
If this were a pill, you’d do anything to get it - vellum
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/28/if-this-was-a-pill-youd-do-anything-to-get-it/
======
glenra
One big problem with medicine in this country is that bad hospitals can't just
go out of business and be replaced by better ones. If you want to open a new
hospital today, there are hearings in which all the crappy existing other
hospitals have to say it's okay before you can get a "Certificate Of Need".

So if you had an idea for a new hospital _structure_ that would dramatically
improve patient health and cut costs, you wouldn't be _allowed_ to just build
it and try it - the existing providers all get a veto.

So we have hospitals that hide all the prices and make MORE money if they
screw up and introduce complications, and it's ILLEGAL to drive those idiots
out of business with a more customer-responsive system.

It's like if you couldn't open a new coffee shop without permission from
Starbucks or a new restaurant without permission from McDonald's. In anything
even vaguely resembling a free market, reforms like this wouldn't need to be
pushed by a monolithic central bureaucracy - they'd just spread on their own,
with old providers rushing to adopt the modern changes for fear of becoming
obsolete.

<http://en.wikipedia.org/wiki/Certificate_of_need>

~~~
pekk
The free market offers no incentive to give health services to people who
cannot pay for it, or don't know that these services will reduce
hospitalization by 33% and costs by 22%.

Basic health care is not McDonald's because your mother does not die
prematurely (and miserably, and expensively) for the lack of McDonald's. The
core issue is not about some private business being 'customer-responsive' in
the vein of Starbucks. You can, today, start private clinics which are more
"customer-responsive" (leave a mint on your pillow, etc.) but how are you
going to recoup the costs and in particular, how does that benefit the
populace in aggregate?

~~~
HarryHirsch
> The free market offers no incentive to give health services to people who
> cannot pay for it, or don't know that these services will reduce
> hospitalization by 33% and costs by 22%

Amen to that. The major killers at the turn of the last century were
tuberculosis and waterborne diseases, and the free market did nothing to
improve living conditions or supply clean water to the urban population then.
I am in Portugal right now, where Dr Sousa Martins, a physician who
spearheaded the fight against tuberculosis, is considered a saint. Public
health is always political issue. It is as true 100 years ago as it is now.

~~~
tosseraccount
Free market didn't improve living conditions? The supply and demand for more
spacious housing and fuel to boil water didn't help things?

~~~
lukeschlather
For the upper 50%, sure, but the free market failed and generally fails to
give the lower 50% of earners access to sufficient resources to do proper
sanitation. Treating clean water as a commodity rather than a public utility
is a public health disaster. Each household needing expertise and equipment
for water purification does not scale.

~~~
tomjen3
Define failure in this case. Yes the poor have less than the rich, but so
what? What is the cost of clean water today? How much for a fridge?

As it turns out, 99.9% of us households have a fridge
(<http://www.eia.gov/emeu/recs/appliances/appliances.html>). Those weren't
really available in 1900, yet I don't remember any huge government subsidy for
those (and by keeping your food fresh they prevent diarrhea and improve
hygine). I do remember huge, private, factories making them, however.

But even then soap is likely also one of those things that really help prevent
deceases through proper sanitation -- yet how poor do you have to be to not be
able to afford soap?

~~~
lukeschlather
> What is the cost of clean water today? How much for a fridge?

A fridge is much more expensive, but it's also much more a luxury. You don't
need to refrigerator to avoid diarrhea, it just helps. Pure running water on
the other hand is extraordinarily cheap and makes avoiding waterborne illness
easy. (Due to the fact that running water is provided by public utilities, not
free markets.)

I'm not saying the free market doesn't have a part to play in good hygiene,
but trying to rely on the free market for a water supply and food handling
regulations has been an unmitigated disaster everywhere it's been tried.

~~~
tosseraccount
"unmitigated disaster everywhere it's been tried".

England is served by private water companies. Is this a disaster?

~~~
lukeschlather
Public utilities aren't necessarily public companies. Private companies own
and manage the lines, yes, but prices are fixed by the government, and
companies are required to supply water to residents, often even in cases of
non-payment. Hardly a free market, and definitely what I would call regulated
public utilities.

