
Unnecessary medical care is harming patients physically and financially (2015) - oftenwrong
https://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
======
hliyan
I live in a 3rd world country (Sri Lanka). Healthcare is not as advanced as it
is in the US, but it is decent for all except the most complicated cases. The
vast majority of people use the free services at state hospitals. If you want
slightly better care, you can go to a private hospital and still come out with
most of your wealth intact.

I recently had a minor surgery to remove a conjunctival granuloma from my left
upper eyelid. It was a private hospital, and it cost all of $50. Compared to
US standards, the facilities were spartan, but adequate and hygienic. Also,
doctors and hospitals do not live in constant fear of malpractice suites. I
suspect these factors have a lot to do with the costs (in addition to the
obvious cost-of-living adjustment for the third world).

~~~
0568p11xf
Interesting. There are hundreds of other cost issues in the US in addition to
malpractice. Perhaps foremost is the obesity epidemic and the chronic diseases
that result from it.

------
oftenwrong
This article came to mind this morning when I made my second visit to the
orthopaedics department at a local hospital. The department schedules all
patients for pre-appointment x-rays. That is, before the patient is even seen,
before the doctor can determine if an x-ray would even be useful. On my first
visit, I missed my x-ray appointment. The doctor I saw that day later said
that was no problem. According to him, an x-ray wasn't necessary given my
symptoms. I was scheduled for an expensive, unnecessary x-ray for no reason,
basically. On today's visit I simply declined the x-ray, and the doctor I saw
today was fine with that because he also did not recommend that any imaging be
done.

~~~
rbanffy
You were scheduled for an expensive, unnecessary dose of radiation that would
be billed to your insurer and that's how the provider makes a ton of money out
of you.

The _only_ priority of any sane health system should be to make people's
health better.

~~~
troycarlson
Bundled payments are slowly gaining traction and help align incentives a
little better.

[https://en.wikipedia.org/wiki/Bundled_payment](https://en.wikipedia.org/wiki/Bundled_payment)

------
davidscolgan
In the book Antifragile Nassim Taleb cautions against medical care unless it's
truly necessary. He argues that since so many things can go wrong in a
hospital (you could get sick from someone else, mistakes could be made, etc),
only go if the benefits outweigh the risks.

And so if you have cancer, it's probably worth the risk. But if you have
something that could just go away naturally, that's got a higher expected
value of positive outcome.

He is in favor of subtractive medicine - many harms are caused by adding such
things as smoking, sugar, preservatives, etc, and instead of adding medicine
or surgery, remove the elements that the body isn't evolved to tolerate and
see if it heals itself.

He gives the example of how he hurt his back weight lifting. The doctor
proposed surgery. He just waited and his back healed itself, and in a way that
is now more robust than if he had had surgery.

As with all things, it's not a black and white kind of decision, but this
mindset has worked well for me as a heuristic for health.

~~~
hidenotslide
Nassim Taleb is great at providing backward looking advice. My back got
better, therefore I was right to ignore the expert advice. He has predicted
about ten of the last two financial crises. I wouldn't take medical advice
from a financial pundit who can't seem to go more than a day without picking a
fight on twitter.

~~~
scottlocklin
My blog making fun of Taleb used to have higher page rank than his personal
website. However, Taleb is totally correct about this, and his Antifragile
book is very good (though he still needs an editor).

Most of modern medical science is quackery and pharma companies trying to milk
the populace for profit. Trauma surgery is quite good, and antibiotics and
vaccines are important. Other than that, I'm pretty sure going to the gym and
the salad section of the grocery is much more important than going to the
doctor.

~~~
hidenotslide
He may be right in this case, I am not a doctor and don't know the details of
his anecdote. My point is that if I'm looking for medical advice from a pop
science author I'd much prefer Dr. Gawande's evidence and experience based
account to some half baked story about convexity.

I'm not even sure whether Taleb's style of writing is meant to communicate
much at all, what's the point of all this phony formalism?
[http://www.fooledbyrandomness.com/medconvex](http://www.fooledbyrandomness.com/medconvex)

I'd like to see Taleb acknowledge at least that medical and financial
estimation risks have a different character. Financial mispricing is
adversarial, whereas you'd have to be more cynical than me to think doctors
are always trying to get you to take the maximum care they can sell you.

