Most dentists are perfectly capable of providing the correct diagnosis. Unfortunately, even if and when they are, there are obstacles:
- Weak incentives to provide an accurate diagnosis
- Strong incentives to provide a particular inaccurate diagnosis
Giving a correct diagnosis often means investing more resources, as well as continuously investing in education and tooling. If the patient doesn’t see the difference between a correct diagnosis and “probably correct diagnosis” then they will react the same in both cases.
This situation where every diagnosis is perceived as the same, an examination is one of the least profitable services provided by dentists and, naturally, falls into the problem of “adverse selection.”
Some dentists recognise the opportunity of giving the wrong diagnosis to get a higher benefit. Be it by keeping or winning over the patient or by leaving room for the ability to recommend costly treatments.
The results of this are:
- Patients on average get a less correct diagnosis
- Dentists earn little to nothing for their diagnostic work
It goes beyond correct diagnosis with Dentistry. Even with a correct diagnosis there are often multiple methods of treatment that vary dramatically in terms of recovery and cost. More often then not the Dentist recommends a costly treatment and doesn't even provide alternatives.
I've seen dentist offices that were just cavity filling mills that filled anything remotely resembling a cavity and using three different methods of pain management during the procedure. The dentist literally had rows of chairs in the same room getting cavities filled.
I've sat in a dentist's chair and been told I had a cavity that needed and could be filled that day. Unfortunately I was not in a position to pay for the procedure so I deferred. I saved up the $$$ needed and returned at my next appointment prepared to have it filled only to be told I didn't have any cavities.
When I was a kid, you didn't get braces until you lost all your baby teeth, now Dentists have started recommending braces for children as young as 4 with the expectation that they'll need braces again as a teen.
Dentists are able to recommend wrong therapy plans without patients knowing. Even when a patient gets the correct diagnosis, they can be recommended drastically different therapy plans.
This happens because there are many ways to solve the same medical problem. Depending on the financial capacity of the patient and the desired quality which is most commonly measured by the length of durability or visual appearance, as well as other factors.
Another related issue is the aesthetic dental work paid for by the patient, which can cause the need for more treatments down the line. All these decisions influence the health of the patient in a way they aren’t able to fully comprehend, and they rely on dentists as experts to advise them.
Generally, advice and diagnosis are not separate. This creates a venue for unethical behaviour. For example, dentists might resort to recommending "tools from their toolbox.” In your case, it was fillings. When you buy a hammer, suddenly everything looks like a nail.
The results of all this are:
- Patients get suboptimal/wrong health treatments
- Treatments are still performed long after there are better approaches available
My elderly mother had such a bad experience with a dentist. She had some tooth pain and the dentist she picked wanted to replace ALL her teeth with implants. I went with her to see what is going on and the dentist insisted and expected the work to start the same day. We walked out and scheduled an appt with my dentist. They instead recommended a deep cleaning and fix one tooth. Then 15+ years later her teeth are doing fine.
Specific example I came across (may have even been a scientific study). Memory is a bit hazy, but roughly:
Dentists routinely recommended the more-expensive ceramic teeth replacements for teeth in the back, even though ceramic is less durable than the metal counterparts. Even though you basically can never see the hind teeth, so cosmetic reasons shouldn't have applied as they do for front teeth.
> Even though you basically can never see the hind teeth
I notice metal in peoples hind teeth all the time. This is still a cosmetic need.
Food for thought. If teeth are constantly grinding against each other, is it good for the opposing teeth to constantly be grinding against a hard material like metal?
I agree with your point about regularly noticing metal crowns but note that dental ceramics are way harder than metal. Dental ceramic is a 7 on the Mohs scale while gold and silver are in the 2.5 to 3 range.
They're still quite noticable from certain angles. I was mildly disappointed when I noticed silver amalgam fillings on someone's top rear molars, because I had some there too. When the time came to replace those fillings, I was happy to switch to white composites.
Choosing the correct tradeoff between cost, appearance and durability is a value judgment. While the importance of appearance is lesser for the rear teeth, I wouldn't write it off entirely.
Knew a dentist. She told me how her mentor mentored her in the art of billing to the max on everything and pushing every procedure under the sun for financial gain.
I fly 3000 miles to see the same dentist I have seen since childhood. Honest guy who has a conservative mind about treatment. It's worth the extra airfare.
In Germany there is a strange policy for hospitals. If you do not do a minimal amount of operations of a certain kind (e.g. hip replacements), you loose the admittance to do any further surgeries of the same kind.
The incentive was probably to focus competency to certain hospitals, but you can imagine how this plays out in reality.
Especially people not familiar about medical necessities should always get a second opinion. Otherwise you might end up with an extra hip or something like that.
At least it begins to be common knowledge that hospitals do operate too often.
Still, with all its problems, and there are many, I certainly would prefer to be operated in any country of the EU compared to the US. Not because of capabilities of doctors, but to me it seems US health care as a example how private business can be worse than governmental services. Common market mechanisms don't work if your life depends on it. It is just about extracting the most amount of money from suffering and this article describes a problem to which there is no solution in my opinion.
The US’s healthcare is hardly an example of private businesses going awry. The US’s healthcare is by far the most heavily regulated in the country with a near majority of spending by the various governments. We have the worst of both worlds, some kind of Frankenstein’s monster of regulatory capture, government incompetence, and age old corruption. 20% of Medicare billing has been fraudulent for decades and now the government can’t fix it because so many parts of the industry rely on straight up theft.
So yes the US health care system needs a push to be more socialized or less regulated, but it’s not some prime example of a free market gone awry.
“so many parts of the industry rely on straight up theft.”
This will be a big issue in any kind of health care reform in the US. if they want to get costs even remotely in line with other countries a lot of people will either lose their job or make much less money. That won’t happen without a lot of resistance.
To be fair, a lot of those people are economic parasites, providing no actual good anyone would ever want to exchange money for. So their only economic value was dispersing their earnings as spending. Which whomever that money is directed to will also do, but also while adding service/value people would be willing to pay for.
yep, health care reform to single payer will basically guarantee a recession - a huge percentage of GDP/jobs will evaporate over the course of the transition.
there is no such thing as having this cake and eating it too: there will be immense pain for a sizable part of the economy whenever this gets tackled.
While those who are negatively affected by the reform would suffer, that money doesn't evaporate. It goes elsewhere, so it wouldn't cause a recession on a macro scale. Look into the Broken Window Fallacy in Economics in One Lesson. its a great book.
The money doesn't evaporate, but it very likely would result in less total money spent. And people spending less money is the textbook cause of recessions.
if its not spent, its saved somewhere. Very few people put substantial amounts of cash in their mattress. Most goes in the bank, which helps set the rate if interest rates for loans. So, even unspent money goes somewhere and gets spent. Still not a recession.
The problem is near term interest rates are near 0, so the casual pathway of money saved -> lower interest rates -> more investment isn't as effective. This is why quantitative easing has so little impact.
And a saved dollar is spent less than a spent dollar.
low interest rates are supposed to provide information regarding the value of money spent vs. money saved. However that function isn't allowed to work. Further quantitative easing add(s|ed) further noise to the flow of money from investment to spending.
"in any country of the EU" thats a very broad statement. A poor eastern EU country will not have remotely the level of surgeons and facilities that say The Johns Hopkins Hospital has this would be true even for many richest EU countries.
> Hopkins probably isn't in-network for him even if he works across the street from it.
Hopkins probably isn't in-network for a lot of people who physically work in the hospital every day. Custodial, cleaning, security, etc. often are contractors and therefore do not have access to employee benefits of their platinum-level customers.
That's the whole point. Big institutions can decide that certain job roles shouldn't have access to benefits. Then, it's trivial to outsource those roles. This commonly happens for low-status job roles like janitorial, facilities maintenance, groundskeepers, and building security.
JH may be relatively unique in being a 100% employee shop, but it would definitely be a case of the exception proving the rule.
*Edit -- it looks like JH has a history of fairly high-profile labor conflicts. If they are 100% employees, I would bet their history is a factor in why they are this way now.
Its not strange you want to concentrate the difficult stuff so that you get experts who do this a lot working on you
(hip replacement is not one of those)
For example transplant work in the UK is very concentrated I went to the royal free and they have the best equipment and surgeons and do world leading operations.
