You don't just get to declare that medicine is the same thing as everything else and call it done. Frankly I can't recall other industries telling me they were uniquely weird, my friends in most industries emphasize how similar they are to each other and go what the fuck when I explain how things go in medicine. "You get paid less for working in higher cost of living areas or for more prestigious jobs? What the fuck." "More years of training decreases your salary? What the fuck." "More complicated jobs pay less? What the fuck." "What do you mean a routine procedure could cost five thousand dollars or one million? What the fuck." "What do you mean you do 20+ hours of unpaid labor a week? What the fuck."
To emphasize: name another business that is forced to work for free and is prohibited by law from closing unprofitable businesses segments (example: the ED). Healthcare is prohibited by law from being more efficient and cost effective.
As previously mentioned we have a parade of outside actors coming into medicine in attempt to take care of low hanging fruit and apply general business knowledge because they assume everyone must be idiots. And then they catastrophically fail.
The complexity of medicine is higher than nearly every other field for a number of reasons including the fact that actual human lives are at stake. Bad outcomes are unacceptable so that makes things expensive in a way that does not apply to other industries. Voters have elected to avoid tort reform or rationing or a reduction in administrative and documentation burden and others things that might address the problems.
You are right of course that people will attempt to solve the problem by increasing regulations and doctor salaries will be likely cut. Well administrative costs are about a third of healthcare spending. Guess what is going to go up with increased regulation? Physician salaries are about 8%. Guess what's not going to move the needle if it is cut?
And of course price controls lead to shortages, which we already see quite a bit.
You seem to think that everyone in healthcare is stupid and that nobody has tried to apply general business knowledge to these problems. Of course they have. Some well run places have managed to improve things slightly, but we don't have to speculate as to how hard this, just point to the parade of corpses that tried what you are suggesting.
And of course you have things like HCA which seem to be legitimately profitable! Great. Oh wait no they are grossly unethical and constantly under investigation for illegal business practices and nobody who works there wants any of their family members anywhere near those hospitals.
EDIT: Let me add one more - where else in modern America do you see costs kept down by using indentured servants? The closet thing to Residency is visa abuse in tech and that's not anywhere near the same level of insanity.
Throwaway05
6mo ago
Healthcare is like aviation and nuclear in that bad outcomes are considered unacceptable, therefore there is a ton of regulation and complexity that does not exist in other industries, there is also more variation in health care than aviation and nuclear because people's bodies are variable and much of the more complicated stuff cannot easily be standardized.
It is its own entity not like other economic segments and intuitions brought in from elsewhere have a tendency to be incorrect. This is why companies like Amazon, Google, and Apple all tried to start healthcare projects and bailed out. This is why PE firms buy hospitals, crash them and then just sell the land. This is why Theranos happened. Healthcare doesn't work the same way as everyone else. Maybe it should but it doesn't.
Part of that, and something you really need to simply address is "who the fuck cares about the prices" the prices are made up, they don't matter, insurance pays and insurance NEVER actually pays the price. There is no value to you in knowing what the price is, and as given in an example in my last post sometimes the prices DOESN'T EXIST.
There is no cash value for my professional time if I don't see cash patients and what the insurance company will give me for my time is a big fat question mark.
Throwaway05
6mo ago
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"Your surgery will cost anything between 4,000 and 5 million dollars, as those are the minimum and maximum recorded prices we have charged in the last ten years." Is not a satisfactory answer. "The median price for the surgery is 5,000 dollars" is not viable either because patients will sue if it's wildly off that. Either way the cost doesn't matter, it's almost entirely removed from how much the hospital gets paid or collects.
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This like a governmental procurement process. The person who has knowledge of everything is the head of the OR or billing department, not the person who is on the ground doing the thing. You can't have the head of the FBI come down every time and explain what the cost of an investigation is, the individual agents sure as hell don't know, why would they need to?
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Healthcare systems (including doctors) are the victims here, victims of a predatory insurance industry and unhelpful overregulation that needs to be replaced with functional regulation or needs to be understood to be reducing the amount of and increasing the price of care. Don't blame us doctors and nurses are leaving the field and hospitals are shutting down because insurance companies are winning the battle. Blaming us helps them collapse the system faster.
Throwaway05
6mo ago
There are multiple parallel problems here.
The cost is fundamentally unknown. It is reasonable to determine what the average cost of a thing is, but that is not helpful information because when we leave the average the costs can become profoundly immense. More people are upset with an estimate that is off by multiple orders of magnitude than by no estimate at all, and that will happen.
