
Medical Anarchy - prot
http://chrispacia.wordpress.com/2013/10/29/medical-anarchy/
======
chimeracoder
> The AMA, which is little more than a union for doctors, doesn’t allow any
> policy changes that threaten to increase competition and reduce their
> monopoly profits

That's like saying that Comcast/Time Warner are a "union for Internet users".

If the AMA were "little more than a union for doctors", doctors would have a
lot more respect for it, instead of the great contempt that they currently do.

If anything, you could argue that, because power follows the money, the AMA is
an advocate for the insurance companies that the doctors are beholden to
(essentially every doctor in the country must pay their fees to the AMA in
order to process billing, because the AMA has a monpoly on that[0]). One of
the big disadvantages of dissociating with the AMA (yes, a provider _can_ do
this) is losing the ability to use these insurance codes.

I don't think that that characterization is quite fair either, but it's a lot
more correct than saying that the AMA is a union for doctors.

If you want to know more about CPT codes and billing, my startup[1] works with
hospitals and outpatient providers to handle the billing process - I am happy
to tell you far more about CPT codes than you ever wanted to know. :)

[0] The AMA owns and controls the CPT codes - the billing codes that payers
use. The providers don't always pay them _directly_ (especially if they're not
independent practitioners), but they do end up paying them in the end.

[1] [https://www.boardrounds.com/](https://www.boardrounds.com/) (plugging
shamelessly because it's relevant).

~~~
nickff
> _" That's like saying that Comcast/Time Warner are a "union for Internet
> users"."_

Comcast and Time Warner are most comparable to hospital chains in the medical
context (or perhaps insurers, depending on what parameters you choose for the
comparison).

> _" If the AMA were "little more than a union for doctors", doctors would
> have a lot more respect for it, instead of the great contempt that they
> currently do."_

Many rank-and-file union members hold their organizations in contempt.

> _" If anything, the AMA is an advocate for the insurance companies that the
> doctors are beholden to"_

The AMA's members are physicians, and other medical personnel; you may look at
the AMA as a union, lobbying group, or a professional association, but it is
certainly not advocating for the interests of the insurers.[1]

[1] [http://www.ama-assn.org/ama/pub/membership/faqs.page](http://www.ama-
assn.org/ama/pub/membership/faqs.page)?

~~~
chimeracoder
> The AMA's members are physicians, and other medical personnel; you may look
> at the AMA as a union, lobbying group, or a professional association, but it
> is certainly not advocating for the interests of the insurers.[1]

Explicitly, certainly not. But in some ways they do end up empowering insurers
(whether intentionally or corruption of their original intent).

(And by the way, I didn't mean that this was the case either; just that it was
a slightly less ludicrous interpretation than the original statement.)

~~~
nickff
I think you are right that the AMA often ends up helping insurers in a number
of ways, much like the California prisons guards' union which has interests
that coincide with those of the prisons.[1] The way I look at industry-wide
unions, they act as a tool for the companies to collude without direct
communication.

[1] [http://www.policymic.com/articles/41531/union-of-the-
snake-h...](http://www.policymic.com/articles/41531/union-of-the-snake-how-
california-s-prison-guards-subvert-democracy)

------
steveklabnik
I'm quite torn about this. In some ways, it seems massively irresponsible, but
framed another way, it makes some sense.

I think it's important to distinguish here between "screw experts they don't
know anything" and "I've taken your professional opinion into account, and
will be making my decision." The second has a long, long history in anarchist
thought:

    
    
      > Does it follow that I reject all authority? Far from me such a thought. In
      > the matter of boots, I refer to the authority of the bootmaker; concerning
      > houses, canals, or railroads, I consult that of the architect or the
      > engineer. For such or such special knowledge I apply to such or such a
      > savant. But I allow neither the bootmaker nor the architect nor the savant to
      > impose his authority upon me. I listen to them freely and with all the
      > respect merited by their intelligence, their character, their knowledge,
      > reserving always my incontestable right of criticism and censure. I do not
      > content myself with consulting a single authority in any special branch; I
      > consult several; I compare their opinions, and choose that which seems to me
      > the soundest. But I recognise no infallible authority, even in special
      > questions; consequently, whatever respect I may have for the honesty and the
      > sincerity of such or such an individual, I have no absolute faith in any
      > person. Such a faith would be fatal to my reason, to my liberty, and even to
      > the success of my undertakings; it would immediately transform me into a
      > stupid slave, an instrument of the will and interests of others.
      > 
      > - Bakunin, "What is Authority" http://www.panarchy.org/bakunin/authority.1871.html

------
vezzy-fnord
Time for a reality check.

Okay, so I like the idea of CoinMD. It's a nice way for people with medical
knowledge to get paid for their tips, but so far that's really about it. It's
just yet another forum for medical advice, but with a gimmick. It's not even
an original gimmick. The whole "integrate Bitcoin into everything" appears to
be motivated by more of a cargo cult to appear modern and countercultural than
anything rational.

However, it does offer an alternative payment system and in this case it
works, so I won't complain about that.

But can we please let go of these childish fantasies that Bitcoin will
overthrow all government and usher us into an anarchist utopia of voluntaryism
and global human liberation? Those kinds of libertarian/anarchist pipe dreams
were excusable during the very beginning of Bitcoin, when the protocol was
still being sharpened and everyone was enthusiastic about this new idea.

I don't know what kind of world the author lives in where he thinks people
posting textual descriptions of their conditions on the Internet, backed by a
digital currency, will revamp the healthcare system into an anarcho-capitalist
institution and turn government irrelevant? What bullshit. Do I seriously need
to explain that writing about your condition isn't enough to get diagnosed
with _anything_ beyond the most rudimentary of advice ("This might be that,
but I'm not sure. Go see a doctor and try this herb in the meantime to see if
it stops.")?

Bitcoin will not render government irrelevant. You see, the thing is that even
if the concept of Bitcoin theoretically can allow financial independence from
the state, it's completely meaningless when your ecosystem is a mess. The
Bitcoin ecosystem, as we have witnessed so many times, is absolute chaotic
mayhem that can ironically only be controlled through state regulation, which
many hardcore Bitcoiners are advocating for.

Homeschooling is opting out of the state? Uh, last I checked, homeschooling
requires one to be registered with the state, as well as offer vigorous and
regular checks with it to ensure you're in line.

The Silk Road isn't any different from your standard drug dealing market, only
it's online and just as volatile and unreliable as the physical thing.

Look, Bitcoin is certainly capable of great things, but these here are just
naive pipe dreams.