------
hestipod
I was preparing to make a long post asking for ideas/help (been saying that
for weeks but it's ready and I was waiting to Monday since weekends are
slower) This sort of thing ruined my life, cost me everything, and has finally
brought me to the precipice. I was convinced 15 years ago to have surgery to
"prevent later disability" and it ironically left me disabled and in severe
pain. I later found out abroad from several doctors that I never needed the
surgery but the catastrophic damage was done, but they did improve things
slightly and Ive been trying to get back to live there but cannot.

A few years later in some nightmare the "repair" surgeon messed it up far
worse and changed the procedure we had agreed on, but I signed the vague forms
hurridly shoved in front of me as I was being prepped and legally he as
allowed to. I never would have agreed to that procedure he did had I been
clearly informed. They got paid...my life got ruined...and things slid
downhill from there as systems and people failed me. Now I am facing seemingly
insurmountable needs and costs and more surgery which terrifies me and I would
never trust having in this country if at all.

It's long story that has no TLDR. I am at my wits end and don't know if a
comment here is the right place to share whole thing, or if I should make my
own post now or Monday...I need as many eyes on it as possible if there is any
hope.

~~~
TallGuyShort
>> vague forms hurridly shoved in front of me as I was being prepped and
legally he as allowed to

One of the many problems when the legal system has just become "formalities"
that only get used by the powerful against everybody else. Last time we had a
baby the hospital was so prepared they were able to bill us for the entire
pregnancy when we arrived for our first prenatal check-up. But somehow they
couldn't show my wife the forms that waived her right to sue the hospital, her
agreement to pay whatever they billed her regardless of correctness of
timeliness until she was dilated to an 8.

~~~
conanbatt
> they billed her regardless of correctness of timeliness until she was
> dilated to an 8.

This has to be contestable in court

~~~
hestipod
I had faith in the legal system to a degree as well before my experiences
started. The doctors have more expensive lawyers and theirs and the hospital's
insurance and business lobbies have succeeded in getting legal conditions set
in their favor. Low award caps making contingency unavailable to clients,
short statutes of limitations etc. It's why surgery centers often cluster in
certain counties etc. Those places have more amenable courts and juries. It's
a LOT harder than people think from TV etc to win at a malpractice case. There
are doctors who have negligently killed people still doing surgeries etc and
in one case I read the hospital isn't legally allowed to inform patients of
his censure and past.

------
joncrane
Sounds like another one of those "this is what happens when money (as opposed
to patient wellbeing) becomes a driving factor in health care."

I remember I tried to find a PCP once and I showed up for my intake
appointment and the young, rushed doctor said they wouldn't enroll me as an
official member unless I had two intake visits. They were gaming the insurance
system.

~~~
whb07
More like, “what happens when the patient does not directly feel the financial
bill and the doctor tries to charge/do unnecessary things to make more money”.

This is a direct result of the laws and regulations distorting the market.

~~~
HarryHirsch
Have you heard of the high-complexity drug testing scam? It works like this:
at the intake visit the physician has the patient piss in a cup and it gets
sent off to a drug testing company somewhere. They run a GC/MS, and then a
very substantial bill (~5 kUSD) shows up a few weeks later. It's a stroke of
genius, no one is responsible. The physician says "you peed in the cup", the
drug testing company says "services were rendered", and the insurance says
"out of network".

How is such behaviour _encouraged_ by laws and regulations? It's encouraged by
the _absence_ of laws and ethics.

I said to all three "send it to collection, so I can dispute the debt, I'm not
going to pay"; eventually the insurance paid at their negotiated rate (~USD
250), which is closer to the cost it takes to provide the unneeded service. It
took several hours on the phone to put that matter to sleep.

There need to be some laws, but in the present situation neither the Medical
Board nor the Attorney General is interested, consequently it continues.

~~~
dsfyu404ed
>How is such behaviour encouraged by laws and regulations?