To torture your mechanic analogy, it's like if you go to buy a car and ask for a Corolla, but 5% of the time you get a Bentley whether you want it or not.
The average cost is not necessarily known to your doctor. If I'm your surgeon I know what my professional fees are and how long my average case takes. I probably know the billing codes used, if I'm business minded I may know something about the average cost of supplies, instruments, and equipment. However a run of the mill routine surgery requires a team of 40+ people between the office visit, PAT, pre-op, intra-op, PACU, and post-op. It is unbelievable how many hands are involved and it is incredibly difficult to keep track. You immediately start running into problems like "cleaning staff are a critical part of the OR and are a cost to the hospital but are not usually considered a part of the surgery, is that a cost or is it not a cost?" or "does this facility charge by the minute for anesthetic gases or use a flat fee" both options are viable, your anesthesiologist probably knows, your surgeon probably doesn't. Keep track of "costs" is a full time job with an entire department just for the OR. Your surgeon might be able to say "your surgery probably costs 10k" because they asked someone in a billing meeting what all the averages on the spreadsheets said, but nobody wants to have a 20 minute conversation about how much of an oversimplification that is.
Additionally that is fundamentally not the surgeons job and does nothing to improve the surgeons provision of medical care. We evaluate whether to perform a case or not based off of the medical risks and benefits, not the cost. This is part of why healthcare is expensive in the U.S. but most people prefer that to the alternative.
Doctors wear a lot of hats. Things like increased regulatory burden and the dance with insurance below mean that you have of multiple departments involved in figuring out how to deal with the above. We already do a lot of things like that slow us down and prevent us from actually spending time with patients. Making it worse is not desirable to us or our patients.
The cost is irrelevant, which disincentivizes processes involved in streamlining all these things and makes it useless for your doctor to know and be able to relay to you. Almost all procedures are paid for by insurance or involuntary charity care by the hospital, with a small rarity of actual self-pay. Getting insurance to pay for something involves complicated negotiations where they try and pay you less than "cost" so you exaggerate cost as much as possible in hopes you don't actually lose money. It is not uncommon for the payment mix to end up being something like medicaid reimbursing 80% of cost, medicare 85% and private insurance 110%. If you mostly care for medicare and medicaid patients you go out of business (which has happened a lot lately) or require government bailouts. This is why the sticker price is so insane, and hospitals will almost always drop 90% of the bill if you end up being cash pay. You have to negotiate with the insurance company and that involves the "official cost" of a gallbladder removal being 100k instead of 5k or whatever.
A surgery has more in common with a government procurement and bidding process than getting a car repaired.
Even more simple things like an office visit are a pain in the ass to figure out. Unless you are doing very specific types of PCP practice or outpatient cash Psychiatry you are taking insurance. Therefore I don't know what the visit costs. I know what my billing team will try and charge for my time, they'll use the specific office visit billing code, I'm told to make sure to put X and Y thing in my note so they actually cover the work I did, but then I know that even the insurance company is supposed to pay for that code they'll make a big stink about it and require hours of the billing teams time going back and forth to make sure that its not worth it to actually get paid for that, even though the other insurance company always takes it if I put in X and Y, so my office staff will adjust the coding and bill you for the down coded visit even though that's not what I did and that's somewhat illegal, and your sister will get billed the actual billing code because she has "better" insurance.
All kinds of asinine shit like that happens for the most routine interaction with healthcare.
This is why psychiatrists are like "dude just pay me 100 an hour and we are good" and why there are now multiple forms of primary care that avoid working with insurance.
"What's my rate for a visit" is never a viable question because every insurance company pays me differently and its constantly changing year to year and I'm effectively only paid for by insurance.
Throwaway05
6mo ago
I don't know how many times I can tell people that medicine isn't like other fields.
A gallbladder removal can cost say roughly 5,000 dollars or 1.5 million. Sure the latter is 1% of the time, but you need to plan around it because it's a regular occurrence with the numbers involved.
We don't know what is going to happen, and if we told patient before they went under that they'd be paying 5k and woke up to a million dollar bill....that's not better.
Magnifying this is the fact that nobody knows what your insurance will pay because your insurance breaks the rules and makes shit up all the time. Regulate them better, most things are getting paid for by insurance anyway.
