Before I worked in healthcare, it all seemed so easy. The doctors were the good guys, and the insurance and drug companies were the bad guys. Now I see it differently.
Healthcare companies are massive bureaucracies because there are people at every end trying to scam them. All that redundant paperwork is for a reason.
You wouldn't believe some of the things that people try to get away with. Plastic surgeons billing tummy tucks as emergency C-sections. People pretending they were the hospital so they can get the insurance company to reimburse them for the IV "hangover cures" they got every morning while partying in Vegas. People walking into office buildings and play-collapsing in the lobby so they can get an ambulance ride to the hospital across town, then once they arrive they run out of the hospital and down the street because all they were really looking for is a free ride. People who have six or seven dependent children from multiple partners on their insurance, then yell at us because the partner they're living with didn't know about all those other children from all those other spouses until they opened some piece of mail from us.
I'm not saying that insurance companies are all good. IME, most are not. But if people were just honest and decent, a large part of the healthcare system dysfunction wouldn't exist.
In my view, a broader observation is that every group claims to be protecting us while accusing every other group of gouging us. This leads me to suspect that they are all gouging us. The system is so labyrinthine that literally nobody can figure out where the money is going. And many of these groups have ownership stakes in the other groups. For instance, doctors are prominent owners and investors in clinics, providers, and even malpractice insurance companies.
It's attributed to Abe Lincoln, that in order to get down to the truth, you have to get all of the liars in the room together.
In my imagination, a potential benefit of a government health care system is that it could eliminate this rat's nest of business entities by paying directly for the things that are needed. And we'd know who is getting paid how much by just publishing the government's checkbook register. Doctors can attend medical school for free, and then work for the government, for a good professional salary. They don't have to engage in all sorts of monkey business with LLC's and insider investments to earn a living.
Block chain should be used to provide a legit health history on a per person basis ... It's all about trust ... Similarly insurance and healthcare businesses must also be on a transparent block chain ... As is it's only benefitting lawyers
>Similarly insurance and healthcare businesses must also be on a transparent block chain
How is blockchain the answer to this at all?
He might just mean "Merkle tree with digital signatures", which most people intimately familiar with block chain won't distinguish from block chain, despite the former being in general use in the software industry and the latter in general use by Ponzi schemes.
For all those downvoting the parent:
https://www.psjhealth.org/news/2019/02/psjh-acquires-lumedic
I firmly believe blockchain is over hyped, but that doesn’t mean it doesn’t have its potential use cases. Medical payers/providers are in fact giving it serious consideration.
I don't see an implementation of blockchain that would address this, especially considering blockchain is intended to be trustless.
And make everyone's health history public? Why couldn't the government do something similar but with more privacy?
Second this! My gf used to do part-time work (before she started her residency) for a couple of doctors doing mostly data entry works (to eClinicalWorks and whatnot). She would always tell me how these doctors instructed her to add more diagnosis codes so that they can get paid more (esp. from medicaid/medicare patients).
My host family father is a doctor in the US. He said to me once something like, "Be prepared to be scammed by people whether it is a brain surgeon or a carpenter. Never ever trust the original price they quote on you and be critical of their output."
Have you seen how pharma reps treat doctors? I have. Hundreds of dollars worth of dinners/lunches (one of the dinners my gf and I were invited to, it served unlimited Wagyu beef for bbq; of course, we had to sign in before the dinner). I am disgusted by how cozy the relationship between pharma companies and docs are.
The more I talk to and observe doctors, pharma and healthcare industry in general, the more I lose respect to the parties involved (of course, there are a few respectable professionals, but they are a minority because of the sheer amount of money to be made in that industry).
> Have you seen how pharma reps treat doctors? I have. Hundreds of dollars worth of dinners/lunches (one of the dinners my gf and I were invited to, it served unlimited Wagyu beef for bbq; of course, we had to sign in before the dinner). I am disgusted by how cozy the relationship between pharma companies and docs are.
In France (and California), there's a website where you can see how much your doctor got from pharma.
That’s not California-specific:
https://www.cms.gov/openpayments/
I checked my doctors on that a few months back.
I found out that one of my doctors received $200K for the last reporting year from the manufacturer of my medication. The medication is $600/month. Granted the medication does work for me and insurance picks up most of it, but it still seems like a massive conflict of interest. I honestly have half a mind to switch doctors.