Because the laws and regulations create an environment where there is so tons
of complexity and little transparency.

A piss test is routine. The cost does not vary and can be forecast wit 100%
accuracy.

You wouldn't agree to let a mechanic charge $500 for a $25 oil change. Only a
very careless person would fall for that. The current situation in medical is
such that the proportion of the population who would/wouldn't fall for that
scam is flipped.

------
kreco
For the physical harming, Nassim N. Taleb wrote a book called "Anti-Fragile"
desribing the concept of iatrogenic illness.

[https://en.wiktionary.org/wiki/iatrogenic](https://en.wiktionary.org/wiki/iatrogenic)

An alarming fact was less dying patients when an hospital workers were in a
strike action (during 2 weeks).

~~~
manjushri
Johns Hopkins study suggests medical errors are third-leading cause of death
in U.S.

[https://hub.jhu.edu/2016/05/03/medical-errors-third-
leading-...](https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-
cause-of-death/)

~~~
mobilefriendly
I was on a multi-corporate task force on medical errors in the late 1990s and
the working number was about 80,000 deaths per year. I remember GM saying that
statistically it worked out to something like one GM worker or retiree like
every week, and that if they had that kind of mayhem on the assembly line
there'd be outrage... but the inept health care system just quietly kills
people.

------
gjem97
It's a question of fundamental incentives. Doctors and hospitals are paid for
procedures, treatments, and appointments. Is it any surprise that there's
incentive to undertake these activities? You don't even need to believe that
your doctor is greedy to understand that if there's a borderline case, they
might order the test or treatment "to be safe", or "because there's no
downside", or because "we have the available capacity". Even if they aren't
explicitly considering payment as part of the equation, it's not unreasonable
to think that subconsciously the monetary incentive will tip some of these
cases in the direction of overtreatment.

IMO, the only way this is going to change is a movement away from the "pay for
services" model that is dominant in US healthcare today.

~~~
novalis78
I slightly disagree - what's missing is price transparency inviting
competition. Through competition the payment and cost side of things will be
added to the equation and shift incentives to cut waste and increase quality
of service. That includes all aspects of the healthcare services.

~~~
shawndimantha
It is probably both. The primary reason for healthcare cost growth is price
not utilization (refer to work from IHME, others), but there also have to be
appropriate incentives in place such as exist in ACOs to ensure quality care
is delivered cost effectively. Agree that value based care by itself may not
be the answer, just look at the way drug companies claim to price medications
based on value such as Gilead’s Sovaldi curing Hepatitis C.

------
maroonblazer
Growing up with a mom who was a non-working registered nurse, every time I or
my siblings came down with symptoms like fever, nausea, vomiting, etc she
almost never took us to the doctor. Instead it was rest and liquids, maybe an
aspirin. I would always plead with her that we needed to seek professional
medical advice. Now as an adult I realize that she knew too well the
limitations of that advice when it comes to most minor maladies people suffer.

And yet today I still see friends and colleagues go to the Dr or call the
"teledoc" when they have these symptoms. They usually get an antibiotic (which
has its own issues) or told they simply need to rest.

~~~
bobo_legos
Same exact story except my mom is and still is a working R.N. There was no
running to the doctor or emergency room if I got sick or banged up an knee or
elbow. To this day as a grown adult I still work this way. It's a completely
foreign concept to me to automatically run to the doctor like so many people
around me seem to do.

You're other point about knowing the limitations of doctors is completely
valid. Every night at the dinner table I heard one horror story after another
about the crazy shit doctors would do at her hospital. Maybe its why today I
don't run to the doctor for every little thing. I got the understanding that
just because someone went to medical school and got an M.D. doesn't mean
they're a miracle worker. There's just as many screw ups in that industry as
any other.

On the upside though if something does happen where I(or someone in my family)
need a doctor I can go to her(and my R.N. sister) to tell me who the good ones
are and who to avoid like the plague.

------
edwhitesell
After recently getting a cancer diagnosis and going through surgery and
chemotherapy, the best advice I can give is: ask lots of questions and you are
your own best advocate.

As with any profession, there are some great doctors who are truly looking out
for your best interests and will pursue any direction you want. There are
others who simply want to "follow the standard practice", even if what they
know as "standard" is 35 years old. There are others who just want to get
through as many procedures as possible and "see what sticks" when it comes to
a diagnosis.

Asking questions helps you better understand which of these you're working
with, and what actions you need to take on your own.

Finally, EMR sounds great, but in my experience it just doesn't work. Find a
PCP who is part of a hospital system with specialists using the same computer
system. This means they can all see each other's notes & test results. A lot
of the time, even doctors in the same building are basically "private
practice", or part of some other partnership that is not part of the hospital
you are at.