Throwaway05
6mo ago
I mean it is impossible to know. You know how much an average thing costs more or less, but a bad outcome or routine complication can make the cost 10x or 50x, or more very very easily, and that's just with the planned treatment.
If you find something incidentally that needs management then you start getting into the territory of "oh yes, you could later make a case that not treating this immediately led to the patients death and lawsuit" or "anesthesia is bad for you and has excessive risks, doing it now while the patient is under will improve recovery time and decrease overall costs." Costs are way more complicated than is typical in medicine because people have more variety than manufactured products.
And that says nothing about charges, your insurance company can approve everything or nothing for a variety of reasons that are constantly changing and may be appealable or not appealable.
Healthcare providers can't easily predict what the insurance company is going to do because of enemy action, and many things are not practical to be done via cash pay outside of sketchy situations because if anything goes wrong the patient is on the hook for a bill they can't pay and the hospital has burned a lot of resources.
Throwaway05
6mo ago
Truth is much more fluid than we often given it credit, even in the West. Yeah nerdy/sciency/rationalist types are going to focus on statements being made with "truth" but compare with "no defund the police doesn't mean defund the police" types or "don't take Trump literally" most people engage with reality in a more flexible way "this is the best meal/game/movie ever" is felt in the moment despite the hyperbolic content.
For non-Western examples, in many countries scamming is taken as a fault of the victim, and face saving activities are more important than literal truth (as is the case in China).
Not sure what OP is talking about specifically but it is likely the way that "lying" is considered more acceptable in China (with the idea that most people in the cultural milieu know what it is exaggerated, false, and accurate).
Throwaway05
6mo ago
Why is it the physicians job to know what things cost? A hospital will literally have hundreds of employees whose full-time job it is to figure out what things cost and deal with insurance companies, who are always changing things constantly. Even a small practice will usually have 2-3 employees minimum who spend most of their day figuring that stuff out.
It's entirely orthogonal to providing good medical care.
We do cost benefit analysis all the time, but it is in terms of the risks and benefits of a given intervention, wouldn't you rather us be focusing on that?
Throwaway05
6mo ago
Yeah - what happens with a denial?
Well I can appeal, and often the appeal is successful, but generally what will happen is that they'll tell me we'll have a call at X time, which means I need to reschedule or be late to appointments, maybe skip my lunch or charting time, or even stay late. I'll sit on the phone for an extended period of time and then have a retired outpatient OB nurse who has no fucking clue what she is talk about go "oh yeah sure that's fine, we'll approve" or "wow I don't know about this, let's schedule another phone call with a relevant specialist, but I'm going to deny or now" or whatever other insane shit they do.
The goal is to make paying for things as inconvenient and expensive as possible. That means less time spent on actual patient care and more burnout and exhaustion in physicians.
Throwaway05
6mo ago
Not all subjective depression and depression symptoms come from major depressive disorder. People with psychosis are also depressed, as are those with borderline personality disorder (well-ish, that's more complicated).
I've read some papers identifying the mass shooting type as typical narcissists (specifically malignant narcissist), which may be superficially depressed but it manifests in a very different way.
Throwaway05
6mo ago
The other poster nailed it, most people who are suicidal have severe depression which will involve low levels of motivation, planning, concentration, and energy.
Some people with other forms of mental illness can end up violent and suicidal but those generally involve significant disorganization (medical impairment, substance abuse, psychosis, and mania).
Most people who are personality disordered and like this are also disorganized and shitty at planning (as in severe borderline personality disorder). Anti-socials and narcissists are better at forethought (ish) but typically mostly care about themselves and don't usually see the benefit of making this kind of statement.
So you need something weird like malignant narcissism, a relevant delusional disorder, and so on.
Mentally healthy and well people with other motivation (such as a person with terminal illness who is handling it well but knows they will pass away soon) are much more able to complete this type of action but don't do so because...healthy and well.
You need the perfect storm of ability, interest, and organization.
Most with those three find better ways to spend their time but politicization may change that.
Throwaway05
6mo ago
Current physician salaries are 8.6% of healthcare costs per Stanford. Looking closer at your data, it seems to be very old - it's missing 15+ years of physician salary pay cuts (which have been going on yearly for decades) and 15+ years of increased administrative bloat and other factors (such as increased excess services).
If you cut physician salaries in half across the board (which simply isn't possible, if you did that some specialties would be making less than nurses, and specialties like OB with an immense malpractice burden would be financially impossible), then you would barely make a dent in total expenditures and introduce significant new problems - who is going to work weekends and holidays and nights after such a massive pay cut?
