Author Topic: A Better Healthcare System  (Read 5606 times)

DocSnowball

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Re: A Better Healthcare System
« Reply #30 on: June 28, 2018, 08:04:04 AM »
I have a pretty intimate understanding about healthcare from a provider level in orthopedics. To add a couple points to the discussion that certainly add to healthcare costs.

1. Malpractice fears. I myself as well as many others who work in the healthcare field over order tests/admit more then we should, give more meds then we should etc because its not worth getting sued. Id much rather order a CT scan of the head on every patient that walks in the door at the ER that hits their head then have the pt end up with a "bad outcome" If it happens and I didnt do it Im fucked. I then have 2 options, settle for limits of my policy or go to a jury trial and be liable for any amount they see fit. Dont let the BS you hear from politicians fool you. EVERY PHYSICIAN/PA/NP/NURSING HOME/REHAB FACILITY/HOSPITAL over orders tests for this reason. Every day all day long.

2. Compliance. How do we make healthcare better if the pt doesn't comply? Very difficult to do. Sicker non compliant pts means more costs, and usually more expensive costs.

Agree. This is why Gawande is a good choice to lead the new initiative - the "bottleneck" or key in solving the cost and quality puzzle is understanding what all drives the decisions that healthcare providers and nurses make. Financial incentives, loss aversion, waste, emphasis on individual productivity rather than outcomes for the patient are all part of the root causes. Burnout of providers is happening like the "frog slowly being boiled in the pond" as Munger states - if so many good providers are cutting back/ moving to other fields, the problem is being compounded further every day.


mrholty

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Re: A Better Healthcare System
« Reply #31 on: June 28, 2018, 10:00:44 AM »

In terms of low hanging fruits, ER visits resulting in disproportionate bills to average Americans is an interesting area. An opinion (not fact) is that the care given in the last months of life is terrible overall in terms of quality of life. The reasons for this are many but, like most substance of recent posts in this thread suggests, sometimes incrementally added poor incentives result in a very deplorable (is this still a controversial word?) situation.

The hard part of healthcare is that everybody knows there is not one solution.  Its going to take many solutions from overtesting, to price differences in drug to a real discussion of our lifestyle and the outcomes that come from it.  One of the strangest things that I have seen as I have gotten older is how much we spend on end of care and yet how many people don't get decent end of life care.  I grew up near LaCrosse Wi and I remember everytime going to the doctor they always asked my Mom is she had her End of Life Directives done.  It simply was a question right after can we see your ID and insurance card.  It wasn't unique to me until I went to college, moved away and started my own family that I realized I didn't get those questions. 

https://www.npr.org/sections/money/2014/03/05/286126451/living-wills-are-the-talk-of-the-town-in-la-crosse-wis

Hopefully, having these conversations with not just your health care provider but also your family leads to less issues, less costs for society and a more peaceful process.
I volunteer my time at a local Hospice facility.  What has struck me is the the variance of how people and families deal with this.  One of the things I do is I try to help some people get their financial records in order.  I've been thanked numerous times by both the people and the families and its real. 

Cigarbutt

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Re: A Better Healthcare System
« Reply #32 on: June 28, 2018, 10:56:59 AM »
I grew up near LaCrosse Wi and I remember everytime going to the doctor they always asked my Mom is she had her End of Life Directives done.  It simply was a question right after can we see your ID and insurance card.  It wasn't unique to me until I went to college, moved away and started my own family that I realized I didn't get those questions. 

https://www.npr.org/sections/money/2014/03/05/286126451/living-wills-are-the-talk-of-the-town-in-la-crosse-wis

Hopefully, having these conversations with not just your health care provider but also your family leads to less issues, less costs for society and a more peaceful process.
I volunteer my time at a local Hospice facility.  What has struck me is the the variance of how people and families deal with this.  One of the things I do is I try to help some people get their financial records in order.  I've been thanked numerous times by both the people and the families and its real.

In terms of low-hanging fruits, interesting to note that the La Crosse significantly improved experience for end-of-life care arose from a simple local initiative (1991) that required the systemic utilization of a simple form including four basic questions. Technology, which actually compounds the problem now, may become a useful tool in the future but, as you may have realized from your noble work, a pair of ears may be the most important piece of equipment.