------
danso
This reminds me of the health care cost paradox that Atul Gawande wrote about
in 2011. In Camden, NJ, one percent of the patients accounted for as much as a
third of the city's medical costs. A doctor proposed in a small study that
giving these lost causes _better_ care actually reduced costs overall. But
good luck convincing politicians to devote more money to cocaine addicts and
extremely obese patients.

[http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...](http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all)

~~~
tomjen3
Why more money? It seems that even more money could be saved by _excluding_
drug adicts and those who are so fat that their fatness interfere with their
treatment.

~~~
brown9-2
Most of us don't want to live in a society where making bad choices in life
(or having bad luck) excludes you from live-saving care.

~~~
Evbn
And since HN tends to lean anti-social: for the objectivists: most of us would
don't want to get denied care because we look like a junkie during an
emergency.

~~~
randallsquared
I think you meant anti-socialist. While HN might or might not lean anti-
social, I'm not sure it would have a clear effect on political arguments.

------
kens
This looks like a good approach to health care, and I don't want to be snarky
guy, but... Health Quality Partners is about to lose their funding and they
get an 8-page glowing article on washingtonpost.com about how great their
program is and why it should be continued. It looks like some PR agency is
really earning their money.

See, of course, Paul Graham's article on PR agencies:
<http://www.paulgraham.com/submarine.html>

Going back to the subject of the article, I wonder how much this visit program
actually costs, and whether it could be direct-marketed to wealthy people with
elderly parents. "For $10,000(e.g.) a year, we can reduce your parents'
hospitalizations by 33% and help them live independently." Sort of like
concierge medicine.

~~~
davycro
> Going back to the subject of the article, I wonder how much this visit
> program actually costs, and whether it could be direct-marketed to wealthy
> people with elderly parents. "For $10,000(e.g.) a year, we can reduce your
> parents' hospitalizations by 33% and help them live independently." Sort of
> like concierge medicine.

Better yet, maybe health insurance companies could offer lower rates to
chronic patients who enroll in a visit-program. They are the organizations
with the most financial incentive to implement these programs.

~~~
tomjen3
They absolutely would (and I still don't see why they don't the cost/benefit
ratio of paying for that should make sense) but in this case they are talking
about the people who have no insurance or whoes bills are paid by the federal
tax payers.

And while there are a fair amount of positive things to say about the federal
government, prudent financial planning isn't exactly one of them.

------
ajtaylor
The money quote for me was this: “If we scaled what Ken is doing,” Brenner
says, “you would probably shut down a third of the hospitals in the country.
It’s a disruptive innovation. It just guts the current business model.”

Wouldn't it be better if people never had to go into the hospital in the first
place? Aside from the supplemental costs - "surgical complications increase
the margin the hospital makes on the patient by 330 percent for the privately
insured and 190 percent for Medicare patients." - consider the quality of life
issues.

If Medicare is concerned with scaling this program up from a couple thousand
people, instead of completely cutting a program which has proven its ability
to cut costs AND improve quality of life, why not try it with five or ten
thousand people first? If that works, then try it with 20 thousand people,
then 50 thousand. If it doesn't scale at that point, then cut it.

Another possible solution is to find a way to eliminate the for-profit
hospitals. But Medicare's solution - "It’s pushing providers to band together
into accountable care organizations, or ACO, that get a flat fee for all care
related to a patient." - sounds destined to fail from the outset to this
layman.

~~~
DanBC
Yes. For illnesses like diabetes it's best if you can prevent people getting
it, but if they have it it's best if you can help them to avoid getting the
complications.

"Diabetic foot" sounds funny, until you realise that it kills people and is a
reason for leg amputation. (Prognosis after such amputation wasn't great last
time I looked, in about 2004.)

Sending a real person in a car to visit someone at their home sounds
intensive, and sounds expensive. Compare it to a tele-medicine device that
takes measurements and sends those to a centre somewhere, with people calling
over the phone. It's a shame that the evidence base appears to be being
ignored. __EDIT (after adestefan and ajtaylor commented) -- it _feels_
expensive, but the evidence base is clear that it's not expensive because it
works, where as the thing that feels cheap is wasted money because evidence
shows it doesn't work. And it's a shame that people in charge appear to be
ignoring evidence, and going by 'gut feeling', because it means effective
interventions are not happening. __

I hope that mentioning the research that a decision is based on becomes more
widespread. Even organisations that claim to be evidence based can make odd
decisions.

