how rapidly such systems would improve if the backbone of medicine would be dependent on them, and enough revenue would be shifted towards them.

[1]http://www.ncbi.nlm.nih.gov/pubmed/24573664

[vacri]

give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles.

They are not tried and true. A friend of mine worked as a QA engineer at my city's most prominent children's hospital (a minor power on the world stage). His thankless task was to find ways to improve communications between departments and curb the errors. It was simply not possible - every doctor had their preferred provider, sometimes from merit, sometimes because they liked the shiny goodies that the sales reps brought.

All the individual systems interoperated very poorly, and none of the physicians would budge, and the hospital administration could not force their hand. Any time admin tried to regularise something, the affected physician would just state "If we make this change, children will die". It didn't matter that everyone at the table new that this was a total lie, because the official authority for that department (or speciality) was that specialist. They got their 'free market', being able to use their preferred products for each individual specialist, for personal preference at the cost of better overall treatment. The whole was very much less the sum of its parts.

Another friend became a sales rep for a pharma company. The rep she took over from was a fairly standard rep, but she was quite ethical, and would only allow her 'freebie' budget to be used on things that developed the practise. Some doctors already do this. Others were more like "ah, well, the ride is over with this rep". Some were absolutely outraged that she should dictate to them what this 'extra income' was spent on - how dare she suggest medical charts instead of football tickets?

I myself have personally seen a specialist in a field report on some clinical studies so badly that we technicians had to go to other specialists and get them redone. That specialist didn't get any more of that kind of work at our practise, but his utter incompetence was never followed up beyond "don't hire him again".

I guess the moral of the stories are that freedom to run practises as you see fit does not mean ethical (or even ethically neutral) behaviour, and that an environment where every physician uses their preferred products does not mean better care is delivered.

[momerath]

I worked in a hospital, and saw similar things, but I think the moral of the story is that huge organizations operate internally more like a feudal oligarchy. They crystallize, regardless of the external market.

[vacri]

This one certainly was. Another story of my friends was sitting in on a meeting, where one of the old-school specialists of nearly 30 years experience made a snide remark about 'newcomers not understanding how things are done'. The target of the remark responded 'I've been here 17 years...'.

The point remains the same, though - letting physicians choose whatever they want is not a magic bullet given by 'the free market', and can make things worse in practise. And it's not like 'the free market' has shown us that comms protocols are followed with any particular veracity in the software world, for things that have no regulation on them. Do we have an open video codec yet that runs on all browsers, for example?

[humanrebar]

Healthcare has been such a regulated industry in every aspect that anecdotes like these do little to discredit free markets.

[vacri]

People who have to solve problems in the pragmatic world, like my QA friend above, are poorly served by your ideology. At least anecdotes are a reference to a real-world event; blindly sticking to ideology is pure fantasy.

[seanstickle]

Point of clarification: physician assistants are qualified to diagnose, treat, and recommend courses of action related to health care.

Per the American Academy of Physician Assistants: "PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling and make rounds in hospitals and nursing homes. All 50 states and the District of Columbia allow PAs to practice medicine and prescribe medications."

http://www.aapa.org/the_pa_profession/what_is_a_pa.aspx

Disclaimer: I work for the Physician Assistant Education Association.

[eldavido]

Interesting. This seems like a step in the right direction. What can't PAs do, that MDs can?

[cwal37]

Just FYI nurse practitioners (NPs) can also diagnose/prescribe/refer. I happen to know this because my mom's finishing up school to become one. When she's finished, she'll get a huge pay bump, and have quite a few options open to her. A clinic at Walgreens, for example, is often staffed by a nurse practitioner. Cheaper than a doctor, but with their general prescriptive abilities.

http://en.wikipedia.org/wiki/Nurse_practitioner

[clarkmoody]

> give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles

I agree completely, but you forgot to add under what we believe: (5) "government has the solution for everything." At least that's what it feels like lately.

The cynic in me says that the healthcare industry will continue to get worse for some time before it gets better, if ever. We may see complete nationalization because the government must swoop in and "save us" from the monster it has helped to create through misguided regulation.

[cwal37]

In countries with socialized healthcare systems, costs are much lower, as is the overall amount spent on healthcare.

Americans actually display stunning recalcitrance towards this fact, and as a result we have an incredibly polarized debate which has led to a bastardized and amalgamated system comprised of several other, and often conflicting, constructs.

[eldavido]

I actually agree with this (wrote the GP). If we could have either whole-hog free market or public option, I believe either would be better than what we have now.

I think integrated systems could help, where the financial and operational sides of healthcare are combined (e.g. Group Health in Seattle, or Kaiser). The key thing is to remove the conflict between the payer and operator -- it's just madness that we have a system where one party has 100% of the incentive to control costs, and the other is completely responsible for outcomes, cost be damned.

[collyw]

Not only that, many Americans seem to believe their system of having insurance companies as middlemen improves the system somehow.

My girlfriend is a doctor here in Europe (though she has worked in Mexico). As such she has worked with private and public systems (generally in Europe, you are automatically part of the public system. You can pay private yourself and generally have to wait less).

Anyway, both her and her boss pointed out that if you have anything serious, go to the public system. Why? Because insurance companies always want to pay the least for the cheapest drugs / treatment. The doctors don't enjoy working for the private, because too much of it is trying to justify using the more expensive treatment to the insurance companies.

At the end of the day the public healthcare system exists to help people get better. The private healthcare system exists to make money.

[jjoonathan]

International comparison: http://healthcarereform.procon.org/view.resource.php?resourc...

Administrative overhead of government vs private insurance: http://healthcarereform.procon.org/view.resource.php?resourc...

[ams6110]

How do outcomes compare?

[cwal37]

Here's some basics:

http://www.commonwealthfund.org/~/media/Files/Publications/I...

Essentially, we excel in a couple very specific things, like survivorship of breast cancer. We're middle of the pack in some things, like general cancer survivorship. And we're the worst by quite a bit in others, like chronic diseases. Basically, I would say we're not getting our $'s worth.

Here's some Commonwealth Fund info if you don't want to trust some random white paper.

http://en.wikipedia.org/wiki/Commonwealth_Fund

Oh, and if you want something from an organization with a known bias: http://www.rand.org/content/dam/rand/pubs/working_papers/201...

Key abstract quote: "But one key finding emerges – the US ranks poorly on all indicators with the exception of self-reported subjective health status."

[LordHumungous]

>I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles

Holy meaningless platitudes Batman. How do you have a system that is simultaneously profit driven and that allows everyone a fundamental right to healthcare? Short answer: you can't! You can either have a system that avoids treating the most expensive (free market), or you have a system that ensures a certain level of care for all (socialism), or you have some bastardized hybrid that costs ungodly amounts of money and does not serve the sick and poor well. (the system we have).

[eldavido]

I don't think it's either-or. Conditional and unconditional cash transfers [1] have many of the benefits of free-market competition (focus on efficiency and cost reduction) with many of the social benefits of an expanded welfare state. I could easily see a system where people get "medical vouchers" to spend on their most pressing care problems, and providers compete to supply care at the lowest possible price to either vouchered payers, or those paying in cash.

[1] http://en.wikipedia.org/wiki/Conditional_cash_transfer

See also: http://www.economist.com/news/international/21588385-giving-...