Another I hope gets an update is
https://projects.propublica.org/docdollars/
I have an anecdote: I had a small fat cyst near my eyelid and the doctor removed in less than 45 seconds.
I later got the bill for multiple cyst removals in both eyes, granted it was only $75, it still was wrong. I contacted the office and said that this is simply not true and if they don't remove this from the bill, I would contact the insurance company. They argued with me saying that they had in fact removed many of them in both eyes.
If you look at it from the Doctor's POV, he is lying because there is a low risk of getting caught. The penalty for getting caught is probably not high enough.
This happened to me as well but with a dentist. When I first moved to Boston I had never had any cavities but my new dentist kept remarking about how great my dental insurance was - I was in the insurance sweet spot of under 26 so I was covered by my mom's policy as primary and had secondary coverage through my dad's policy and my school's policy. Well wouldn't you know, I averaged two cavities a year during law school even though my brushing & flossing habits were unchanged.
When I finally graduated and switched to a dentist closer to my office I insisted to my new dentist that I had had six cavities filled and he insisted that I most definitely hadn't. There wasn't a single filling to be seen on my x-rays. Dentist #1 had been scheduling me to have a cavity drilled after every regular visit. Apparently he was just giving me a shot of lidocaine and pretending to drill in my mouth for an hour so he could bill my "great" insurance.
You’re lucky he didn’t actually do anything to your teeth. Story of a dentist giving unnecessary root canals https://www.theatlantic.com/magazine/archive/2019/05/the-tro...
You should report your previous dentist. I’ve found dentists that are trying to make money start pushing deep cleaning despite never needing it ever.
I did actually but I never heard anything back, though the dentist retired about a year later. I always wondered if it was related to my complaint or just a coincidence.
I worked out an out of network surgery center which targeted high reimbursing insurance companies. The standard tact is to lie to patients, telling them not to worry about high deductibles because the surgery center won’t collect on them.
I seen an endoscopy be reimbursed $28,000 from a major county’s government employee insurance program in CA. At a hospital, it would cost around $2,000.
I heard established surgeons say that some surgeons would purposely perform shoddy hernia surgeries to require further surgeries. Or add more procedures etc to inflate the charges.
They’ll bill as much as possible, using billing codes in the most strategic ways. Insurance companies would then reimburse 15-20% on average.
The entire system is flawed and opaque so it’s hard to know who is exploiting who.
>The entire system is flawed and opaque so it’s hard to know who is exploiting who.
Doctors are by far the highest paid career in the USA. Surgeons are paid enormous salaries. Its pretty clear who is winning.
I know there is a complaint that medical school is very expensive. If we offered free medical school for cutting salaries in half, I'm pretty sure doctors would prefer to keep as it is.
> Doctors are by far the highest paid career in the USA. Surgeons are paid enormous salaries. Its pretty clear who is winning.
Right. People talk about drug company executives. There are a few hundred at most. We have hundreds of thousands of specialist doctors making hundreds of thousands of more dollars a year than their counterparts in other countries.
Exactly! Medical training in the US is unnecessarily long. The med students don't need 4 years of undergrad studies on top of another 4 years of med school. In my home country, 5 years of med school and 2 years of residency is sufficient to train a competent generic physicians (not brain surgeon). Physicians from my country, when they came over to the US to be trained in the residency programs here, found that the medical exams and residency training to be not that difficult (it is extremely difficult to get into one because they are foreigners, but once they get in, almost every one of them become multi-millionaires by their 40s).
My gf externed at a hospital just outside of LA in California. The attending physician there earn ~300K/year for a total of 14 days of work per month. She met two physicians (both from my country again), who work at two hospitals near that area as attendings; they go to one hospital for one week; then work at another the week after; and the cycle repeats. Each of them makes easily >$500K/year (one of them said so to my gf).
Despite majority of Americans are led to believe by doctors, born and trained in the US, that they are the most hardworking folks out there doing 70-hours/week shifts, it is simply an exaggeration. Sure there are some outlier residency programs that made its first or second year residents work maybe 60-hours/week, but 70 to 80-hours? I know so many former and current residents in a the biggest metro area in the US (and another one who just finished her residency at JHU), and asked them about their working hours. NONE of them had to work that much. The average for first year residents is ~50 hours. Then it drops off to normal 40-hours/week starting second year and third years.