~~~
adestefan
There is something special about having that physical person with you, in your
home, talking to you one on one. Yes it's somewhat expensive up front, but the
human contact is a major component of what makes this a success.

There is one extra photo in the print edition of this story. It's the nurse,
Ms. Graefe, hugging Mr. Bradfield in his kitchen.

~~~
Evbn
Because much of our health needs are mental, and much of mental health is
social. Living alone is a chronic debilating condition, akin to diabetes.

Live with your parents, and later live with your kids. Or outsource to home
aides.

------
MichaelGG
Why do people like to use average life expectancy? "Average life expectancy
was 45 years old at the turn of the century."

That provides very little information about the distribution of lifetimes and
provides a biased view when compared to the 85-year-olds mentioned in the next
sentence. Infant/child mortality skews the average a lot. You could have
everyone living to 90, if they survive to 5, and still have an average of 45.
War and other disasters can also change the average in ways that have little
meaning for the medical programs in question.

~~~
rocky1138
It also bugs me when people say "at the turn of the century," since we just
recently had one of those but the person is talking about the one previous.

/nitpick

~~~
Evbn
Fin de Ceicle

------
wisty
> Medicare is referring to the newly created Center for Medicare and Medicaid
> Innovation, which gives the program power to create and expand projects
> without congressional authorization. This authority could also be used to
> create projects based on HQP’s lessons. It’s not. Instead, Medicare has
> created a raft of projects and experiments meant to move the system from
> fee-for-service toward pay-for-quality — with the hope that if they can get
> the payment incentives right, then the market will have reason to support
> programs like HQP.

Yep. As long as the government bureaucrats develop perfect payment incentives,
the market will do its job. It's the same story in education. And programming
- if you can find the perfect metric for code production (SLOC? function
points? story points?) you don't need to do anything else.

But with an imperfect metric, Cambell's Law
(<http://en.wikipedia.org/wiki/Campbell%27s_law>) kicks in.

Want to reduce waiting times? Kick out patients so they die at home. Increase
successful surgeries? Tell the doctors to fix a lot of ingrown toenails.
Increased lifespan? Make decisions which increase life expectancy, at the
expense of quality of life. Or just try to get rid of patients who have poor
prospects.

The greatest strength of markets is also their greatest weakness - they are
much smarter and more agile than government departments. They can become a
malicious literal genie, which optimises whatever the incentives are.

~~~
notatoad
Well there needs to be some sort of artificial incentive if you're going to
keep medicine profit-based. The best way to generate profit without those
incentives is to keep as many people as sick as possible, because sick people
are more profitable than healthy people.

------
CurtMonash
My grandfather, a physician, made house calls 7 days a week. It was just
assumed in those days. When he couldn't drive during WW2 (German refugee =
enemy alien) he couldn't be in private practice.

Replacing doctors with nurses in that story is a perfectly sensible modern
adaptation. But the house calls are a really good idea.

Not coincidentally, they're a central aspect of the exploding trend toward
assisted living.

~~~
jnbiche
Please forgive me for going off-topic and for asking a personal question (and
please don't answer if it's too personal), but how did the government inform
your grandfather that his movement was restricted during WWII? Did he receive
some sort of notice from the FBI?

I'm sorry that our government chose to restrict the civil liberties of a very
important member of his community during WWII on the basis of his ethnicity.

A cautionary tale for today's America.

~~~
adestefan
Note that the OP's grandfather was not a US citizen, but a refugee from a
declared enemy during a time of war. There's a huge difference between the
two. That fact that he was even allowed to practice medicine is amazing.

~~~
Evbn
The atomic bomb was built in large part by refugees from a declared enemy
during time of war.

~~~
adestefan
Most of the US based scientists were either US citizens (some natural born;
others naturalized) or came to the US in the 20s or early 30s. Even then very,
very few of these men were German citizens. Fuchs, who was one of the few
German refugees, was part of a contingent from the UK. The only reason why
Fuchs was even allowed to be a part of the project was because of political
pressure outside the project.