~~~
thomastjeffery
> Find a PCP who is part of a hospital system with specialists using the same
> computer system.

I really can't comprehend how these people don't feel a critical need for
compatible open formats, and think they are fine using incompatible
proprietary ones. How is sharing information seen as a negative in this
scenario?

------
dipppy
Everyone has a story like this.

I went in for a physical and even though they said to my face my insurance
would fully cover a heart electrocardiogram (my family has a history of heart
problems) I wound up with a huge bill, month long fight with insurance, and
ended up just having to foot it.

Maybe if medical care was driven by some other force besides capitalism this
wouldn't be such an issue.

~~~
dboreham
Essentially identical story in my family. And to address the sibling comment's
question in my case : the hospital has a _recording_ of the insurance company
rep on a phone call stating that the procedure was covered. However it appears
this achieves nothing because the insurance company can use their magic powers
of "pound sand suckers" and we had to pay anyway. Hospital denies any
responsibility because they called insurance and were told they had coverage,
and they kept a recording of said call. The fact that providers routinely
record their calls to insurance companies tells you something in itself.

------
learnstats2
The article pins part of its argument on the claim that advances in
diagnostics have not changed the death rate for (e.g.) breast cancer during
the past quarter century, but a superficial search immediately suggests this
to be grossly false.

"Death rates from female breast cancer dropped 39% from 1989 to 2015." \- all
other things being equal, it _ought_ to have increased: age is a risk factor
for cancers, and we have an older population. Instead, it has greatly
decreased.

So I dispute the veracity of several of the article's claims, but also: what
is considered unnecessary changes with the benefit of hindsight.

I would argue that it's expected that a majority of diagnostic tests deliver a
negative result (i.e. turn out to be "unnecessary"), and this is actually a
mark of a healthy healthcare system.

~~~
Consultant32452
There are other likely explanations for that data. If more women are getting
screened more frequently then their cancers will be detected earlier and
improve survival rate. That doesn't mean the diagnostics tools themselves have
improved the survival rate, only that the diagnostic tools are now used more
frequently.

~~~
learnstats2
There may be other explanations, but the article denies the truth of the data
to claim this point.

------
wdn
There issue is two folds here.

1\. Medical liability. Doctors must cover their basics or will get sue.

2\. There is no cost relationship between doctors and patients. Doctors and
patients work with 3rd party call health insurers. Worst, a lot of people
(medicaid recipients) have no skin in the game.

Obama could have fixed item #2 with a universal health care that require (1)
doctors to list the price of their services and (2) cover major catastrophic
health expenses, such heart issue, cancer, long term care, etc. Prevention
care should physical, cold should be out of pocket for the first 5 or 10
visits of the year, then it is covered.

I know some may called foul because poor cannot pay. Paying $20 per visit, at
10 visit, it is $200 out of pocket. They have have skin in the game. This will
cut down a lot of abuse.

~~~
arkades
>Paying 20$ per visit...

Such experiments have been made with Medicaid demo projects in the US. They've
failed every time. People can't distinguish needed care from unneeded care;
they end up foregoing needed care, deteriorate, and end up costing the system
much more in the form of hospitalizations, disability, etc.

~~~
michaelmrose
Its because poor people overusing free medical care is the problem with the
health care system like people buying doritos with food stamps is the problem
with SNAP.

------
marze
This article makes it sound like medical costs in the US could be halved if
everyone understood this problem, and did their own research on proposed
procedures.