Spouse of young doctor here. I have worked in tech for two decades. During that time, my spouse did 12 years of post-secondary pre-med and medical training. Undergrad, postbacc, med school, and residency; she is now in a fellowship.
You said (paraphrasing): “despite majority of Americans being led to believe doctors are doing 70-hour shifts per week, it is simply an exaggeration.” First, most Americans don’t believe it. Second, my wife worked 60-100 hours per week for her entire 4-year residency. That included month-long stretches on nights doing 6pm-6am shifts, 6 days per week. That included more 24-hour (or, even 28-hour) shifts than I could count. I know the hours precisely because I worked from home the entire time for my tech startup job, and we lived a 5 minute walk from the hospital. It’s a top academic hospital.
I once attended a wedding where all her med school friends were guests, all in their 3rd and 4th year of residency. Polled them about work hours. All similar. Group of 7 or 8 residents at programs all across the US, mostly top programs. Some exceptions in residencies like geriatrics and pediatrics, but any surgical or specialty residency is brutal. The happiest resident had recently quit medicine altogether — to go into tech.
They work that hard whilst earning essentially sub-minimum-wage. The contrast couldn’t be greater vs tech. My company employs over 50 people, mostly college educated, and it is not even remotely comparable. Residents get paid less than our lowest paid staff, and work twice the hours, with higher stakes, a higher emotional toll, and worse working conditions. And it just gets more unequal from there.
She is now in fellowship and the hours are slightly better. But she is now in a more urban area with a longer commute, higher taxes, higher cost of living, and debt hanging over her. As a fellow, she only makes marginally more money for her 13th and 14th years of post-secondary training. This week she worked approx 55 hours so far (if you don’t count the 4 hours of “journal club”, also required), and will need to commute an hour by car on her Sunday morning to round on a single patient — part of her unscheduled, but required, call.
If she becomes a multi-millionaire in her 40s, as you suggest is inevitable, I will be pleasantly surprised — but considering fellowship, for her, ends at age 37, I think it unlikely. First, she has to pay down over $300k of student debt, since none of the journey was paid by her parents. Then she has to earn for awhile, and make up a little for lost time, since she doesn’t have decades of savings behind her, living right at the breakeven mark for cost of living for so many years. And even if it does happen, I’ll think it a justified renumeration for her countless sleepless and low-paid nights saving lives in her 30s, not to mention the opportunity cost (and real cost) of educational years. After all, should we expect the personal sacrifice of one’s 20s and 30s have no reward at all?
Doctors should be paid much more, sleep much more, and they should suffer much less ire from people like you. As someone with two decades in tech and first-hand, concurrent experience of the contrast, I feel that much more now than ever.
Some earlier comments:
https://news.ycombinator.com/item?id=20437414
https://news.ycombinator.com/item?id=15182632
I think you're agreeing. The 10+ years of doctor training is too much, too long and too expensive. But I think you're double counting the residential years as medical training as well as an underpaid job.
Yes I agree software developers are currently overpaid as well.
"Yes I agree software developers are currently overpaid as well."
This reminds me of an old Romanian joke a family friend once told me, translating to English.
Two pig farmers, one Romanian and one Bulgarian, live across from each other along the countries' border. A genie magically arrives on the Bulgarian side and says to the farmer, "I can grant you any wish in the world." The humble Bulgarian farmer thinks on it for awhile and says, "I wish for 10 beautiful and healthy pigs, so that my farm may thrive for the coming years." The genie grants the wish and the pigs appear.
The genie flies over to the Romanian side. He says to the Romanian farmer, "I can grant you any wish in the world." The Romanian farmer thinks pensively for a little while, and then it comes to him. He points to the Bulgarian side and says, "Kill his pigs."
Doctors are the highest paid career, if you have no concept of opportunity cost. To earn a surgeon’s salary, you need a surgeon’s training. In the US, that means 4 years undergrad, 4 years of medical school, 4 years of medical residency, and often a few more years of specialty fellowship. My wife will have racked up $300k of debt and done 14 years of training before earning her first year of a “surgeon’s salary”. I suspect a tech salary earned 10-14 years earlier, and earned for 10-14 years running, without debt, combined with smart savings and the miracle of compound interest, will beat her every time.