The guy across from me was the oldest patient in the world to have a new type of key hoe surgery for example.
I had much more success researching my own health problems than by visiting any doctor (and have seen a lot, unfortunately). As a bonus, I learned a lot about the body and the mind.
I see misdiagnosis happening at a very high rate but I also understand they don’t have the time and/or energy to dig very deep into each patient and they do fine (money and respect-wise) by doing the bare minimum so many don’t try to fight it by e.g. setting up their own consultation and trying to do better (not necessarily making less money).
Of course, a bunch of exceptions can be found and they do shine a lot, but the average doctor isn’t going to be helpful after the very typical and simple checks don’t yield anything and they’ll happily prescribe things that won’t actually help you. That’s been my experience in at least couple european countries.
In my experience the situation in the US is about on par, only with very few shining exceptions. I never bother to see a physician unless I'm fairly confident there's something going on I can't fix and I have a good idea of what it is and isn't.
The alternative is spending 20 minutes talking to someone filling out forms on a PC and pretending to listen before working as quickly as possible to get you out of their office. Oh, you have some kind of acid-related chest pain? We'll just prescribe a proton pump inhibitor for the rest of your life rather than worry about fixing anything, thank you come again.
Hell, when I was a child and my thyroid failed physicians spent 2 years telling my mother that I was just lazy. My symptoms were so textbook that a coworker of hers diagnosed hypothyroidism, sight unseen, from the mere description. Even so, she had to demand they perform the incredibly simple blood test to confirm.
Needless to say, I have very little respect for physicians in general.
I think it's very important for people to be proactive about their out health and care, but I think listening and working with your primary care doctor is just as important. If you don't think your doctor is helpful or listening then you probably need to find a new doctor.
The problem is that, IME, the vast majority of primary care doctors match the OP's description. They order a standard test, check if the results match the most common problem, and then either prescribe the typical medicine the patient probably came across with a few minutes of searching, or shrug and send them on their way.
I know in theory they are supposed to look at the big picture and weigh a myriad of factors in coming to a diagnosis. In practice, they mostly just check if any of the blood test results are outside of the reference range and call it good.
I'm sure there are great primary care doctors out there that want to defy their own incentives and do the right thing, but trying out a bunch of doctors can take a lot of time and money, often with no payoff.
My mother did this on my behalf when I was an infant, just a few weeks old.
"Nothing is staying down. Always throwing up. Not gaining wait."
"Oh yea yea sure new mother. You'll get the hang of it. Come back next month see you then. Naturally under weight since birth it's normal for the kid. Thanks bye."
Rinse and repeat until some doctor got bloody tired of the repeat visits. "Fine, come on in and I'll take a look." A few minutes later it was "oh fuck" and I was on a gurney being wheeled into surgery.
So now that it's decades after I didn't starve to death thanks to a procedure that didn't exist before 1912 [official diagnostic criteria at 1888] ... yea. Maybe sometimes you should bother your doctor(s). Sure, humour them and leave a lot of the time but when you know it's Not Good ... make them stop humouring you.
Just watch a season of Mystery Diagnosis if you want to lose faith in doctor prognoses. Most of the individuals end up figuring it out themselves and then finding a specialty doctor.
Main treatment program for a doctor: go home and see if it gets better
I think some "industries" shouldn't work as a normal business, health, education, law / police. They just don't work as a business and will end up corrupt because money.
Education hasn't gone well publicly so far in America. I'm not sure completely private is the answer but something needs to change. Government funding has led to massive amounts of money being spent for negligible results. Agree on health, law / police though
But isn't the problem with public schools in the US that the funding comes from taxes in the school district itself, so ppor districts will get a underfunded school while rich districts get a well funded school?
Anyway, the school system should be changed dramatically everywhere. The current paradigm is hurting children and should be abolished.
In Michigan, where I grew up, Detroit public schools got about 50% more funding than the public school I attended. Want to guess which schools had better outcomes?
I would expect schools in impoverished, troubled neighborhoods would cost QUITE a bit more than schools in wealthy neighborhoods in order to get the same results.
The students are more likely to be facing food insecurity and odd parental schedules at home. The school may need to spend more keeping their student body safe. And one kid with a violent parent who reacts by being violent in turn can wreck havoc on the rest of the classroom. That kind of person might need an education that is more therapy than academic.
While proper and equitable funding of schools is an issue, unfortunately, it seems the peer group and home life of a student make a very big impact on their probability of success, and if we allow a people to freely move around, society seems to sort itself by socioeconomic status and as the income/wealth gap gets wider, there is no amount of funding that can make up for the effects of not having a wealthy, knowledgeable, and motivated peer group.
The problem with schools in the US is and has always been segregation. The problem is that local versus federal control of schools allows local politicians to bow to the deranged, racist fears of upper class parents, as opposed to policies, like integrative bussing, that actually improved outcomes.
Forcing integration, which would mean forcing people to live in certain places and not be able to send their kids to private schools) is less likely to succeed than efforts to structurally reduce income/wealth gap (aka wealth transfer from rich to poor).
> Forcing integration, which would mean forcing people to live in certain places
Not sure I follow. Busing was premised on the exact opposite of this?
I’m all for structural change on many fronts, but I’m not sure that private schools should even exist. It’s hard to build successful, high performing universal services, and especially for education, if the wealthy can just construct a separate, parallel system that becomes a social marker for perpetuating elite status.
Private schools enabled my family to give me better opportunities than they had. Rather than go to the school next door with the heroin dealers, I went to a neighboring town full of motivated peers. Why do you believe private schools shouldn't exist? For some it's the only way out.
They stated why. If you allow people with the means to do so to opt-out of a system, they do not participate in the system. The system now loses the governance and to some degree resources of those people with means.
More specifically, rich families put their kids through private schools and abandon the public school system. Without skin in the game, they vote to reduce the budget of the public school system. Rich families generally have more time and resources to spend being involved in the schools. They won't be spending those resources advocating for improving the public school systems. Additionally, their kids, who are well-cared for and come from a family who values education, do not form a peer group with the other less fortunate kids. This deprives those kids of better peers to model.
Now, you can argue that the freedom of and benefits to the rich families trumps the benefits that the poorer families would receive, but there is a greater good argument.
I've seen it argued that universal social programs are generally seen to work better and are more popular compared to means-tested ones. For example, Medicare and social security vs Medicaid and TANF.
I doubt people with means are going to want their children to waste time being transported from the rich side of town to the poor side. I would just move one town over.
You're not likely to get American voters to vote for the government picking their location and/or income. As an American in flyover country, the people here would rather die than become reliant on the government or work
I agree that that is a sentiment (being from one of those states originally), but then you have to start talking about how very reliant those same areas are on government programs (in other cases those same people would call hand-outs):
1. Rural telecommunication is highly subsidized. People living in cities almost entirely fund the expensive infrastructure needed to connect those living outside them.
2. Rural electric is mostly done through semi-governmental agencies (co-ops) that are largely built using government-subsidized loans (small hand-out) and grants (larger hand-outs). Urban electricity is more (but still not completely) private.
3. Farmers (the basis of most rural economies) are generally protected by government-subsidized and run crop insurance programs, and have a number of programs that pay them to fallow their land at times (direct payments not to plant things to manipulate the market). There are also numerous subsidy programs to make direct payments to shore up effective commodity prices.
4. Social Security is just a baseline everywhere. Despite the system that is designed to fool you into thinking you pay for your later payments through wage taxes, most people who make it to retirement get out much more than they ever put in (even adjusted for interest and inflation).
So I would submit that those same people who talk about not being dependent are in face highly dependent.
> Education hasn't gone well publicly so far in America
It has in most the rest of the developed world; maybe (as with healthcare) the problem is that the system has been deliberately compromised to benefit private providers for financial and (more for education than healthcare, though it's a factor in both) sectarian reasons by the same people that use the poor results to rail against the public system and for (usually, publicly subsidized) privatization to further benefit the same private financial and sectarian interests. And not a fundamental problem with the service being publicly provided, which plenty of countries manage to do quite well.
> Agree on health, law / police though
To be fair, public provision of both of those are pretty bad in America, too, though the private provision of the former is worse.
The US however is not a good example of public education. School fees are quite high. Private companies push student loans eagerly. Funding to schools is highly depended on neighbourhoods.