Jurgis

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Re: A Better Healthcare System
« Reply #33 on: June 28, 2018, 11:22:58 AM »

In terms of low hanging fruits, ER visits resulting in disproportionate bills to average Americans is an interesting area. An opinion (not fact) is that the care given in the last months of life is terrible overall in terms of quality of life. The reasons for this are many but, like most substance of recent posts in this thread suggests, sometimes incrementally added poor incentives result in a very deplorable (is this still a controversial word?) situation.

The hard part of healthcare is that everybody knows there is not one solution.  Its going to take many solutions from overtesting, to price differences in drug to a real discussion of our lifestyle and the outcomes that come from it.  One of the strangest things that I have seen as I have gotten older is how much we spend on end of care and yet how many people don't get decent end of life care.  I grew up near LaCrosse Wi and I remember everytime going to the doctor they always asked my Mom is she had her End of Life Directives done.  It simply was a question right after can we see your ID and insurance card.  It wasn't unique to me until I went to college, moved away and started my own family that I realized I didn't get those questions. 

https://www.npr.org/sections/money/2014/03/05/286126451/living-wills-are-the-talk-of-the-town-in-la-crosse-wis

Hopefully, having these conversations with not just your health care provider but also your family leads to less issues, less costs for society and a more peaceful process.
I volunteer my time at a local Hospice facility.  What has struck me is the the variance of how people and families deal with this.  One of the things I do is I try to help some people get their financial records in order.  I've been thanked numerous times by both the people and the families and its real.

Great post.  8)

I'd send you $20K, but I'm not Charlie Munger.
"Before you can be rich, you must be poor." - Nef Anyo

Gamecock-YT

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Re: A Better Healthcare System
« Reply #34 on: August 28, 2018, 03:25:32 PM »
https://khn.org/news/a-jolt-to-the-jugular-youre-insured-but-still-owe-109k-for-your-heart-attack/

A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack

Cigarbutt

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Re: A Better Healthcare System
« Reply #35 on: August 28, 2018, 04:51:58 PM »
Thank you for the article.

-First reflex: This must be fake news.
It's not: surprise medical bills (out-of-network MDs working in the network and out-of-network hospitals) are frequent and often (because of size and unexpected nature of the bill) a tipping point to financial hardship.

-Second reflex: Let's put surprise bill laws into effect.
This seems to be in the air but IMO unlikely to prevent self-sustaining unintended consequences coming from the foundations.

-Many problems described here but I submit that the basic essential problem is the following:
In a study published in 2014 by Wilson and Cutler (referenced below), it was found that hospitals had profit margins of 39.6% for privately insured patients treated in emergency departments, whereas the profit margin for patients covered by Medicare and Medicaid, and those uninsured were:     
-15.6%, -35.9% and -54.4% respectively.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4285369/

If you're an MD, what is your incentive to sign a contract with the network if you can avoid it and charge 150 to 300% of Medicare rates in order to provide the exact same services?

If you're a for-profit hospital, what is your incentive to become part of a network if you can avoid it and charge sky is the limit rates?

This thing will be a huge challenge and I would say that this file is either one for bipartisan wise men or for the deranged with a "your margin is my opportunity" attitude.
« Last Edit: August 28, 2018, 04:56:16 PM by Cigarbutt »

Cigarbutt

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Re: A Better Healthcare System
« Reply #36 on: September 04, 2018, 08:07:55 PM »
https://www.reuters.com/article/us-berkshire-buffett-healthcare/amazon-berkshire-jpmorgans-healthcare-venture-names-coo-idUSKCN1LK2JX

Mr. Stoddard was with Comcast but was also involved before in strategy with Accolade for many years.
Accolade has shown it is possible to lower costs, improve results and patient satisfaction simultaneously (!).
The idea is to introduce patient-centered technology tools with "concierge health assistants" using guidelines and data to help patients navigate through the "system".
https://d10j0m6hqftivr.cloudfront.net/Whitepaper_PopulationHealth_July2018.pdf
https://d10j0m6hqftivr.cloudfront.net/Paper_CFO_Accolade_Impact-of-Healthcare-Waste_July2018.pdf
https://d10j0m6hqftivr.cloudfront.net/Accolade-Maya-One-Sheet-May2018-.pdf

