
The Illicit Perks of the M.D. Club - randycupertino
http://www.nytimes.com/2016/07/03/opinion/sunday/the-illicit-perks-of-the-md-club.html?ribbon-ad-idx=18&rref=opinion
======
6stringmerc
In the US, if people take the mystique out of health care and treated it more
like food service, then it'd be a lot easier to understand why the industry is
so hit-and-miss with a wide range of issues. In other terms, the demand is so
strong in the industry that I have no doubt the competency is something to
genuinely be concerned about as a patient. I've seen it first hand - Docs and
Nurses are humans, and humans get tired, or forgetful, or distracted and those
aren't personal faults. However, when they screw up, instead of being
apologetic, getting defensive is a very typical response.

What this article points out is something a little deeper, in that knowing the
language and culture will allow an individual to social engineer through
challenges. I've done it with the medical community, also in Wall St. finance,
but it's most useful in my day-to-day life when going out to eat in a
restaurant. There are cues and phrases to drop which can alert a competent
server as to the experience level - and possible expectations - I will have of
the meal. Being deeply involved in such things can have that affect on people,
at least it really has for me. Criticism from another industry participant
tends to sting more, because it cuts to the point.

~~~
danielzh
Can you describe the types of language and culture? Or have resources to look
into this further, I find it interesting.

~~~
Johnie
Read up on Shibboleth [1]. Using language or phrasing, it's a way to suss out
members of a certain group. One can argue that the internet memes are a type
of shibboleth for internet groups. One example is The Narwhal Bacons at
Midnight [2]. I'm sure YC alumni have some type of shibboleth to identify
themselves in situations.

Shibboleth entered mainstream culture (and when I learned it) via a West Wing
episode called "Shibboleth" [3]. The clip is worth a watch.

[1]
[https://en.wikipedia.org/wiki/Shibboleth](https://en.wikipedia.org/wiki/Shibboleth)

[2] [http://knowyourmeme.com/memes/the-narwhal-bacons-at-
midnight](http://knowyourmeme.com/memes/the-narwhal-bacons-at-midnight)

[3]
[https://www.youtube.com/watch?v=fqkaBEWPH18](https://www.youtube.com/watch?v=fqkaBEWPH18)

~~~
thaumasiotes
> Shibboleth entered mainstream culture (and when I learned it) via a West
> Wing episode called "Shibboleth"

The concept of a shibboleth entered mainstream culture many centuries ago; it
is a story from the Bible.

------
Spooky23
The doctor privilege angle is overblown. That's a shortcut, but you just need
to be squeaky to get similar results. I think that instead of trying to create
the fantasy that medicine is some sort of open market, we need to do something
else.

My wife went through a series of medical procedures that are time sensitive,
expensive and require a bunch of expensive speciality medication.

The pharmacy is impossible -- mail order only and dedicated to being
obnoxious. Their aim is very obvious -- push prescription fulfillment into the
next month, quarter or year. I'm sure bonuses are tied to this, because their
stupid behavior wastes money... On three seperate occasions drugs were
couriered to my wife (as in, a dude carrying a box got on a plane and took a
cab to my home from the airport)

It's dumb behavior that results from applying market incentives to one
stakeholder. For want of a $1000 drug, a $15000 procedure could be rendered a
waste.

Some party should be given a "project manager" type role, and be responsible
for overall patient outcome.

~~~
brbsix
It seems like every time I have to deal with a pharmacy, I am continually
blown away. It's a uniquely terrible experience, more akin to the DMV than a
retail store.

~~~
arethuza
Out of interest (I'm not from the US) - how can a pharmacy be bad - every time
I go to one it's a case of handing across a prescription, waiting a few
minutes and then getting the drugs/whatever.

~~~
Spooky23
Insurance craziness. CVS is becoming a classic horizontally integrated
monopoly for drug distribution (benefit management, wholesale distribution and
retail) so it's getting much worse in recent years.

For normal drugs they have "step up" process for new drugs so they won't pay
for a 90 day script without you first getting two 30 day scripts. They make
more money via co-payments on 30 days so shockingly, they fuck this up all of
the time to make more money.

In my case, I am on a blood pressure med that went generic. So the script
changed to the generic... Which triggered the 30 day "step up" for the same
drug. I lost alot of weight and had the generic script changed to a different
dosage... Again, back to the 30 day "step up". My insurance penalizes you for
short term scripts for maintenance medication, so I get to pay $50 each for
two 30-day scripts vs. $25 for a 90 day.

My wife was different, "speciality" drugs, which include stuff like type-1
diabetes and fertility meds require that you use the insurance company's
pharmacy and jump through more hoops. My co-worker has a daughter with type-1
diabetes. He's a "type A" PM and actually has developed a project plan with
about 100 documented steps to ensure that her medications are delivered on
time. He did that after he daughter had to be admitted to the hospital when
they ran out of drugs -- which cost the other insurance coverage $25k or more,
so it's not saving money.