To see that publicly education can work very well. Look at Finland e.g. But there are also many asian countries showing good results with public education.
Based on my experience as a foreigner in the US, the US school system strikes me as something operating far more like private enterprise. Schools compete for students while there are no strong national standards and so you get insane grade inflation. I was shocked when I studied in the US how high grades where. Anything to please the "customers" I mean the students I guess.
The logical reaction should be to analyze the problem and try to suss out the cause. Unfortunately, the cause seems to be a widening wealth/income gap creating a segregated society and a lack of stable and supportive families on the lower income end. The solution to that, a long term initiative to change culture and create stable families and wealth transfers, is politically impossible, so the next best, easiest thing one can suggest is more funding for the schools.
US has fine reasonably affordable public colleges. The student loan crisis is about people who shouldn't have attended those private schools in the first place.
Whether or not you officially "privatize" them police departments having to insure themselves, pay their own lawsuits, justify their expenses (i.e. departments that don't need APCs probably wouldn't have them) and deliver sufficiently high quality service that their customers don't decide to hire someone else to do the job and generally behave like a business that cannot rely on always being propped up by the city/state is a wet dream of many (dare I say most) people seeking police reform.
While this doesn't invalidate your point entirely, I have never met a person who want the police run as if they fear being replaced by a different agency.
Everyone I have ever meant who want police reform, at their core, want accountability and a lesser reliance of lethal weapons as a primary tool.
There are other topics depending on where you come from, e.g. racial diversity, but I've yet to meet someone who wants the police to act like a private force.
Yes, but a thought is that if police were private they would have liability for their actions which perhaps is stronger than accountability in someways.
They change names every chance they get it seems. I recalled that they went to Xe, but that's not accurate any more either. It's incredibly twisted how easy it is for them to get away with literal murder, but if the wrong person aggravates the wrong cop it can ruin your life.
It's orthogonal to the linked story, but I attended a dinner the other night where the presentation was on advances in MS research.
The speaker, an MS researcher and clinician, noted among other things that we've been really really wrong about how many folks in the US have multiple sclerosis - like, by a factor of 2. There are lots of reasons for this, but it's not JUST the lack of easy diagnostic tests.
Until relatively recently, there were NO real therapies for MS, so doctors were hesitant to make the pronouncement. Add to this that a diagnosis of MS would qualify as a pre-existing condition, and would prevent the patient from getting health insurance (pre-Obamacare, anyway), and would absolutely put the kibosh on life insurance.
So there were real world consequences, and they were therefore hesitant.
This is still the case. I've had ongoing neurological and digestive problems for years now, and each primary physician or neurologist I see has been hesitant to run tests let alone attempt to diagnose what's going on. So they labeled it as "stress" which made me feel like I was crazy for a very long time. Paradoxically this caused me a great deal of stress. I ended up seeing two different mental health specialists - one with experience in somatic disorders - that concluded (after months of therapy) it's not a psychological problem.
There's so many experiences reported in MS and other neuro-based communities online where people were given the stress and anxiety label only to be diagnosed months, years, and sometimes decades later with an actual illness like MS. I feel truly bad for people that have the extraordinarily rare diseases because chances are slim they'll find someone to actually investigate beyond the standard textbook procedures.
I think part of it, but also not the entire story.
Take cancer, for example. The treatment is so toxic (potentially deadly) that we want to make sure that our diagnosis is as close to 100% as possible. To the point where if you want to transfer where you get your chemotherapy, the new place will insist that you bring not just the biopsy report that shows that you have cancer, but the actual 'slides', the actual biopsy tissue for them to independently evaluate.
Contrast this with MS where there is virtually no therapy (until recently), the tests themselves are very expensive (multiple MRIs over time) and the tests aren't even that much better than just talking to the patient and examining them. But, both the MRIs and the clinical exams/interviews require multiple visits, sometimes with years of monitoring in between to truly make the diagnosis.
The system just doesn't incent this type of care and certainly doesn't reimburse it very well. Patients want answers and answers now. Doctors are hurried. Insurances change so you have to change networks, etc, etc, etc.
> The treatment is so toxic (potentially deadly) that we want to make sure that our diagnosis is as close to 100% as possible.
I think you're ignoring how obscure some symptoms of cancer are, though. My cousin went back and forth with the doctor about a recurring cough, for 3 or 4 years. It turned out to be bowel cancer, and while they did treat it, it was too late by the time anyone in the medical system thought of that. The only indication that would point them towards bowel cancer, was the medical history of her family, her grandmother had it too. She was rather young as well, late 20s/early 30s, so they just didn't consider it.
Many focus on the doctor, and surely his moral compass was off. But from a birds eye perspective the primary problem here is companies paying doctors to recommend certain pills and procedures.
This can make a doctor which was semi-decent and quickly turn him into a greedy immoral person.
I don't think it should be legal for companies to pay doctors to promote their products. Do anyone disagree?
My wife is a resident. She used to intern at PCP clinics and was invited by her supervisor (a physician) to one of the dinners hosted by pharma companies (Sanofi, if I remember correctly). The dinner was a feast. The doc invited everyone in her clinic and their immediate family members. We had Shirmps, Lobster, Wagyu beef (I know it's a redundant word, but that's how it's known in the US), lamb to our fill. Sanofi rep footed the bill (and asked us to sign our names on a sheet when we arrived).
Experiencing that dinner and seeing my host family mom (a practicing psychiatrist in the US for a private psychiatry hospital) getting food every week from pharma reps, makes me feel disgusted about the connection between doctors and pharma companies in the US.
I have MDs in the family too, their continuing education classes are sponsored (free) and with feasts provided as well.
Lawyers have to pay for our required continuing education classes. Sponsored courses and retreats are clearly a conflict of interest for MDs.
Also, as lawyer, I remain shocked and saddened to see how US medical providers have abandoned patient privacy in the wake of the US opioid crisis. Patients prescribed any controlled substance are now put on registers that almost any state actor (or local police) can review at will.
US MDs have thrown their patients under the bus because they (or their colleagues) were (lazily/blindly/greedily) writing too many opioid prescriptions.
Ask the AMA. Docs should have stood fast or at least forced more patient privacy protection. As it is, some health providers require patients to sign broad privacy waivers before issuing prescriptions for controlled substances (including ADHD meds).
My GP didn't even think it was an issue -- here sign this. I couldn't believe what I was reading. I refused and didn't get the meds I needed -- resulting in harm to put it mildly. I am lucky that I am not suicidal because it got pretty dark for me, after a few weeks I had to crawl back to get the meds I need.
The doc invited everyone in her clinic and their immediate family members.
Wow. That's a violation and could get the company the smack-down. No way that family members should be included, even if they pay for their own meal.
"The Code provides that it is not appropriate to include a spouse or guest at a meal in connection with an informational presentation, regardless of who pays for their meal, unless the spouse or guest would independently qualify as a healthcare professional for whom the informational presentation is appropriate."
Congress disagrees. They tried to get that into the ACA but it was a few votes short. They had to settle for more transparency in payments to doctors: https://openpaymentsdata.cms.gov/
That is a tricky one. I agree with the all the problems people point out from the current system. However I also want my doctor to know about all the possible treatments not just the ones that were in vogue when he was in school. That means learning about all this. Doctors - like everybody - have their lazy side and won't always keep up. Continuing education is a part of this, but manufactures reps marketing is another way to get doctors to learn something they might not otherwise.
Again, it isn't perfect. I don't have answers, just a knowledge about how complex things are.
I was keeping an open mind about this doctor, until I read that two other doctors were willing to testify they had thought he was misdiagnosing patients.
Its notoriously hard to get doctors to testify against each other at a malpractice case and the fact that doctors who worked with him were Ing to come in on their own accord is damming
The medical industry has the biggest conflict of interest I have seen in any industry. It's actually bad for doctors if preventive healthcare takes off the way it should, we all eat healthy, balanced diets and exercise to take care of our bodies and mind.
That coupled with genetic diversity, ignorance of their customers and relative ignorance of the practitioners itself (we still don't know more than we know) could truly be a recipe for disaster.
My celiac was misdiagnosed for pharyngitis for long, and since I've stopped taking any doctor very seriously. I read A LOT, visit a bunch of doctors (preferably leading to specialists) and ask a lot of questions before deciding what course of action I want to take.