This is all documented in exrutiating detail in Rhodes' series on the making
if both the atomic and hydrogen bombs.

------
dkarl
_According to a new study in the Journal of the American Medical Association,
surgical complications increase the margin the hospital makes on the patient
by 330 percent for the privately insured and 190 percent for Medicare
patients._

This is scary when you consider how good people are at the subconscious mental
gymnastics that allow them to justify pursuing their own interests at the
expense of others. Either human beings are perfect angels -- inhumanly good,
too good for much of human history to have actually happened -- or many people
have been tortured and killed for those margins.

~~~
Cass
How many doctors actually stand to gain by mistreating patients, though? I
don't know about the USA, but in my country, most medical care is provided by
salaried doctors who are paid the same regardless of the hospital's profit
margin.

Now, obviously we do want the hospital to be profitable enough that they don't
start firing us, but there's certainly no immediate benefit along the lines of
"Well, I don't this guy to get an infection, but I'd make an extra $ 1000 if
he did," which I agree would certainly provide skewed incentives. The only
thing that happens when my patients get complications is I get to pull more
unpaid overtime.

~~~
dkarl
Complication rates are affected by hospital procedures and policies, staffing
levels, training, and presumably the pressures that are or aren't put on
doctors. All of those are under the control of the administrators who look out
for the bottom line. Whether complications make money or cost money surely
affects administrators' eagerness to revamp and/or enforce handwashing
policies, update training for nurses, keep staffing levels high enough that
inexperienced nurses are properly supervised, and put pressure on doctors with
high complication rates.

To make it more concrete, there was an article on HN a few years ago
suggesting that post-surgical complication rates could be reduced by creating
surgery checklists where very basic surgical steps would be checked off as the
surgery proceeded: patient identity verified, everything properly sanitized,
materials accounted for afterwards, things like that. You would expect a
hospital administrator to make a cost-benefit analysis taking into account the
cost of researching this idea, creating a trial program, and monitoring
compliance and effectiveness. The cost-benefit analysis looks like this: If
the program is ineffective, we lose money. If it's effective, we lose even
more money. If it's really, really effective, it could screw up the bottom
line so much that I lose my bonus or even my job.

------
rocky1138
My Taiwanese friends frequently remind me of the historic Chinese practice of
a doctor visiting the family regularly to keep health well. The doctor would
receive weekly pay only while the family was well; once someone got sick, they
stopped getting paid until the doctor helped them recover. This preventative
practice reminds me a lot of what my Taiwanese friends speak about.

It seems the age-old cliche "An ounce of prevention is worth a pound of cure"
applies here.

~~~
mikeash
That sounds like it could go very badly if you have a mercenary doctor and you
come down with an incurable but manageable condition.

~~~
roguecoder
By the time you've spent years caring for a family, you probably care about
their health for more than just the cash. Not to mention the reputation
effects of abandoning sick patients...

------
tokenadult
I repeatedly post this chart that shows life expectancy stratified by age to
HN:

[http://www.scientificamerican.com/article.cfm?id=longevity-w...](http://www.scientificamerican.com/article.cfm?id=longevity-
why-we-die-global-life-expectancy)

I learned about this article from another participant's submission to Hacker
News.

I happen to be part of a "journal club" with a researcher who studies, among
other things, demography of aging, and from him I've learned some startling
facts about increases in life expectancy around the world. Girls born since
2000 in the developed world are more likely than not to reach the age of 100,
with boys likely to enjoy lifespans almost as long. The article "The
Biodemography of Human Ageing" by James Vaupel,

[http://www.demographic-
challenge.com/files/downloads/2eb51e2...](http://www.demographic-
challenge.com/files/downloads/2eb51e2860ef54d218ce5ce19abe6a59/dc_biodemography_of_human_ageing_nature_2010_vaupel.pdf)

originally published in the journal Nature in 2010, is a good current
reference on the subject. Vaupel is one of the leading scholars on the
demography of aging and how to adjust for time trends in life expectancy. His
striking finding is "Humans are living longer than ever before. In fact,
newborn children in high-income countries can expect to live to more than 100
years. Starting in the mid-1800s, human longevity has increased dramatically
and life expectancy is increasing by an average of six hours a day."