It's all about delaying expenses over some reporting period and maximizing
revenue. Nickel and diming co-pays is how they make a profit with a huge
employer like mine with lots of bargaining power. Delaying issuance of
speciality drugs is also a profit center, as they are paid a
commission/incentive for "controlling" costs in a given quarter/year.

~~~
matt_wulfeck
Honest question, is it possible to get these prescriptions filled from mail-
order or international pharmacies?

It seems there's a demand for reliable, no-bs medication delivery from
_outside_ of the system.

~~~
Spooky23
Yes, absolutely. But the insurance won't pay for those.

Many self-employed folks import drugs from Canada. For awhile, local
governments in my area were doing it as well.

~~~
toomuchtodo
When my disabled mother was covered by Indiana Medicaid (which provided
abysmal coverage), before the ACA took effect, I would import most of her
drugs from Canada (except those that the DEA would not look fondly upon, those
had to come from the local CVS).

It saved me thousands of dollars per month.

~~~
matt_wulfeck
Did the Aca specifically forbid you from importing drugs?

~~~
toomuchtodo
It didn't, but the copays are now so much lower due to subsidies the ACA
provides (compared to Indiana Medicaid), it makes no sense to import said
drugs.

If you live in a state which refused ACA subsidies, this plan of action would
still make sense. Or moving to another country with cheaper/universal
healthcare depending on your income arrangement (disability/social security).

------
markvdb
"These workarounds are necessary because the health care system doesn’t follow
any rational rules of economics, where the customer should be king." The
health care system how it's currently organised in the US _does_ follow
rational rules of economics. It is very good at extracting value from the
medical process. It's horribly bad at solving health issues, let alone
efficiently.

~~~
wyldfire
> The health care system how it's currently organised in the US _does_ follow
> rational rules of economics.

Really‽ If prices of service were disclosed in some sane way the market could
reward the efficient providers. Instead it's shrouded in mystery and the
providers hide behind the complexity of the agreements among the many
insurance agencies. They're certainly able to figure it out once it's time to
generate a bill.

If there were healthcare providers that worked like my auto mechanic or
plumber, it would be so much easier to work with. "sign here, not to exceed
$150 for diagnosis, etc..." and then you discuss with the physician later, "Ok
treatment option 1) these pills, $50 for your insurance, 2) amputation, $3000
for your insurance and BTW you satisfy your annual deductible, ..." It's not
that they couldn't do that, it's just that there's little incentive for them
to do it and none of the competition does it. And much of the time the
diagnosis would reveal "Sir it's probably just a virus which means that we
could spend tons more time and money diagnosing this and then just rule out
tons of other things and end up with no treatment options anyways. If your
symptoms don't go away in three weeks then come back."

~~~
gleb
You misunderstand the grandparent post. He is saying that you don't get to
change rules of economics. But you (in this case the government) does get to
setup the rules of the marketplace. And it is this combination of basic
economics and rules of the marketplace (in this case government hiding cross
subsidies for Medicare) that results in the mess we are in. But the basic
rules of supply, demand and self-interest are the same here as they are in the
auto mechanic business and as they were in Soviet Union.

------
neuro_imager
The real issue here is not perks for physicians but the corrupt, inefficient,
self-serving system that insurance companies and hospital bureaucrats have
devised for the American public.

~~~
joelx
Ever wonder why the cost of healthcare is so ridiculously expensive in this
country? The American Medical Association (the AMA is the most powerful union
in history) has pushed through laws to protect its members from competition,
making it extraordinarily difficult to provide low cost healthcare. Basically,
all entrepreneurs who don’t join the union are shut off the health care
industry. This is why you pay so much money in insurance & for simple doctors
visits. Do you think if a fresh entrepreneur opened a hospital you would pay
$8,000 per day for a room? I very much doubt it.

~~~
carbocation
If physicians were the primary driver behind high healthcare costs, I would
expect physician income to be a larger fraction of healthcare expenditure.
Currently, physician pay represents about ~10% of US healthcare spending. This
is dwarfed by administrative costs, which represent 25% of US healthcare
spending.

If the AMA/AAMC are to blame, then it seems likely to be implicitly: by
keeping entrepreneurs out of the hospital administration game so they can't
reduce inefficiency. But you don't have to be a physician to be a hospital
administrator, so this doesn't make sense to me.

Reducing physician salaries to 0 only reduces healthcare costs by <10%, and
entrepreneurs can become hospital administrators without becoming physicians.
So, I think that the ire directed at the AMA is misplaced, but I'd be
interested to hear more (and I'm an obviously interested party, though I'm not
an AMA member). The regulatory bodies are most likely what you have concerns
about.