Luckily, in India, doctors don't charge as much (~$20-40) per session.
> The medical industry has the biggest conflict of interest I have seen in any industry
Private prisons come close. They incentivize having more people in prison.
So, when you see people lobbying against legalizing weed, some of that is genuine concern, but it also aligns very closely to people who realize what a drop in prison inmates could mean for there business...
> So, when you see people lobbying against legalizing weed, some of that is genuine concern, but it also aligns very closely to people who realize what a drop in prison inmates could mean for there business...
Do you have any evidence that this is a legitimate problem? It doesn't really make economic sense IMO. It's a small percentage of people in jail who are non-violent marijuana drug offenders.
The corrections corporation of America only spends a million a year on lobbying- this would be small change even if it was solely spent on anti-marijuana lobbying. But It's more likely that the majority of their lobbying budget would be spent on issues directly related to regulation and spending for private prisons
Not lobbying, but "Kids for Cash" is the worst case I've seen that demonstrates the conflict of interest.
Several judges took bribes from private prisons to incarcerate juveniles for minor offenses. While the judges have substantial jail sentences, the developers got off light at <2 years in jail and some fines. For wrongly keeping minors imprisoned, and leading to the suicide of at least one of the wrongfully jailed.
While it's a small percentage at any given time, it would be interesting to know what percentage of the prison population were "introduced" to prison by that route. Once someone has been imprisoned once, they are at a much higher risk for subsequent imprisonments.
from the second link: "This is a total of 11,533 people incarcerated as a result of their involvement with cannabis products."
Considering that the percentage of prisoners in private prisons is below 10%, we can see that there are less than 1100 people in private prisons for marijuana related crimes.
There is no way that you can generate returns on lobbying for one of the most hot issues in US off of the profit of 1100 prisoners
Totally agree on not trusting any one doctor. Nowadays, I basically assume doctors are narrow minded experts and do the broader thinking myself (by reading widely). It’s the old saying that when you have a hammer everything looks like a nail. I wish I realized the extent to which this is true earlier.
My issue happened to be with sesamoid/metatarsal fracture, flat rootedness, and poor gait. No doctor cared about my gait which turned out to be the root cause of my other symptoms. They all wanted to do surgery/orthotics and basically thought that would fix it alone vs combined with PT.
Those companies where you count some kind of points as you eat and pay membership to turn up for a weekly weigh-in and pep talk rely on the good habits being poorly embedded so that you get fat again without the meetings.
I disagree with the conflict of interest RE doctors.
At least with doctors, people will always get ill. If people no longer turn up for lifestyle-related ailments, they will still come in with a rash or pain or whatever. They will also have fewer complications or confounding factors for diagnosis.
In a profit-driven healthcare system, I would imagine that lots of healthy patients is more profitable for a GP than a few sick ones. The sick ones incur more costs, and end up getting referred away to specialists for much of their care anyway.
I assume you're getting downvoted because short comments are perceived as "low effort", but my sister-in-law is a registered dietician at an eating disorder in-patient facility. She has used the phrase "Uber for eating disorders" to describe those programs...
Yeah, it wasn't intended to be low effort. The entire idea of "dieting" effectively encourages people into eating disorders.
For me, losing a bunch of weight was as simple as cutting out big sugar bombs and alcohol. After about a month, anything that could be classified as a "dessert" became cloyingly sweet and gave me indigestion. I pretty much eat whatever I want otherwise.
In my experience having lost and kept off half my body weight, and I'm sure my family would agree with me on this, effective weight loss basically requires an eating disorder.
I don't know how much weight you lost, but I can't imagine it was all that much if all you had to do was cut out sugar and booze, unless that was the majority of your caloric intake.
About 50 lbs from my heaviest (200 -> 150, or a quarter of my peak body weight). I would say I had an eating disorder before the weight loss -- I frequently ate my emotions and booze and sugar were a big part of that behavior. High quantities of sugar and alcohol make it very easy to consume calories while still feeling hungry. As my relationship to food became one of sustenance rather than consumption, the weight naturally came off.
Encouraging this shift is largely how eating disorders are treated; though in my case it came as a result of dealing with a lot of trauma that I had buried. But ultimately it's about holistic emotional and physical health, and reframing your relationship to food in that context.
> unless that was the majority of your caloric intake
Even if it is only 10% of the caloric intake, it works. Obviously not for losing 100kg, but a 200kcal deficit per day (one less dessert or one bottle of beer) adds up to 10kg weight loss within a year.
Even ignoring perverse incentives, GPs are actually pretty clueless about diagnosing anything outside the 90th percentile bracket. There's a surprisingly low standard of knowledge and no system in place to enforce up-to-date knowledge like there is for e.g. pilots. Go approach 5 different GPs with the same presenting symptoms and story, and you'll get 4 different answers.
Having consulted for the healthcare sector a little bit, I am terrified of ever going into the system if I develop anything slightly unusual.
This is a sector that really needs to be overhauled with evidence based practice and heavy, heavy use of automation and ML to minimise the human element.
> no system in place to enforce up-to-date knowledge
I don't think that's correct. Many states require a certain amount of continuing medical education to maintain a medical or nursing license. It's often not a TON of training and you have some flexibility in what topics you choose to study, but it's something.
Doctors get one thing wrong and then people want to self-diagnose with the internet. It's like a programmer originally thinking a bug is in one function when it's really in another. And then the customer reads a Java for dummies book and thinks they can find the answer.
It does apply to most fields but not all. Notably, pilots are really good at what they do and improve constantly.
It's hard to compare doctors with other fields because a fuckup in most fields will cost money, but a fuckup in medicine will cost permanent damage and lives. If doctors can't live up to a higher standard (and they can't) then we need to minimise the human element in diagnosis and treatment as quickly and aggressively as possible.
Anecdotal but I've personally been saved from a potentially permanently-crippling medical procedure only because my med student friend visited me in the ward and questioned the procedure as it didn't make sense given my condition. If he wasn't around, I would be spending the rest of my life with a mild disability. That's not acceptable, but it happens all the time.
> Notably, pilots are really good at what they do and improve constantly.
This is a fantastic example! I often think about the distribution of talent/competence in fields and that is a very interesting anomaly.
Does anybody know why this is the case? I understand that it's a (fairly) repetitive task, and technology certainly assists, but I think I recently read that there are .2 "incidents" per million commercial flights.
How has an entire industry created a standard that seems to be well above any other?
Because the aviation industry has powerful regulators and an absolute culture of safety first. Every mishap is dissected until a root cause is found, and steps are taken to ensure that root cause never happens again. After a major incident, it's almost impossible for the same incident to occur the same way again.
Nothing like this exists in the medical industry. In fact surgeons and doctors are notoriously anti-process, anti-statistics, and basically don't want anyone scrutinising how they work. I'm not sure how they've been able to get away with it for so long.
Funny thing is, no one programmer can know all languages and systems, and with a short consult into an aspect of a system they're unfamiliar with, would be unlikely to give more than general advice.
Sounds an awful lot like the situation every GP is in... no one human can know everything about the body, so there are GPs that legitimately can't diagnose you.
On the other hand, the person with a particular bug to troubleshoot in themselves has all the time in the world to become their own specialist and do the knowledge synthesis that the generalists don't have the scope for.
I've read way more about my relatively common condition than anyone but the specialist I'm seeing, and I've come up with some things that he was not aware of in the process. Once down a certain condition's rabbit hole, the patient/specialist dialog really should be a give and take.
Late reply, but it often is if you find the right doctor. The problem is the right doctor is often very expensive. All doctors should do this however there are so many quacks that read webmd and think they should be part of the given and take. It reminds me of the thread about words you can use that let people know you know what you are doing. Usually once I mention "peer reviewed" it seems to help.
The reason it's unquestionably better than humans is because it's not possible for humans to be aware of every recorded case of every recorded disease and the various ways it presents itself. But as long as data capture capability exists, an ML model can be updated to incorporate all that knowledge on a regular basis.
The second element of this is that the vast majority of doctors just follow a primitive flowchart to diagnose conditions. It's not like Dr House where they're experts on human anatomy and drug interactions etc. GPs are better compared to phone customer service reps running through a script. ML is better than that.