The training requirements aren’t much different in other OECD countries. Their med schools and residencies are still at capacity. Their outcomes are better and their doctors are paid much less, but still more than most others.
I doubt the outcomes being better has much to do with the lower physician pay. But it wouldn’t surprise me that you can “get away” with paying doctors less, while maintaining outcomes above some level.
My question is: why bother? Or, put another way, what if we paid them more, reduced their hours, and had more of them? What might that do for outcomes — especially since physician salaries are a rounding error of total healthcare system costs, and since the best and brightest working in medicine means more patient lives saved and more physician happiness?
1) is it a rounding error? There are a lot of doctors, every one of them making a lot of money. I don’t know but every doctor making a lot more every year has got to add up.
2) Doctors are overtrained. This is by design, to keep salaries high. Nothing about their job demands the salary they command other than the artificial scarcity imposed by regulation.
How about: streamline the process of becoming a doctor; remove 4 year degree requirement, lower cost of med school or make it free. This has the benefit of both improving care (more doctors/patient) and making care cheaper (fewer ludicrous salaries).
Absolutely I believe doctor pay is a big part of the racket on the hospitals end. A fair amount of it goes to the higher education racket via student loans, but I guess that is a different problem.
"Is it a rounding error?"
Likely yes: https://i2.wp.com/www.dgarciamd.com/wp-content/uploads/2016/...
"There are a lot of doctors, every one of them making a lot of money."
So what? That's the way it is supposed to work for highly skilled jobs adding tons of societal value in our capitalist society. What, sacrificing your 20s and 30s isn't enough for you? You also want doctors to sacrifice their future, their comfort into adulthood, and their retirement? All the while keeping a steady hand on the scalpel while they operate on you and your children?
There is nothing wrong with well trained and well skilled people getting paid to do what they love -- especially if that hugely benefits society. Go looking for overpaid waste in leech sectors like finance and insurance instead.
I agree with you on the rest.
Doctor pay isn't a "racket" though -- you are seeking the wrong boogeyman. Remember, in the healthcare system, they are the ones adding so much of the value, at the cost of personal time, training time, opportunity cost, and emotional cost. Can the same be said by the millions of administrators in the back office of highly profitable private insurers?
Especially surgeons can easily make >500k. they can pay off their debt in a heartbeat and then the dough keeps rolling in.
Love when people that are not in healthcare have an opinion about how healthcare pays
However, doctors are by definition done with medical school.
> I heard established surgeons say that some surgeons would purposely perform shoddy hernia surgeries to require further surgeries.
This is hands downs the most disgusting thing I’ve read in this thread. I hope for humanities sake it’s not true.
Its well known.
But not for FFS. For the most part i believe that is nonsense. Instead it was SOP. Like doing blodletting on a sick patient. You did it because it qas the thing to do.
In 1970s it was hip replacement
1980s it was tonsil removal
Etc
>Healthcare companies are massive bureaucracies because there are people at every end trying to scam them. All that redundant paperwork is for a reason.
And what about other countries with way lower healthcare expenditures (by % of GDP)? Are people scamming the healthcare system an American problem?
> Are people scamming the healthcare system an American problem?
Definitely not. In Poland we have public healthcare, and the stories I hear from my doctor acquaintance still reveal ridiculous levels of fraud, mostly the usual scams against large bureaucracies.
Public healthcare may be more efficient, but is still full of bureaucratic scars.
One of the major savings is single payers have more data on each provider. This means they can randomly audit a lower percentage of cases and become just as likely to spot fraud.
Not necessarily, the amount of data that is collected in France vs the US for example is much much lower.
Maybe, maybe not. In France all my information is in EMR in my Carte Vitale. The US I have to fill in a paper questionnaire every fucking time. They may have more data, most likely it's redundant.
In the US, link to survey is sent by text, or through automated voice prompt.
Feedback loop. The more expensive healthcare gets, the more money you can get by scamming insurance companies, which in turn increases costs even more.
NHS and other nationalized healthcare providers, doctors and nurses working in hospitals get salaries, so they could scam some overtime but that's about it. I think local primary physicians get paid per visit, but most are way overworked anyway so kinda hard to fake extra visits.
There's still fraud in the NHS.