Increased administrative costs are unnecessary, expensive, and much easier to reduce.
Throwaway05
6mo ago
It's common for insurance companies to do things like randomly deny clearly indicated treatment for no apparent reason, this costs the doctor and health system time, as they have to schedule an appeal, during the appeal you almost always get a rubber stamp but its massively inconvenient to cancel appointments, skip your lunch break (which is typically just catching up on documentation anyway), etc.
This is legal even though it is practically speaking fraud, and I have no idea how they accomplish this on the training end at the insurance companies, but some of them are way worse than others.
Throwaway05
6mo ago
Something to keep in mind with EDS is that their are a number of subtypes, and "surprisingly" the one we see in these types is the one with least ability to be objectively assessed.
Throwaway05
6mo ago
but the lion's share of the extra money goes to doctor's salaries
Doctor's salaries are not a significant percentage of healthcare spending. What percent of spending would be required for you to consider "lion's share" to be an accurate description?
Throwaway05
6mo ago
Unfortunately that was a serious answer, even public options like medicare and medicaid are pretty awful.
Which puts United having an even worse reputation in an uncomfortable place.
Throwaway05
6mo ago
looks around furtively
Yeah.
But United has a particularly bad rep.
Throwaway05
6mo ago
Of note, United is known to be pretty much the most scummy one, which moves the needle a bit towards what we are all thinking.
Throwaway05
6mo ago
Yeah my understanding is that we are sitting on a stockpile of at least 5 mill doses, and our routine process could be reasonably effective at dealing with this without resorting to "novel" technologies, but it's very severe and potentially a fast moving problem.
Throwaway05
6mo ago
Uhhhhhh I don't want to do a lit review so please forgive me if I get some of the details wrong but basically they try and predict well in advance which mutations are going to be prevalent the next year (like almost a year in advance) and make all the vaccines accordingly. The mutations are typically pretty well understood, that's what the H and Ns are about.
This is also why the flu vaccine doesn't always stop the flu, you can end up with one of the other variations, which annoys people to no end and makes them feel like it's pointless, it's not.
I believe the specific issue with H5N1 is that it stays trapped in the lower lungs which makes it even more dangerous (because you get more ARDS) but less contagious since you have less of the virus carried in cough and so on. The specific elements responsible for this are not necessarily in the same place in other animals, which can be why something is virulent in pigs or whatever but not humans.
My favorite example of this is the fact that allergic reactions for dogs are more diarrheal as opposed to throat closing, because that's where the histamine receptors are mostly located in dogs.
Throwaway05
6mo ago
Random flu combinations is a yearly occurrence and something that is tracked by global public heath authorities. Also reminder that the flu is really fucking bad but we mostly forget about that because at risk persons are strongly incentivized to get flu shots.
Here's a link-
It is worth noting that the type of flu most likely to result in human to human transmission does have a strong possibility of resulting in lower lethality.
However we've had presumed mammal to human transmission in the U.S. already, IIRC.
The problem is when it goes human to human (which it may not).
Throwaway05
6mo ago
Yep, you'll see posts on Meddit every once and awhile.
The bad news: It's really really bad (as much as 50% CFR) and it's likely going to happen sooner rather than later. This is a real threat that will probably happen, BUT-
The good news: We actually have a vaccine stock already (only 5 mill doses IIRC), everyone is mad about the new vaccine type but we can roll that out fast if need be, and we really understand flu rather well. Flu mutates more frequently because of its structure but we know a lot about that, and what to look for in terms of human to human transmission and all kinds of other junk.
This is much less of an unknown and the U.S. would likely be able to do a safe and actually temporary lockdown (that...obviously a lot of people wouldn't listen to) that would solve the problem.
Other countries may be fucked.
Throwaway05
6mo ago
When I've seen this come up it's been in the setting of what women perceive as low status males being misogynist, however their is one community that uses females to refer to women a lot - low class/income inner city blacks, one of the groups that is most disrespectful to women.
I think a lot of the incoherence is stemming from that.
Throwaway05
6mo ago
Yes there is an over supply of residency spots, residents, and medical students. Somehow this doesn't result in an over supply of doctors.
It's complicated.
For instance medicine is overwhelmingly female now, they retire and go part time very easily - so our "finished" supply constricts.
Good example! However that specific point is meant to illustrate the oddity and complexity of healthcare delivery, not be the specific reason for lack of price transparency.
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