Celiac here too. I hold a very similar opinion about doctors. I used to have regular sinus headaches. They would prescribe nasal spray. Even after I stopped eating gluten and noticed a correlation I would bring up that gluten gives me sinus headaches and these geniuses would advise me to avoid it. Yea, thanks for the help doc.
I can not believe I had an issue for decades and no medical professional suggested an elimination diet.
> It's actually bad for doctors if preventive healthcare takes off the way it should, we all eat healthy, balanced diets and exercise to take care of our bodies and mind.
Maybe in the short term. In the long term, people will get older and will get more ailments due to age and still go to the doctor. When I visit a GP in the Netherlands, I mostly see children and old people in the waiting room.
I think the problem is less for doctors than companies. Doctors have to personally face their patients. You can only take being an immoral asshole so far.
The problem is health care companies. To them patients are just faceless entities with wallets. The executive making decisions screwing them over never have to see their pain.
There is a parallel to Nazi Germany here one could use. The reason concentration camps were made was because it was mentally taxing to just gun down innocent people day after day for normal soldiers. Concentration camps in contrast got organized so that the victims had to pick up the dead ones and car them off. All the ugliness was out of view for the evil people running the show.
It was easy for Nazi bureaucrats to kill people with the stroke of a pen. Just names on a list. Never had to see somebody choking or bleeding to death.
Hence you get a big problem when power is moved away from doctors to companies. In this example e.g. the doctor while immoral may not have been quite as immoral had it not been for a company actively pushing him to provide patients.
Private enterprise should not be allowed to provide financial incentives to doctors. Who the doctor sends their patients to, should be entirely decided by medical necessity and not influenced by a potential for profit.
> Private enterprise should not be allowed to provide financial incentives to doctors.
One side of the coin. Pharmacy benefit management companies should be scrutinised for their choice of drugs included in an insurance policy and how they price them, etc.
It’s technically true that doctors need patients. But does anyone believe any doctor actually thinks in those terms?
Not just because it’s unethical. The mechanism doesn’t work: your future income will benefit a lot more from being regarded as a competent doctor, than it ever would from the minuscule damage you could do to public health with being purposefully bad.
I’ve also rarely seen doctors that cared about patient acquisition in the way normal businesses do. Since health care is somewhat expensive, governments tend to try running the system with a slightly low number of people.
> It’s technically true that doctors need patients. But does anyone believe any doctor actually thinks in those terms?
> Not just because it’s unethical. The mechanism doesn’t work: your future income will benefit a lot more from being regarded as a competent doctor, than it ever would from the minuscule damage you could do to public health with being purposefully bad.
Almost none - certainly not when it comes to preventive care. The original article shows misaligned incentives with a tiny, short feedback loop, and even then these instances are (thankfully) not common on a large scale.
The idea that a GP would encourage their patients to have unhealthy diets and never exercise, just so that in twenty years some other doctor - a cardiologist, endocrinologist, etc. - could have a greater supply of patients in need of care is absurd. The GP's expected lifetime earnings are not going to go up if their patients decide not to engage in preventive care, and the GP's expected lifetime earnings definitely will go down if they actually discourage preventive care, because they'll develop a reputation as a shoddy doctor.
Where do you actually find good mental health practitioners in India?
My luck ran out last time I tried to find one. I wonder why there isn't any repercussions for lot of self claimed doctors...though government tried to deny the WHO report that said approx 65% doctors are not qualified in India and the rest are dubious to good. Doubled down and passed a bill for recognising ayurveds, homoeopaths, etc as actual doctors.
> The medical industry has the biggest conflict of interest I have seen in any industry. It's actually bad for doctors if preventive healthcare takes off the way it should, we all eat healthy, balanced diets and exercise to take care of our bodies and mind.
Not in countries with a national health system, where the government is incentivized to keep people healthy in order to reduce cost.
In general you are correct but sadly there are perverse incentives even in a system like the NHS. There are two problems. (1) treatments are approved only if they make financial sense for the country and (2) sometimes those calculations go wrong. At one point people were being allowed to go blind based on a cost calculation. Even though letting people go blind was more expensive overall to the country. The cost of treatment to the NHS budget was greater than non-treatment but the social care costs came from another budget.
Because the NHS doesn't optimise for cost, it optimises for cost per QALY (quality adjusted life years). Given the high impact to quality of life for blindness your claim is dubious.
NICE make the decisions over cost effectiveness of treatments, and publish their findings. If you can tell me the name of the drug we can find the actual report.
They may be talking about Avastin which there was a controversy around a few years ago. IIRC despite being originally used as an anti-cancer treatment it was found to be very effective (as effective as other treatments) for Wet AMD (age-related macular degeneration, a degenerative condition of the retina). The NICE approved drug options for the condition were significantly more expensive.
Some Trusts were attempting to make this the first line treatment as an off-license prescription as it was cheaper and the pharmaceutical companies were trying to sue the Trusts for "not providing NICE approved medications and therefore disadvantaging patients" while simultaneously not seeking to license Avastin for wet AMD.
This was a few years ago so I may have misremembered some details.
Surprise, surprise, the underlying complication was someone's profit motive regarding drug selection.
I'm getting really repetitive but transparency transparency transparency.
Let's make public the cases where the suppliers collude to withhold drugs for actual effective usages "because we have this other more expensive option that's the only one we sent in for approval" whine bitch stfu and do what's best for the patients you money grubbing bastards.
Avastin / Lucentis does not support the point being made. Lucentis, a very expensive medication, was both licenced for AMD and was approved by NICE for that use.
Avastin is identical, but was not licenced for AMD and so NICE was not able to recommend its use for AMD.
Doctors were using Avastin off label, and they wanted the government to force Avastin to be licenced for AMD which would have allowed it to be recommended by NICE.
The makers of Avastin and Lucentis fought this in the courts for years, and took action against NHS Trusts using Avastin off-label. The NHS won that legal case.
There is a problem of people going blind while waiting for treatment, but this is related to cataracts and glaucoma, not AMD, and it has nothing to do with NICE (who are the organisation that decides about cost effectiveness) and everything to do with a government that has chosen to de-fund the NHS.
The government may have that incentive, but what about the individual doctors who are actually examining patients and diagnosing people? Do these employees truly share their employer's desire to cut costs?
I don't really believe that doctors are keeping people sick on purpose to keep demand for their profession high, but if that were going on, I don't think socialized healthcare would necessarily erase that incentive. There are plenty of government and private sector workers who try to preserve their own jobs to the detriment of the whole.
Universal healthcare doesn’t erase that incentive, nothing does. You need a vigilant medical board that penalizes bad doctors to deal with that, fortunately something like that can be reconciled with the system we have in the Nordics.
Of course, it’s far from perfect just like any regulatory agency ever.
In countries with national health system, doctors have the opposite target to not referr people further for expensive procedures. A good example was in London,where a hospital was paying to GP practices so they won't refer people for certain treatment ( because of the workload the hospital had). You need to go to your GP at least 3 times before they even start listening what's going on or prescribe more than just paracetamol.
Government is in theory incentivized to reduce costs because it has limited funds.
The thing with healthcare is that the purchaser, if private, pays whatever (s)he can afford (how much is your health worth it to you?). Whereas if the state is the purchaser, it is (a) A monopsony, having substantial power over healthcare providers; and (b) Doesn't care as much about any individual patient, thus being able to make decisions that are rational on the aggregate level
On short: much better to be a healthcare provider in US; much better to be a patient in EU.
Can you please provide some form of a source for your statement? I read this a lot, but I can't find any factual basis for the statement. The US is known for having the highest cost of health care per capita, more than twice that of France and the UK, two countries commonly named for having socialized health care [0].
He's actually right about exploding costs outside the US. Just as costs have exploded in the US, they have also exploded in most other first world countries (and also many non-first world countries). Source provided below.
Yes, the US has the highest cost. But the ratio between the US and others has stayed roughly the same over the last 50 years (maybe longer--that's as far back as my data source goes). The US pays twice as much as France now because we paid twice as much as France in 1990, and both systems have had costs explode by about the same factor since then.