~~~
tinokid
Nice idea, but how realistic is it? Most patients are not scientifically-
literate, some are flat out incapacitated.

For all the stories about heartless insurance companies denying to pay for
things, perhaps they should actually be _more_ strict. As in, refuse to pay
for anything unless there is 1) rock-solid (i.e. double-blind, placebo-
controlled) evidence that it helps 2) for a specific, objectively verifiable
indication 3) when provided by a doctor whose track record is demonstrably
non-inferior to that of other practitioners. But for all three of those
things, no $.

I would be interested in buying insurance like that.

~~~
maxerickson
In the US system you agree to pay any bills the insurance will not cover prior
to receiving treatment.

Which is an obvious opportunity for improvement. When a giant hospital and a
giant insurance company get in a knife fight over whether a procedure is
covered, the patient shouldn't be the loser.

(Maybe some sort of system where if the provider states that something is
medically necessary then they are on the hook if insurance denies the claim)

~~~
tinokid
>Maybe some sort of system where if the provider states that something is
medically necessary then they are on the hook if insurance denies the claim

Not only should a provider be legally prohibited from trying to collect
payment for unnecessary treatment, they should be held responsible for
complications. Even unnecessary x-rays can cause cancer.

------
jrnichols
"or doing a CT or MRI scan for low-back pain in patients without any signs of
a neurological problem"

A hospital system in California _should_ have done one of these on me, but
instead didn't and I went with a herniated disc for 10 years longer than I
needed to. Finally a hospital in Texas did an MRI and discovered it and I had
surgery to address the issue. Previously it had been brushed off as a muscle
strain or sciatica and i was constantly given pain medication that only masked
the symptoms of a bigger problem. My life may be a completely different place
right now had someone just done an MRI years ago. unfortunately I didn't know
to ask for one. :/

"I am far more concerned about doing too little than doing too much"

this is exactly why so many "unnecessary" tests and procedures happen too,
unfortunately.

There's also a lot of "I want you to DO something" that causes physicians to
overprescribe antibiotics/etc because otherwise, they know that the patients
are going to give them a lower survey score, which directly affects
reimbursements. Tying reimbursements to patient satisfaction scores is an
awful idea that needs to go away yesterday.

[http://kunr.org/post/patient-satisfaction-surveys-make-
docto...](http://kunr.org/post/patient-satisfaction-surveys-make-doctors-feel-
pressured-prescribe-antibiotics)

------
whowouldathunk
A small example is my girlfriend getting charged for a pregnancy test in the
emergency room even after she told them she doesn't have a uterus.

------
emodendroket
> A third patient had undergone surgery for a lump that was bothering him, but
> whatever the surgeon removed it wasn’t the lump—the patient still had it
> after the operation.

One wonders how the constantly trotted out panacea of making patients pay more
out of pocket would help with a case like this.

------
s3nnyy
Nassim Taleb explains this in "Skin in the Game" rather well. If you are sick
a little bit, don't take drugs prescribed by your doctor. If you come to the
doctor with a little coughing, the doctor knows you're likely fine and there
is a high chance you won't need any meds BUT if you happen to die the next
day, the family of the former patient will find something and might sue you
because you - as a doctor - didn't prescribe the needed drugs. Some drugs are
known to cause problems 10 years down the line, but this is not the doctors
problem because he fixed your primary problem but doesn't really care about
second-order/side-effects of the prescribed drugs.

------
DonnyV
Rationing medical care because the underlining system is broken makes no
sense. People in the US already don't use enough medical services.

"For example, Americans average 4 doctor visits a year compared to 7 in France
and Canada, countries with better health outcomes than ours."
[http://www.pnhp.org/news/2014/january/americans-underuse-
hea...](http://www.pnhp.org/news/2014/january/americans-underuse-health-care)

------
neuro_imager
I would share this article but I've been living on a resident/fellow salary
for way too long and need at least a few years to milk that cash cow first.

------
blackRust
The article's author, Atul Gawande, has written four books. So far I've only
read _The Checklist Manifesto: How to Get Things Right_ and have been applying
it to various aspects of work and life (travel packing checklist, Engineering
team runbooks, etc). I would strongly recommend it.