[http://www.prb.org/Journalists/Webcasts/2010/humanlongevity....](http://www.prb.org/Journalists/Webcasts/2010/humanlongevity.aspx)

A comparison of period life expectancy tables and cohort life expectancy
tables for men and women in Britain

[http://www.ons.gov.uk/ons/rel/lifetables/period-and-
cohort-l...](http://www.ons.gov.uk/ons/rel/lifetables/period-and-cohort-life-
expectancy-tables/2010-based/p-and-c-le.html)

helps make the picture more clear. ("Period life expectancy" is what is
usually reported for a whole country. But cohort life expectancy provides a
better estimate of future lifespans of young people today,

[http://www.time.com/time/specials/packages/article/0,28804,1...](http://www.time.com/time/specials/packages/article/0,28804,1963392_1963367,00.html)

and is still steadily on the rise around the world.) Life expectancy at age
40, at age 60, and at even higher ages is still rising throughout the
developed countries of the world.

~~~
jameshart
That chart doesn't support the claim of centenarians becoming the norm,
though. It shows that in the last 50 years in the US we've increased the life
expectancy of an 80 year old by two years, from 86 to 88. extrapolating that
linearly it suggests that children being born today will, if they live to 80
in the 2090s, have a life expectancy then of about 91, so while they may well
expect to see the 22nd century dawn they won't generally get to see their
hundredth birthday. This is backed up by the UK cohort life expectancy you
gave which shows the current cohort life expectancy is still around 91-95, and
doesn't extrapolate to predicting hundred-year lifespans even for children
born 20 years in the future.

------
adpirz
Atul Gawande wrote about a similar initiative in Camden, NJ, two years ago:

[http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...](http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande)

------
bconway
_Average life expectancy was 45 years old at the turn of the century. You
didn’t have 85-year-olds with chronic diseases._

Yes you did. That's like saying there weren't old people a hundred years ago.
The reason the average was 45 years is because of the astounding rate of
infant mortality (much improved now).

~~~
jmhain
Thank you, I was hoping somebody would have already made this point. Funny
thing is, both statements are true; you really didn't have 85-year-olds with
chronic diseases. There were 85-year-olds, they just didn't have chronic
diseases. The idea that we have them now is due to improved treatment of other
diseases ignores tons of epidemiological evidence that says otherwise.

------
claudiusd
The challenge with health care in the US is that nobody has incentives for
reducing health care expenditures. Hospitals get paid when you get sick.
Insurance companies see higher margin from reducing administrative costs.
Patients are largely uninformed and there are few services out there to help
them make lifestyle changes... not to mention that they expect somebody else
to pay for it. Employers actually bear most of the non-medicare/medicaid
financial risk, but they aren't health experts and have been burned in the
past by tele-medicine programs that don't work.

Preventive care programs like the one at HQP are proving that preventive care
is effective, but sending a nurse to your home regularly is expensive and I'd
question the ROI from doing so, absent some focus on a particular disease.
With a solid ROI and some good hard evidence, HQP shouldn't have to rely on
CMS to keep them afloat... with some work they would be able to sell their
program to payers.

HQP also isn't addressing the systemic issues I mentioned above, so what's
especially frustrating about the article is that they bash on ACOs, which is
one of the first attempts by CMS to actually align incentives and mend those
issues. And frankly, those changes aren't going to be good for hospitals...
I'm sure a lot will go out of business as people get healthier and don't need
them. This piece of the article in particular makes me question HQP's motives.

------
josephlord
In the UK the NHS has district nurses one whose roles is exactly this sort of
work and it can make big difference especially where the GP is
underperforming. These patients can be unwilling to change GP to a better one
(which you can do in the NHS).

------
tomohawk
Three points were interesting to me:

1) The chart with the blip for the 1918 flu. If we reduce costs by closing
facilities, how we cope with the next blip?

2) This is an area ripe for disruption, but regulatory capture seems to
prevent this.