Here's a table of costs per capita in US dollars for the UK, France, and the US:
Year UK FR US
1980 385 659 1036
1990 782 1458 2700
2000 1561 2686 4557
2010 2871 4048 7939
2018 4070 4965 10586
Here it is, with each country's cost divided by that country's 1980 cost:
Year UK FR US
1990 2.0 2.2 2.6
2000 4.1 4.1 4.4
2010 7.5 6.1 7.7
2018 10.6 7.5 10.2
If you do the same thing with most other EU countries, or OECD countries, or other first world countries, the results are similar. Everyone's costs are going up at rates that are in about the same ballpark.
2. Uncheck "latest data available". This enables the year range selector control.
3. Use the year range selector to expand the range to 1970-2018.
4. The chart will then show the total costs in US dollars/capita by year of health care in 50 countries. You can use the "Highlighted Countries" drop down to narrow that to select a "background" of OECD, EU, Euro Area, G7, or G20 if you want. You can then add individual countries using the list on the left of that dialog.
5. You can change what is shown from total to government/compulsory, voluntary, or out-of-pocket and you can change the measure from per capita to % of GDP.
Please find me another country that creates as many new drugs as the US and that has a national health care system. If you dont have such an example it cannot be a fair comparison. the world is not summed up by a single variable.
Why are you moving the goalposts by now requiring the country in question to "create as many new drugs as the US"? I don't see how that relates to this discussion at all.
> Many new drugs are developed in European countries. This is not something that's unique to the US. Americans just pay more for the same drugs.
About 50% of all R&D worldwide happens in the US. The US's global share has shrunk a bit, but only because China and India have grown rapidly, not because Europe has ramped up (it hasn't).
Some new drugs are developed in European countries, or by European pharmaceutical companies - that's true. But European pharmaceutical companies all make a disproportionate amount of their revenue off of sales in the US market. So Europeans quite literally benefit the most from the fact that Americans pay more for the same drugs.
Yeah, but that's America's choice to pay so much more for drugs that the rest of the world pays less for. It doesn't make the US system in any way better.
> Yeah, but that's America's choice to pay so much more for drugs that the rest of the world pays less for. It doesn't make the US system in any way better.
Yes, I agree that it's a foolish choice for the US to subsidize foreign countries' healthcare in this manner. Regardless of this decision that we both agree is foolish, it means that it's misleading to compare cost-effectiveness between the US and other countries directly.
I disagree. You can still compare. There's nothing that requires the US to subsidise corporations. They just choose to do so by not negotiating lower prices.
Switzerland (unfortunately) doesn't have what I (as an Australian) would recognise as universal healthcare. It's very similar to the "public option" to use the US terminology. It is still closer to modern healthcare than the US, but it's not the same thing (and suffers from problems that other more progressive healthcare systems do not suffer from).
If a lot of people in the US can’t afford treatment, then why does the US lead the world in several cancer outcomes? If people were just dying for lack of treatment, that would make outcomes far worse.
Yeah, it's hilarious that this argument is used by Americans as many Americans die because they can't afford treatment [0]. They even pass away from the flu, because they can't afford going to see a doctor.
Because the system has been chronically underfunded for years, been the victim of private-finance initiatives and other underhanded privatisation-by-stealth tactics and is currently tens of thousands of doctors and nurses short. And that's before I get onto the collapse of primary care (GPs).
Still better than getting cancer, getting expensive treatment, still dying, and leaving your family bankrupt.
The US even had a popular TV show about someone who got cancer and started making and selling meth to be able to afford treatment. Fantasy, sure, but nobody outside the US would even consider that a remotely plausible premise.
> Fantasy, sure, but nobody outside the US would even consider that a remotely plausible premise.
Sounds like you've never had a friend or family member die because the NHS found a reason to refuse treatment for their non-terminal cancer. At that point, if you don't want to die, your options are actually more expensive than in the US.
Yes, this happens - a lot more than people on HN like to admit. It's one of the reasons that the UK has one of the worst success rates for cancer treatment out of all of Europe.
The difference is that one system is designed to heal people, while the other is designed to profit from it. In a system designed for profit, poor people have little or no access to medical care, and anyone who's not filthy rich is at risk of bankruptcy when they're struck by an expensive medical condition. There's a drive to make healing people as expensive as possible, because that means more profit. In this system, people being unable to afford healthcare is by design. If you want better care, it's the system itself that needs to be replaced, because not taking care of people who cannot afford it, is part of the system.
For a system designed to heal people, the priority should be to heal people, and to make the cost of doing so as low as possible. In this system, when somehow someone is unable to access healthcare they need, it's a failure of this particular implementation of the system, and something that needs to be fixed. The goal of the system is to take care of everybody.
> The difference is that one system is designed to heal people, while the other is designed to profit from it.
The US system isn’t designed at all. Many if not most hospitals and insurers are non-profits, while others are operated by varying levels of government. The resulting patchwork is regulated on multiple levels of government with a variety of differing policy outcomes, but “profit” is not generally one of them.
There are, indeed, for-profit producers of drugs and medical equipment, but this is also true in the UK (GlaxoSmithKline is a British drug company).
> For a system designed to heal people, the priority should be to heal people, and to make the cost of doing so as low as possible. In this system, when somehow someone is unable to access healthcare they need, it's a failure of this particular implementation of the system, and something that needs to be fixed.
Minimizing cost and maximizing access are, in fact, competing goals. If a certain medical treatment is inherently costly to provide, you have to make a specific choice between cost and access. If you are unwilling to budget for competitive pay for health care professionals, you directly affect the availability of care by risking shortages of these professionals. Likewise if you don’t build enough hospitals. This fundamental constraint applies to all health care systems.
I would argue that having the government individually operate each hospital and directly employ each doctor and nurse imposes a heavy administrative burden that is fundamentally impossible to optimize for cost-efficacy. “Failures of implementation” are inevitable and systemic in this model; you may have paved a road with good intentions but that doesn’t mean it leads where you want to go. This is why the NHS is relatively unique even among universal systems and was not broadly replicated even in other European or Commonwealth countries, most of which seem to have better health outcomes.
I’m not saying the US system is perfect, or even better for that matter, but countries like Switzerland and a Singapore have systems that are arguably more privatized than the US while providing better outcomes as well. Even most countries with universal health insurance have some private sector involvement. The problems with the US health care system are far more complicated than the oversimplified conspiracy theories people keep spouting (theories that aren’t far off from those of anti-vaxxers or known frauds like Kevin Trudeau).
> I would argue that having the government individually operate each hospital and directly employ each doctor and nurse imposes a heavy administrative burden
Current inefficiencies in the NHS are caused by lack of investment in buildings and in staff. The NHS has less management than similarly-sized commercial companies, and none of that management is The Government.
> NHS England is responsible for overseeing the commissioning, the planning and the buying, of NHS services. In practice it also sets quite a lot of NHS strategy and behaves like an NHS headquarters. NHS England commissions some services itself, but passes most of its money onto 200 or so clinical commissioning groups across England, also known as CCGs, which identify local health needs and then plan and buy care for people in their area – people like you and me.
> CCGs buy services from organisations of different shapes and sizes – from NHS trusts that run hospitals and community services, to GPs and others that provide NHS care, including organisations run by charities and the private sector.
Right, so “the government” funds a few public agencies which themselves pass on money to the CCG’s, which also seem to be quasi-autonomous public agencies. The actual care providers are sometimes in the private sector. I’m not sure what distinguishes NHS England or the CCG’s from “the government” other than semantics, but sure.
This is still more administrative overhead than other “universal” systems and does not seem to address the tradeoffs between cost and availability of care. Per Wikipedia:
> A survey of CCGs by the Health Service Journal in April 2015 found that more than a third were planning to save money by restricting access to services, particularly on "procedures of limited effectiveness", podiatry, IVF, and limiting access to procedures based on aspects of a patient's health, for example whether they smoke or are obese, which can affect outcomes.[30] A similar survey by the GP magazine Pulse, in July 2015, found that many CCGs were planning to restrict access to routine care in various ways.[31]
> I’m not sure what distinguishes NHS England or the CCG’s from “the government” other than semantics, but sure.
They're not run by a government minister; they're not staffed by civil servants; they're not a government department.
> This is still more administrative overhead than other “universal” systems
It really isn't though. Of course some management exists, it's a budget of over £100bn. But compared to other healthcare systems the NHS is relatively efficient. "The NHS is over-managed" is a persistent myth. See for example chapter 2 of this study: https://www.nuffieldtrust.org.uk/files/2018-06/the-nhs-at-70... (This study does contain a lot of stuff that the NHS is poor at).