~~~
joelx
Medical professionals are the highest paid profession in America -
[http://www.businessinsider.com/top-paying-jobs-in-
america-20...](http://www.businessinsider.com/top-paying-jobs-in-
america-2015-9). 16 of the 30 jobs and all of the top 5 on this list are in
the medical profession.

The high pay in these professions is simple economics: supply is tightly
constricted through the number of residencies allowed. Those in the profession
have a strong interest in continuing to restrict the number of people in their
field and so they have trade organizations that do this.

The line of defense they use is that consumers are too stupid to select a good
healthcare provider without their intervention. I believe consumers would be
very good at selecting the best provider, and would love to see all of the
regulations dropped to open free competition into the marketplace.

~~~
carbocation
Your previous post leads in with:

> Ever wonder why the cost of healthcare is so ridiculously expensive in this
> country?

The major point that I make is that physician salary is under 10% of US
healthcare expenditure, so that's not why healthcare is so ridiculously
expensive here, and driving it to 0 would likely make little overall impact.
You haven't made the case that a constrained supply of physicians is the
reason why there is a large amount of healthcare regulation in the US. Much of
that regulation is to the consternation of physicians as much as it is to
those who want to innovate in healthcare.

Finally, part of the reason that 16 of the top 30 jobs are different
subspecialties of physician is that those jobs have existed for quite some
time and are cleanly delineated into subspecialty. If you were to break out
different roles in investment banks and hedge funds similarly, you'd probably
not see physicians in the top 30 list.

~~~
joelx
I agree completely with you that the large amount of healthcare regulation is
the ultimate culprit for the extreme high prices Americans pay.

My argument is that the root cause of all of the regulation is not the best
interest of the patients, but what is the best interest of the doctors.

Doctor backed trade organizations push for more and more obfuscation of the
actual price a consumer pays in order to be able to charge more. They don't
allow pricing or quality to be openly shared in the marketplace, and they
don't allow new entrants to compete.

Healthcare is ripe for disruption, but entrepreneurs are prevented from doing
so by archaic laws that harm patient care and increase prices. These
regulations are vigorously defended by doctor backed trade organizations..
it's in their best interests to keep their cash cow.

~~~
northern_lights
The regulations only look like they're in favor of the doctors to those
completely unfamiliar with the field. But who keeps the money from that
$8000/night hospital stay? It certainly isn't the internal medicine doc making
$200k/year (admittedly a great salary, but not at all out of line with the
requirements of the job). I'm an advocate for less regulation in the
healthcare industry, but it's not as simple as just throwing away all barriers
and allowing the free market to solve everything.

Nurse practitioners and physician assistants _are_ new entrants in the
healthcare marketplace, and they are absolutely a "disruptive force" in the
healthcare market, in the original Clayton Christensen-sense of the term. In
fact, these professions were even called out as such in The Innovator's
Dilemma. So your argument that new entrants to the market will somehow
magically make prices lower doesn't hold much water (and for those who think
that these entities should be freed from the regulations which require them to
be supervised by a physician...that's like advocating for a large bridge to be
designed and signed off by a civil engineer 2 years out of undergrad).

As for Certificate of Need laws, which limit the amount of hospitals and
sophisticated equipment that can exist in any given area...certainly most
doctors I know don't love these laws. It's the hospital associations (made up
of many, many people other than doctors) which continually fight to keep them
on the books.

------
icantdrive
It's comforting to see a doctor venting his frustration over Insurance
companies. I've gotten to the point where I've kinda just given up. I'm sick
of the entire mess.

I've gotten to the point where I just wish patients had more of a say over
what medications they could have refilled.

Say, for instance, a person has been taking Blood Presssure medication for
over five years; they should be able to renew their original script? Or, a
person has been on anti-anxiety/depression medication for over five years; let
that person authorize their own refills? Require blood tests--that's fine.

The patient couldn't increase the dose, but wouldn't have to deal with doctors
over refills. The patients who abuse the privilege would have to go back to
our lovely system of being held hostage.

I guess refill are on my mind because I'm going into detox over the lack of a
medication I've been on twenty years. The pharmacy is waiting for her
approval. I think my doctor is on an extended vacation?

Of course this will never take place because Americans are all drug seeking
zombies according to our government, and I don't think AMA lobbyists would
ever even consider such a crazy notion.

As to this, "Nepotism occurs in many fields; friends and family of New York
City police officers often carry Patrolmen’s Benevolent Association cards,
which may confer special treatment in a traffic stop."

Yea, this is very common. In San Francisco, my father best friend (now a
retired cop) gave him a special business card. A "Get out of jail free" card.
My father used it a few times. It saved him from a DUI. My father was a very
conservative man. He hated what that card stood for, but always carried it
around.