All his other books are on my "to read" list...

------
NicoJuicy
Medical care in the US seems... unhealthy.

I'm glad to live in belgium, where i won't go broke if something happens.

------
DINKDINK
Iatrogenics / Iatrogenesis

[https://en.wikipedia.org/wiki/Iatrogenesis](https://en.wikipedia.org/wiki/Iatrogenesis)

------
sharemywin
"some seven hundred and fifty BILLION dollars a year"

------
arkades
I worked in health insurance, and had a graduate degree in health policy,
before I second-careered into medicine. I helped implement some of the
programs that Guwande promotes in this article; I was and am a true believer
in some of these programs, and have built my medical career around
implementing them properly.

I say all that to provide an important caveat: Guwande's a Harvard-associated
surgeon largely insulated from what any of this looks like on the ground, and
basically collects anecdotes that match his views until he can tell a nice
just-so story. The reality is far more complicated than he relates, and shared
savings programs are far from some sort of medical panacea that addresses all
the imbalanced and chaotic incentives in medicine.

A few big nitpicks:

(1) The ACA Shared Savings program is and was bullshit for providers. Because
it was built on top of "traditional Medicare", meaning a non-HMO arrangement
that did not infringe on pt's right to seek as much care as they wanted, from
whomever they wanted, there was no actual __assignment of responsibility __.
If Doctor X is to share in the profits of saving the system D dollars, you
have to be able to measure the savings he generates. However, no patients are
"his" \- we just measure which PCP patients go to the most in a year and give
the doc a benchmark based on those. This was based on an assumption that most
people saw their PCP at least once/yr. Turns out that not only do people not
see their PCP once/yr, but plenty are snowbirds, or have a rotating list of
multiple PCPs. Medicare has not fixed the attribution issue.

(2) The most effective way to create savings remains to deny care. There's a
reason there was an HMO backlash. Creating _that_ incentive reduces
costs/spending, but ...

(3) The vast majority of physicians do not work in pure capitated programs.
They work in a mixture of shared downside, shared upside, and FFS. You can't
manage patients with a mix of payors like this, because you still have to
build your daily operations around the largest volume - the FFS folks. This is
what I saw the most of in the rollout of the ACA: docs were "enrolled," sure,
but ACO's still pay out on top of FFS, and the rest of the patients are normal
FFS + shared risk, the result is daily operations built around volume, not
around "spending 45 minutes to review how to take insulin."

4) Docs over-test and overprescribe for medicolegal issues that no amount of
incentive-shifting can fix. Hell, my hospital antibiogram doesn't even _have_
pseudomonas sensitivity to pip, just pip/tazo, despite the fact that
pseudomonas pretty much never needs pip/tazo (the /tazo is a spectrum
extender). But prescribing pip/tazo over pip is something akin to "no one ever
got fired for buying IBM." Hell, we do baseline kidney function tests before
giving contrast in _emergency_ radiology, despite the fact that the biggest
studies to date show that baseline kidney function doesn't have any predictive
value for contrast-induced nephropathy-related outcomes 6 mos out. It's a
pointless delay that actually hurts patients _and_ costs money. But you know
what? No one sues a doc for getting worse in an ED while awaiting a lab result
- that " just happens". They _do_ sue a doc for contrast-induced nephropathy,
because that looks like something a doc actively caused (well, it is) - and a
malpractice attorney will slam your balls to the wall for "why didn't you look
at his kidney function before throwing kidney toxins at him?"

The malpractice thing is honestly more insidious than that, even. It gets docs
out of the mindset of thoughtfully asking "well, WHY would I order that test?
How does it advance the diagnosis or management meaningfully?" to a "might as
well order it to be on the safe side" mindset that infects the rest of their
practice. The latter creates sloppy, over-broad testing regimens.