>> They found that the NHS spends relatively little on overseeing and planning care, relative to other comparable systems. In 2014, the UK, Portugal and Ireland all devoted 1.5% or less of their government or compulsory health care expenditure to administration. This compares with an average of 3.1%, with 4.1% in France, and 7.9% in the United States.
> "procedures of limited effectiveness"
They're not going to fund things that don't work. Why is that a bad thing?
But, again, I've said that there are problems caused by the choice to de-fund the NHS and that if we had comparable funding as other nations we'd start seeing better outcomes.
That is a dogmatic statement not supported by any evidence. Many countries have really quite efficient governments. e.g. the UK spends less taxpayers money per person on healthcare than the US and we have free medicine, longer life expectancy and better health outcomes.
https://www.bbc.co.uk/news/uk-42950587
> the UK spends less taxpayers money per person on healthcare than the US and we have free medicine
Well, sort of. Some treatments are free. Some other treatments are not covered at all by the NHS, which counterintuitively makes those conditions more expensive to treat in the UK than they would be in the US.
> longer life expectancy
Life expectancy is a horrible way to compare healthcare systems, because there are far too many confounding variables to draw any meaningful conclusions. In reality, factors such as genetics, economic history, and demographics will overpower any effects that healthcare delivery could possibly provide.
> and better health outcomes
Not quite. The UK scores better on some healthcare outcomes, but it scores dramatically worse on others. For cancer treatment, in fact, it's one of the worst in Europe, and far behind the US. (This has been demonstrated by a series of studies that have been replicated multiple times over the past 20 years, the most recent being published only one year ago).
> "It's hard to see how this can be true, since government operations are infamous for excessive cost."
It's only hard to see when you believe what business lobbyists tell you. It's actually easy to see when you look at the numbers.
The real lesson here is: don't believe everything people tell you. Look at the evidence first.
Now there are plenty of government projects that are woefully inefficient, but health insurance seems to be one that governments are actually good at. Maybe not great, but better than an unregulated market.
> Maybe not great, but better than an unregulated market.
The US health system is very highly regulated. For what an unregulated market looks like, see the software business. Consumer costs for software have been largely driven to zero.
The US health system is not as regulated as in other countries where health care costs are much lower.
The software market is a very different market from the health care market. An unregulated software market may not quite be a free market due to monopolies and vendor lock-in, but for consumers, it's quite possible to say no to any software purchase. That's not the case with health care, where often your options are to pay or die. That means that in a profit-driven health care market, prices can be raised indiscriminately, especially in the case of the US where health care prices are often kept hidden, because the people who can afford to, will pay anyway. There's better margins in providing health care to the rich than in providing it to the poor. It's profitable to let the poor go without healthcare.
This makes the healthcare market a very poor market to let be government primarily by a profit motive. Of course health care companies in other systems still make a profit, but they are very limited in how far they can rip off their customers compared to the US.
How much have you paid for Linux and all its utilities and apps on your computer? How much are you paying for your TV and hard disk drives? How about food? clothing? furniture? That's all become so cheap that people constantly give it away to the thrift stores.
Sure, private businesses want to charge as much as possible. But they only succeed when they've managed to get the government to limit or eliminate their competition (as goes on in health care).
That's a meme in the US, but not really elsewhere as far I know. Private organisations are also very good at wasting money, especially if it isn't their money.
And their only driver to decrease costs is profit, not lower prices. If those private organisations could run it cheaper than the government, the rest would end up in the pockets of shareholders.
In France if, for an average employee, you add the employer and employee contribution to social security, for 40 years, you find that it pays two large houses.
At the same time most average employees will struggle to buy a house.
And the social security will reimburse well only medical costs (visit to family doctors or medical acts done in hospitals). For other costs, hospital care, glasses, dental or hearing costs, it reimburses very little.
So for me France's SS is actually a kind of mandatory way to channel money towards doctors.
Lets assume that instead that money would go to the employee and not to social security. And we will assume that a large house would cost about 500k EUR. Thus, in 40 years, you would have collected a million euros more. That is about 25k EUR extra per year. That seems to be about the amount of income tax a French citizen would pay every year.
Thus, that money doesn't just go to health care. It also goes to other social security programs and government projects.
It sounds like you fall into the tail of medical diagnosis. Doctors are incredible good at traumatic response, that's where they're at their best. They're not so great at chronic illness. They're terrible at prevention. If you fall into the edge case of a chronic illness, where it is tough to diagnose (i.e. a test doesn't just spell it out for the practitioner), you may as well be on your own. You have to do tons of research into symptoms, isolate your environment and diet, etc.
I've been through this, and I've seen a close friend go through this, and doctors have been far more harmful than helpful in my n=2 experience. They're quick to diagnose the most common possibility, and dismissive of any other possibility. But here's the thing: that all makes sense! Given the demands on doctors time and the ROI for quality of life for patients, doctors are, and should be incentivized to spend as little time as possible per patient and to diagnose them with what is most likely, given the evidence and previous knowledge.
I think medicine is one of the last great frontiers for the people to relaim through the internet. We don't take anyone's word for it when it comes to any other field, only medicine. I think we should all come to accept that we are our own doctors, first and foremost. We need to research how to take care of ourselves. Doctors are dramatically undertrained on preventive medicine (particularly diet), and I've had them tell me things that are flat out wrong, including outdated science: "losing that much weight is bad for you" when I dropped from being obese over a 6 month period, "that diet is very unhealthy" when I tried Paleo, "fat's will give you heart disease" when I tested with keto and wanted blood work done, "there really is no need to supplement" when my blood work showed severe deficiencies in vitamin D and Magnesium (both extremely important), etc etc.
Preventive medicine and health optimization does not come from doctors, we need to stop expecting it.
I went to several specialists for a chronic digestive disorder and got wildly varying, directly conflicting instructions on which, if any, dietary choices might help me feel better. The common belief was that no dietary choice could make a significant difference.
After 2 years of weekly injections, during which my health declined precipitously, and a couple of surgeries that took ~4x longer than expected for recovery, I abandoned this approach. I have since gotten my condition almost entirely under control through diet and other lifestyle changes.
If a doctor had told me the simple rules I now follow, perhaps surgery and $4k/mo biologics could have been avoided, but the incentives are aggressively aligned against this option.
Similar to Goodhart's law: When a measure becomes a target it ceases to be a good measure [0]. You see it everywhere and it usually happens when we try to quantify a quality (like "competence"...)
Great! Let me hook you up with the latest medical AI technology. Actually, let me hook you up with all of the latest medical AIs, throw your symptoms at them and let them treat all you ailments. And add to that, all the latest medical robotics, and we'll take the surgeons and intensivists, interns, and nurses away.
Good luck with that, I'm sure you will be much happier and healthier when the current AI tries to decide whether you are acutely dying of hypercalcaemia or a cardiac tamponade and Marshalls the robots to save you.
\s
For all the faults and failings of doctors (read: humans), I find many Hacker Newsers vastly oversimplify what doctors do and vastly overinflate what AI is able to do now, or will be able to do in the next ten, twenty, or even 30 years.
It's great that we not have some AI that can diagnose a stroke better than a radiologist on a CT scan. But it can't tell you the scan also shows a space occupying lesion. Or hydroencephaly. Or an extra dural haematoma. Or any other intracranial pathology. And that's about the state of the art.
I welcome new diagnostic aids as I think most clinicians do, but I would take the fleshy system we have of human healthcare providers and suspect that will be the case for a good while yet.
Honestly, many of the obstacles seem to be social and procedural ones. We already have the technology to easily facilitate better communication between e.g. PCPs and specialists to better diagnose rare diseases, but it's not used well. Medical centers are still faxing everything around, doing manual data migrations, and have little in the way of technological standards. There are flatly stupid traditions such as doctors working 24+ hours at a stretch when we force truckers and airline pilots to limit their hours far below that for less mentally demanding jobs. The social structure of medicine is an ossified, dysfunctional mess and all the diagnostic aids in the world aren't going to fix that. That's why I feel that people want to replace it all, regardless of how feasible it might be right now. Fixing the logistical, economic, and procedural problems that prevent people who need to be in a scanner from getting there quickly enough will do substantially more than getting a few percentage points of extra sensitivity or specificity by letting an AI read the scans. We don't need some far future technology, we need medicine to use existing technology intelligently.