~~~
adrianN
If someone is on some medication, it is probably a good idea to have them
regularly check in with a doctor to make sure their condition isn't getting
worse (or better!). Forcing them to see a doctor when their medication runs
out seems like a reliable way to get them to go to such checkups.

~~~
brbsix
I realize that sounds pretty reasonable and all, but I can assure you that no
such checkup is being performed the vast majority of times a patient comes in
to renew a script. It's just an excuse to get the patient in so that they can
cover their ass and increase billables.

------
mschuster91
Here in Germany, we have something called "Gebührenordnung für (Tier)Ärzte"
(fee catalogue for (veterinary) doctors).

Everything you can think of has a standardized pricing set, with the option to
go up to 3.5x the standard rate for difficult procedures.

Kind of prevents that bullshit mentioned in the article; also, national health
insurance covers nearly everything that's medically neccessary and deductibles
are highly limited.

~~~
cperciva
In BC (and I assume other Canadian provinces) the dental association publishes
an annual fee guide. They recommend that dentists charge the suggested fees,
but they do not require it. Many insurance companies use the suggested fees as
limits on how much they will pay for certain procedures. But patients who are
paying cash don't know how much the "suggested" rate is for the services they
received -- unless they borrow a copy from their local library, since the
dental association explicitly refuses to put the guide online. (Their argument
is that the fee schedule is too complicated for patients to understand.)

So despite having nominally standardized pricing, in practice there's nothing
keeping pricing standardized beyond what insurance companies are willing to
pay for their clients.

~~~
Waterluvian
Ontario has it posted prominently. The top Google result is the official PDF.
It's only 76 pages.

BC's page has an FAQ saying public library and that its over 1400 pages.

~~~
cbr
[http://www.health.gov.on.ca/en/pro/programs/dental/docs/hso_...](http://www.health.gov.on.ca/en/pro/programs/dental/docs/hso_services_fees_dentist.pdf)

------
ikeboy
There's also professional courtesy between doctors and police. They'll very
often let you off for minor traffic violations even if you're not on the way
to an emergency (source: relative who's a doctor).

It was described to me as "if they get shot and you end up being their surgeon
they want your goodwill", although it's not limited to surgeons so I suspect
that's not quite the whole story.

~~~
matt_wulfeck
We used to just call that kind of thing "courtesy" and people in the community
who were known for being good were given it, while jerks and scumbags had it
denied.

I imagine it played a large part in community good will until our communities
got too big for us.

------
habosa
> In most realms, those with the least ability to pay should receive the
> biggest discounts. In health care, it is often the uninsured and indigent
> who receive bills with the full “chargemaster” fee — the wildly inflated
> prices that nobody really pays — while large insurance companies get the
> biggest breaks.

This bothers me more than almost any other piece of our system. It's corrupt
from the start, with prices being presented that do not have any relation to
the price that the parties in the transaction actually expect to pay/receive.
So even if we had "price transparency" for medical procedures, it wouldn't
really reflect reality.

A few examples of the system at work:

* I have a HSA so I don't put small medical expenses through my insurance. I went to a doctor for a strep throat check and was told that my 30m appointment would be $350 if put through my insurance (and I hadn't hit my deductible yet) or $150 if I paid in cash at the office. So I paid cash with my HSA. Why should there by these two wildly divergent prices? Even if I had no deductible and took the $350 option that just means my insurance company is paying $200 over what the doctor actually wants for the service, which means some other person in the insurance pool will receive $200 less in services down the road.

* One time I got food poisoning in college and because it happened in a classroom and I was unable to really walk/balance the school said I could only leave in an ambulance. So an ambulance was called to drive me the 0.25mi to the university hospital. I waited a few hours in the ER, then a doctor saw me for 15 minutes and no medicine or care was actually administered since I was fine by then. I get a bill in the mail for $1000 a few weeks later, that's $700 for the drive and $300 for the doctor's time. My dad (a dentist) advised me to not pay the bill and let it go to collection. Then a few weeks later the bill collector called me and since I had my income listed as $0 (college student) they said I could pay the bill in installments or just make it all go away for a $300 lump sum (which I took). So just by waiting around suddenly the cost of treatment went down by 70%.

Medicine should not be a negotation. There should be one price for everyone
and you shouldn't have to know anyone or pull strange tricks to get the real
price. If we don't even know what something costs, how can we begin to drive
the cost down?

~~~
6e0prjs5fv
Just letting you know, the monospace formatting appears as a single line and
is unreadable on mobile.

~~~
habosa
Fixed, thanks!

------
nxzero
Real issue is the public's willingness to provide care for itself.

To glaring examples of this are obesity and fatally rates related to medical
error; 250000 deaths a year are related to medical error.

On the last point, you'd think this is an institutional issue, but if you
account for how little attention the public gives the issue compared to other
issues, it's clear the real issue is the public.

------
markbnj
My wife is a member of the R.N. club, but sadly it appears that there are no
perks associated.