What's the point?
At this point, an incredibly high proportion of people are not getting the right services, at the right time and by the right people.
Still early in the game. Some will decide to compete, some to collaborate and some to ignore.
Interesting parallel development with "Oscar":
https://www.cnbc.com/2018/03/27/oscar-health-raises-165-million-at-3-point-2-billion-alphabet-founders.html

meiroy

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Re: A Better Healthcare System
« Reply #37 on: September 04, 2018, 10:27:44 PM »
Every universal healthcare system I've read of, even those countries whose military budget is almost zero because it leaches its neighbors or NATO's protections, is a healthcare system far worse than what I had available to me 8 years ago. I understand the dilemma with the poor and pre-existing with job loss but I think that should be resolved with Medicaid or SS, even as busted as the two are. What we once had was fine though.
MAGA

Singaporeans live 3 years longer than Americans, spend less than 1/3rd of what Americans spend on healthcare and express very high levels of satisfaction with their healthcare. Wait times in Singapore are also vastly superior to the US. BTW, Singaporeans spend as much on their military in proportion to GDP as the US and also force their young into mandatory service where some of them actually die in training (they run themselves to death).

Healthcare is an input. HEALTH IS AN OUTPUT. You are confusing the two. You can have a space age healthcare system and yet because you order needless tests, over treat, over medicate and don't wash your hands (poor operational effectiveness)...actually make peoples health worse.

Well, I just spent a few minutes seeking a downside to Singapore but can't.

3rd richest country in world
tax rate of 0-22%
corp tax 17%
minute # of poor
apparently, a pretty damn good healthcare system

No clue. Good for you, Singapore!

Singapore like Hong Kong is an Entrepôt. It does not make much sense to compare the U.S. to an Entrepôt...  And it's not necessary as there are plenty of other examples of superior health systems around the world that cost far less than the states'.  The reason the U.S. does not have a decent healthcare system is due to ideological/religious beliefs and that is extremely hard to change.

rb

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Re: A Better Healthcare System
« Reply #38 on: September 04, 2018, 11:22:22 PM »
Thank you, it's true that places like Singapore and Hong Kong are not good comparables. In general small, urbanized, advanced places are not comparable to larger, more diverse countries. They tend to be very wealthy and efficiencies work really well. In addition to enrepot places like HK and Singapore, i'd add others like Switzerland and Luxembourg, but the list doesn't stop there.

As for other healthcare systems let me add an anecdote. Last year I traveled to Italy with a female. While on the plane she picked up an infection. It manifested as something that may look like a rash/inflammation. We didn't think much of it because stuff like that happened to her before and was always some benign thing. But within a couple of days it got so bad that she could barely walk.

So we went to an emergency room in Florence. Now keep in mind that while this was very unpleasant from the patient's point of view, it was far from any life threatening situation. Nonetheless, she saw a doctor within an hour (the doctor spoke English). Got accurately diagnosed etc. We were charged for the visit. I can't remember what the bill was... something like the equivalent of 40 CAD or 60 CAD. Something low enough that we didn't actually file the insurance forms to get it back. Oh and when we got the prescribed antibiotic, the total cost was less than 50% of what the dispensing fee alone would have been in Canada.

I'd go ahead and say based on that experience that it's a pretty good system. And it costs less than half of what the US system costs. Upon further research i've found that it has 25% more doctors per capita than the OECD average and 50% more than the US. So that probably helps a lot with wait times and such. Therefore I say, put Italy up on the board as well.

Cigarbutt

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Re: A Better Healthcare System
« Reply #39 on: September 05, 2018, 05:23:55 AM »
I'd go ahead and say based on that experience that it's a pretty good system. And it costs less than half of what the US system costs. Upon further research i've found that it has 25% more doctors per capita than the OECD average and 50% more than the US. So that probably helps a lot with wait times and such. Therefore I say, put Italy up on the board as well.

Another "side effect" of high #MDs per capita is the possibility (for visitors and locals) of obtaining affordable house calls (or hotel, Airbnb etc).

Indeed Italy scores well overall in healthcare costs/outcomes but fiscal constraints may change that. They also have regional disparities (North-South) to deal with. Other secondary considerations include the need to pay cash for certain out-of-pocket expenses and related party nominations at regional agencies.