People who suspect fraud can report it to the NHS Counter Fraud authority.
They have a fraud awareness toolkit here: https://cfa.nhs.uk/fraud-prevention/fraud-awareness-toolkit
I suspect the extensive part privatization might be opening new and exciting opportunities for scammers..
True, but most other industries have effective, scalable mechanisms to clamp down on such blatant fraud and dishonesty; health care in the US just isn't using the appropriate mechanisms, it seems.
Like a basic one I see lacking is, checking the patient him/herself. I have never gotten contacted for any kind of follow up about "did you actually receive this health care", which would eliminate fraud related to the tummy tuck/C-section you mention.
Or why aren't they keeping track of that person that's constantly calling the ambulance?
Furthermore, where is the crushing power of the state to recover from such people? If you find systemic fraud, why aren't the regulators able to recover a big chunk of the money?
using the ambulance for a free ride is a huge risk: you'd have to be insane to try this. If they get your name, you'll be out 4000$!!!!
People with $4000 in easily seized assets / concern for their credit score probably aren't the ones treating ambulances as a taxi.
But Medicare handles the same issues for a lot cheaper.
I'm still trying to figure out why my health insurance company paid $600 for a dermatologist to spray liquid nitrogen on a wart for 10 seconds.
Because they got a hell of a deal. He originally billed $1200 but they reduced it 50%!
Because they can’t find a dermatologist to do it for less.
> But if people were just honest and decent
I feel you. A lot of anger in the world comes from this, I think, and I want to push back because it can lead to dangerous conclusions. I'm not arguing you would use it as such, but others do. I.e. see xenophobia, religious persecution, violence against LGBTs, etc.
How much of what you say is due to a lack of honesty and decency on behalf of the rich and powerful? How many people have "abandoned their decency" because the system is just fucking impossible to overcome? It's not how I reacted, but some friends did - faced with the often impassible barrier between poverty and the lower-middle-class, they threw their hands up in the air and turned to crime, or vagrancy, or just general dickishness towards the rich ("civil disobedience" they'd call it, as they spraypainted a dick onto the rich neighborhood's entrance sign").
If people were just honest and decent, we wouldn't need jails, because nobody would commit crimes. But if people were just honest and decent, people wouldn't be going to jail because a rotten cop planted drugs on them (https://www.youtube.com/watch?v=UANRvFNc0hw) or because they smoked a plant in the privacy of their own home. People wouldn't get shot for being black.
If people were just honest and decent, other people wouldn't feel the need to squeeze every drop of support out of a system beleaguered by a warring two party system to fund and defund it at the same time. "Hell yes I'm going to abuse food stamps, republicans just got a majority, they might take it away next month!"
If people were just honest and decent, we wouldn't have a rapidly escalating war between tolerance and intolerance. Antifa vs fascists. Nazis vs liberals. Friends in Texas wanting to ban transgenders from public restrooms while LGBT friends arguing "it has gotten to the point where punching nazis in the face is acceptable dialogue."
The "if people were just honest and decent" argument keeps cropping up over the centuries, and I think we should work around it. Moral superiority, it doesn't work. Catholics trying for 1000 years to get people to stop getting pregnant before marriage - a multigenerational failure to understand that that strategy just doesn't fucking work. It takes a bit more creativity.
So, I sympathize with your urge to throw your hands up and say "can we just stop being fucking assholes and taking advantage of eachother?" I agree. I try not to be an asshole. But there are tons of assholes in the world, and some of them, when I sit down to think about it, are kinda justified in their assholeness, because they're in shitty situations that would really stress my ability to not be an asshole. Long story short, it's not a helpful attitude - creativity is needed, alongside sympathy. Acknowledge that helping people will come with shortcomings (free riders), abandon pride, and accept that it's better than the alternative (a war of assholes undercutting eachother at every opportunity).
Seek help.
There are two ways to deal with it, either universal healthcare which is a proven and working system in most of the western world or free market where every procedure has a price tag attached to it and people pay knowing what they pay in advance and for what exactly they pay, like a normal shop in a free market.
The weird hybrid system in the US is like communism, it doesn't work, we can see it doesn't work, it costs more than any other place on earth, both for the government and the people. The US should just scrape it and choose some working system. Until then leave us alone every second week with your horror stories, it is not interesting anymore.