Heck, we can't even utilize the latest research unless we can convince
_multiple departments worth of docs_ to agree on it. Because the standard for
malpractice is what your peers would do, "I did X as part of our department
standard, as agreed upon by all the docs in X and related specialty Y" is a
very strong malpractice defense. If you can't convince all of those people to
get on board and change department policy and just try to practice based on
the most up to date data yourself, a malpractice attorney's question becomes:
"Where did you get your PhD in statistics and clinical trial design? Oh, you
don't have one? So what made you qualified to take in this study and overrule
a panel of national experts on the topic that decided what the standard
practice is?"

We really need an iatrogenesis compensation fund built at the national level,
and to get rid of malpractice suits. That will bring down bullshit spending by
a fair degree right off the bat.

A related issue that people overlook is that about 70% of the growth in HC
costs is attributable to technological advance: new drugs, or hiked up drugs,
new tech, etc. We want all these things, but refuse to take into account that
they demand a premium (even when they're not actually more effective.)

I could rant for ages.

~~~
mortenjorck
_> iatrogenesis compensation fund built at the national level_

An FDIC for malpractice suits is an interesting idea. Is there anything
comparable to this in universal healthcare systems like the NHS?

~~~
arkades
Yes, France has this as the national scale, and we have something similar for
certain federally-qualified facilities aimed at low-income communities. In our
case, they need to maintain an ongoing, federally audited QA/QI program, but
as long as they meet those requirements any malpractice suits get redirected
to a federal malpractice policy.

------
clircle
Nothing gets HN more riled up these days than a good story about healthcare in
America.

------
lostgame
Cue 'unnecessary surgery land' in 4, 3, 2...

------
mhb
[2015]

~~~
sctb
Thanks! Updated.

------
ycombonator
Ivory tower elite have usually all the time to pontificate. Tell that to this
girl who did not see the light of the day.
[https://nypost.com/2018/02/26/girl-dies-hours-after-
doctor-t...](https://nypost.com/2018/02/26/girl-dies-hours-after-doctor-
turned-her-away-for-being-a-few-minutes-late/)

~~~
conanbatt
What a tragedy.

But lets not forget that this is what we see not what it is. It could have
happened the other way: "patient died after not receiving attention even
though they arrived on time. Doctor was busy providing care to previously late
patients".

------
mtgx
It sounds like in the "free market healthcare" system hospitals are
incentivized to get the patient to spend as much as possible. That's aside
from other bad incentives of such a system such as hospitals not wanting to be
transparent with their prices, insurance companies not wanting to take
patients with pre-existing conditions, also wanting to cover as few conditions
as possible, Big Pharma being incentivized to ask for as high drug prices as
possible (while lobbying for a ban on generics and imports), and so on.

~~~
tr0ut
You have the wrong idea. A better example of what you're calling "free market"
would be dentistry or something like Lasik surgery. You can shop around and
figure out the prices because they are very much apparent since you pay out of
pocket for the majority of the former and completely for the later.

Would Medicaid/Medicare be "free market"? Why bother shopping around when
someone else picks up the tab?

Insurance companies mostly reflect the costs of the hospital. If the hospital
charges you $50 for a bottle of Asprin, so be it. ICD10 and Meaningful Use
were designed for billing not really for health care. Those were federal
mandates not "free market"

Pre-existing conditions is a lot more tricky than you think. The political
ploy is to think of a poor person with a serious illness being turned away by
insurance because they don't want to deal with them. When in reality it can be
you're obease or someone who just did not take care of themselves period. You
can imagine a group pre-existing conditions patients could bankrupt a
insurance company. What if to be "fair" you were charged the same as a person
with a pre-exiting condition. Say someone that smoked 2 packs a day for 30
years?

ACA was just a big initiative to add more insurance companies to the mix. Now
it is mandatory you pay insurance companies.

~~~
tdb7893
The underlying philosophy of mandating coverage for pre-existing conditions is
the idea that everyone should be able to have basic medical care. With that
idea it's really not that tricky to say pre-existing conditions should be
covered.

~~~
tr0ut
I don't disagree with the philosophical purpose. Of course by simplifying the
facts. You're leaving out the logistics of insurance companies that have to
now take that responsibility on. Last I checked they dont work of the sake of
goodness.

Better option would be single-payer. I digress...