>It's great that we not have some AI that can diagnose a stroke better than a radiologist on a CT scan. But it can't tell you the scan also shows a space occupying lesion. Or hydroencephaly. Or an extra dural haematoma. Or any other intracranial pathology. And that's about the state of the art.
Why couldn't a model report all discernable co-morbidities?
I don't see any form of objective data analysis remaining optimally in the hands of humans for long.
Double checked by humans, in the short term, sure.
There's arguably zero 'creativity' in diagnostics. It'll be automated within a decade or two IMO.
> Why couldn't a model report all discernable co-morbidities?
It could, but it's not there yet. I was trying to illustrate the enormous chasm which AI has yet to cross. Even if an AI model is trained to interpret all head CT pathologies, that is an absolutely minuscule part of practicing medicine.
Let me be clear that I agree that many of the functions of doctors are theoretically replicable with technology. I just have radically different view to the timescale that this will be on compared to many HN-ers who seem to equate treating patients with analysing a computer program, a comparison which is woefully inadequate.
The advances in image interpretation AIs in medicine are a bit misleading as they are literally the lowest of the low hanging fruit. There are huge amounts of data to mine with both normal results and pathological ones, and the data is already in a relatively consistent and nice format for the model to be trained on.
And yet it's 2020 and we don't even have accurate computerised diagnostics for ECG interpretation which is essentially 12 arrays of floats.
I relish the advances in tech, but the chasm between what "robo-doctors"/"AI" etc can actually achieve right now to benefit patients and what a doctor even just out of medical school can do on a day to day basis is vast. The progress in "potential doctor replacements" we have seen from the technology sector is hugely hyped but realistically has a minuscule effect on patient outcomes at present.
I understand people become very frustrated with inadequate healthcare systems and especially when mistakes are made. The go-to answer of "doctors are scumbags, they don't do anything anyway and AI will replace them in a decade" is facile and ill-informed.
Yesterday I walked past a patient who was vomiting fresh blood. She needed urgent wide bore IV access, bloods, blood transfusion, review from upper GI surgeons and head and neck surgical oncology and immediate return to theatre to open up her neck and explore what was going on to hopefully fix it. There is not the slightest hint of a technological solution to this managing this single random example of which I could have picked many thousands more.
Last week I was called to ED to review a patient who had had an industrial accident with heavy machinery and had an almost complete degloving of his arm and almost complete amputation of the same. The diagnosis is easy in this case, but which software is going to keep the man alive and try and save his arm?
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Diagnosis may not be "creative" but as another commenter points out it is nuanced. I've commented about this before but the main challenge with tech for diagnosis is data collection. It's easy to train and run models on numerical data such as CT scans and blood results because the data collection is easy. Even then the tools we have are pretty useless at present. In my hospital we have an automatic warning if the system suspects a patient has sepsis, which is great. However, it's also often wrong. Which, were it allowed to and able to manage the patient would be a complete disaster. ECGs provide automated interpretation which are usually complete BS.
However, patients are not numbers, or programs; eliciting the information you need to make the diagnosis is the hardest part and that is significantly more challenging than a flowchart. E.g. patient found unresponsive at 3am by a canal, no further info. Where is the AI solving this right now?
Once you have a diagnosis, or at least a working diagnosis, you then need to be able to actually instigate the management for that patient. I have yet to see anything that can automatically take blood, cannulate a patient, intubate a patient, perform a ring block with local anaesthetic, run a cardiac arrest, etc.
The chasm looks small from a distance but when you get up close, it's actually really big.
And who would pay for that AI physician? Hospitals and other for profit corporation. It’s hard to believe that a less transparent, more centralized system could only have positive effects.
The problem is in the US incentive structure, not with the doctors.
Sure. Until the AI makes mistakes and you get seriously harmed but you find that you can't really blame anyone because you were warned not to blindly trust the AI in the ToS.
A benefit of "socialized medicine", provided the government is not corrupt, is that medical practice can be evidence driven. E.g. compare rates for wisdom teeth extraction and tonsillectomy between the US and UK.
The other side of the coin is that there are lot of (or at least some) doctors who will “misdiagnose” a patient to get them appropriate treatments that insurance would otherwise not pay for.
Personally, I had a number of very large lipomas on my body that no insurance would normally ever cover the removal of as they were cosmetic and socially stigmatizing and not dangerous to my health. My doctor filled out all the necessary forms with the proper magic language and my insurance paid the bill. These are simple, 10 minute, outpatient medical procedures that require a knife and $.25 of numbing agent. I could have done it myself if I could buy something OTC to numb myself.
Not all doctors are just looking to pad their billables.
In order to counter these risks, we prefer going to doctors and hospitals that are so busy (and highly regarded) they don’t have time for bullshit.
Of course it helps being in a large city with many options and excellent insurance. Without this, I’d probably be getting g second and third opinions constantly.
This actually sounds like an honest (mis?)diagnosis. Confusing migraine and temporal lobe epilepsy is not a particularly egregious mistake, and the two conditions often occur together. A number of anti-seizure medications are prescribed to prevent migraines.
Jesus. How corrupted people are becoming. And if there's one type of people that absolutely can get corrupted are doctors. They're dealing with lives after all. The implications can result in death or at least a lot of suffering;
Our medical system is completely wrong. Doctors should get payed for the time their patients are healthy. As soon as they fall ill, payment should stop until they are well again.
So patients who have difficult to treat illnesses or low chances of survival don't get treated at all?
"Healthy" is also a bit of a misnomer, as there are plenty of (currently) incurable conditions that require treatment not to improve, but to keep from getting worse. For those people, healthy is either not achievable, or is a very different state of being than others.
Here in Germany we occasionally have similar headline making cases and scandals. We also have similar incentives, since how you make money as a doctor is the same basic principle.
> Could we add "in the US" to the medical news that may not be that relevant in other countries?
The incentives are misaligned in many other countries, including Germany and the UK. This article focuses on examples in the US, but as noted elsewhere in these comments, there are plenty of articles that show examples of similar perverse treatment incentives in other countries.
Except nowhere are the incentives as screwed up as in the US. Sure a doctor does have a financial incentive to not always do what is best for you anywhere in the world. But in most places this concern competes strongly with a sense of moral duty.
In the US you have companies which have no scrupulous because they don't see or know the patients they screw over, actively push and incentives doctors to work against the interests of their patients.
The prevalence of companies paying doctors to prescribe certain pills or suggest certain procedures seem to me more of an American problem. At least in my home country I highly doubt such an arrangment would even be legal.
I mean this just fits in with the opioid crisis in the US. Where medical companies would basically send young prostitutes to doctors to try to persuade them to push their drugs. Yes this is a fact. These companies hired young pretty women, which frequently slept with the doctors they were supposed to influence. The companies made billions while patients died left and right from their drugs.
I cannot think of anywhere in the developed world where anything remotely as horrible has been going on in the health care sector. While everybody has challenges in their health care sector, everything pales compared to what is going on in the US. Greed as completely taken over.
More, short visits that align with high cost billing codes.
And a high % of doctors are walking medical maladies themselves that don't read research studies even in their own field. Simply focused on bill high, follow procedural algorithm, don't lose job/get sued.
Most dentists are perfectly capable of providing the correct diagnosis. Unfortunately, even if and when they are, there are obstacles:
- Weak incentives to provide an accurate diagnosis
- Strong incentives to provide a particular inaccurate diagnosis
Giving a correct diagnosis often means investing more resources, as well as continuously investing in education and tooling. If the patient doesn’t see the difference between a correct diagnosis and “probably correct diagnosis” then they will react the same in both cases.
This situation where every diagnosis is perceived as the same, an examination is one of the least profitable services provided by dentists and, naturally, falls into the problem of “adverse selection.”
Some dentists recognise the opportunity of giving the wrong diagnosis to get a higher benefit. Be it by keeping or winning over the patient or by leaving room for the ability to recommend costly treatments.
The results of this are:
- Patients on average get a less correct diagnosis
- Dentists earn little to nothing for their diagnostic work