3) We should all be spending more time with our elders and noticing these
sorts of issues, if for no other reason than it will improve their health.

~~~
DennisP
1) It's not like those facilities are sitting around empty right now. If we
close them only by the amount that we reduce the need for them, we'll have
about the same reserve capacity.

------
roguecoder
This reminds me an awful lot of the role of village witch in Terry
Pratchette's books. I think we've lost that caretaker role in society because
we always assumed it was their children's responsibility. It seems like if
capitalism can get something for free, it is assumed to be worthless.

------
CurtMonash
As for going into hospitals making you worse -- I agree from experience. One
of my parents went into the hospital for a back procedure, and came back with
her mind significantly diminished. She died 8 months later.

The other, in and out of the hospital, eventually died the same week, and one
of his complications was MRSA.

Both were at Riverside Methodist Hospital in Columbus, OH, which I gather is a
perfectly solid institution.

------
SoftwareMaven
_“The largest group in the top one percent of income in America are
physicians.”_

It is going to be _very_ challenging to introduce changes that negatively
impact a profession with the social respect and the deep pockets physicians
have.

It could probably succeed in a countries like Canada, Sweden or Germany, but
overcoming entrenched interests in the US and not getting labelled "socialized
medicine"[1] in the process is unlikely.

1\. Of course it's no more socialized medicine than Medicare, but it's a good
way to discredit your opponents.

~~~
carbocation
As of 2008, nearly 59% of US physicians supported national health insurance
[1]. Doctors are not the culprit.

1 = <http://annals.org/article.aspx?articleid=740467>

~~~
refurb
What do that "national health insurance" look like for physicians? Does it
include pay cuts? I'm pretty sure in those 59% of physician's eyes it doesn't.

~~~
carbocation
The answer to that question depends on whether you think physicians lack
insight.

I think that most physicians are smart enough to look at the national
insurance that already exists (Medicaid & Medicare) and to recognize that
their reimbursements would be cut. I think they can balance that against the
complexities of the current system and some might be willing to trade somewhat
lower pay for the ability to focus on providing care.

20% of health care costs come from physician pay, of which about half goes to
the cost of running a practice. Most reformers know that cutting physician
pay, while part of almost any plan, is not going to be the most important way
to save money.

------
rthomas6
If this is as cost-effective as it claims, what's to stop private insurance
companies from pushing and covering it? It should theoretically cut their own
costs in the long run, right?

~~~
GFischer
I wish some insurance companies could figure out that.

In reality, if they are something like the one I work for, politicking and
manager infighting will prevent it - everyone wants the OTHER divisions to
lose power, but not their own. My own manager created his own personal
software factory (for a freaking country branch), in spite of my belief that
it's extremely inefficient for the company as a whole. The shareholders don't
care as long as the company makes money.

------
commanda
It seems to me that health insurers are already aligned with the goal of
keeping patients from receiving care for acute conditions, so perhaps some of
them, being private companies, unencumbered by special interests or government
bureaucracy, will adopt systems like the one outlined in this article. Maybe
that's a cynical outlook, but since it has been demonstrated that hospitals,
being for-profit, are tragically misaligned with maintaining patients'
wellness.

------
bjhoops1
The tendency among physicians to be dismissive towards remedies that are
procedural in nature reminds me of the tendency of programmers to show
disinterest in non-technical solutions to problems.

But as Jeff Atwood reminds us, "The Best Code is No Code At All," and I
imagine that physicians could use a similar reminder: "The Best Treatment is
No Treatment at All."

------
teeja
Wow. If we can't maintain ways for the cream to rise to the top in the US,
we'll continue to become increasingly mediocre.

------
loceng
Well, now we're fighting mental illness at an alarming rate due to many
factors - that we could manage better.

I'd like to see the graph of rate of mental illness from the past, to now -
and yes, I realize there's a strong argument for that we're better at
diagnosing people now, however it just doesn't add up IMHO.

------
savrajsingh
"if this were a pill"

------
venomsnake
It is about job description. Just put into law that all government money
should ensure the best outcomes for the patients and then a lot of things
become possible. Give simple and powerful mandate to all health related
businesses.

~~~
brown9-2
A part of the issue is that it's hard to define "best outcome", you'd have to
make sure to not accidentally incentivize drastic short-term procedures like
open heart surgery, where the immediate affect is positive (patient hasn't
died) but a longer term view would have questioned the care that led the
patient to that state in the first place.