~~~
eli5
So, do you think that if enough people want to peacefully live without
government interference at all (e.g. without a government) they don't deserve
to do so and they don't deserve, for example, to be sold a piece of land to
completely secede from state?

~~~
chimeracoder
That's a very loaded (but easy) question.

In the United States, we fought an entire war over the question of whether or
not a state had the authority to secede from the federal government (the
Union). The seceding states lost that fight.

It would be very hard to argue that individuals have that right when the
states do not.

You may wish that it were different, but the fact is that individuals do _not_
have this right, according to virtually any constitutional interpretation
since the mid-19th century.

~~~
wyager
>In the United States, we fought an entire war over the question of whether or
not a state had the authority to secede from the federal government (the
Union). The seceding states lost that fight.

So wars decide what is right and what is wrong?

~~~
aidenn0
It's not about right and wrong, it's about what you can and can't do. If you
do something and the US decides to go to war with you over it, you are SOL.

Philosphers may claim you have a natural right to buy and consume drugs the US
government considers illegal, since you aren't harming others; you can then
scream about your natrual rights from prison all you want.

------
pak
Disclosure: I'm currently attending medical school in New York.

It seems incredibly irresponsible for a doctor to prescribe things based on an
internet conversation without a physical exam. You can't auscultate (listen to
with a stethoscope), visually inspect, run labs, do basic imaging, etc. over
an anonymous internet forum, which are basic facilities that anybody should
expect a doctor in the US to utilize. It is plainly evident, once you become
involved in clinical encounters, that you discover things on exam that the
patient didn't know about, forgot to tell you, or wouldn't be able to find
themselves. These findings are often critical for diagnosis. Telling the
patient to take a certain drug without that data is dangerous and
irresponsible.

You could certainly offer general "advice", but this will never be a
substitute for seeing a doctor. Perhaps interfaces with video and sound are
able to up the bandwidth of internet medicine but currently there is still too
wide of a gap between that and actually laying hands on the patient.

I was not surprised to find that this is exactly what the linked document of
related policies by state medical boards states for New York
([http://www.fsmb.org/pdf/InternetPrescribing-
law&policylangua...](http://www.fsmb.org/pdf/InternetPrescribing-
law&policylanguage.pdf)):

 _Section 80.63 of the controlled substance regulations requires a
practitioner to physically examine a patient prior to initially prescribing a
controlled substance. Issuing a prescription for a controlled substance solely
on the basis of a questionnaire or other medical history submitted to a
practitioner over the Internet does not meet the requirement of a physical
examination or establish a legitimate practitioner-patient relationship and is
not a valid prescription._

I cannot find anything controversial about that. I am all for forums linking
doctors to talk to more patients, even for payment, but keep the "MD" out of
the name because this is not a true substitute for seeing a doctor.

~~~
lotsofmangos
I think attempts like this are symptoms of something really badly broken. It
obviously isn't a good solution, but for anyone to even be thinking of
seriously implementing it speaks volumes.

~~~
joe_the_user
Yes, but it is a symptom of the medical system being badly broken or a symptom
of how we think about these kinds of problems being badly broken...?

Come to think of it, it's both!

~~~
lotsofmangos
If you take the concept of business and profit out of medical services and try
instead to have a culture of medicine as public service, then ideas such as
confidentiality and care become more commonplace.

I am not meaning this as a particularly anti-capitalist view, but I think
there are areas of human existence where profit making should be excluded. For
certain things, like fire departments, that battle was won long ago, and
thankfully we are not in the days of ancient Rome where you would have to
argue prices with Marcus Crassus before your house fire was put out.
[http://en.wikipedia.org/wiki/History_of_firefighting#Rome](http://en.wikipedia.org/wiki/History_of_firefighting#Rome)

------
01Michael10
This article is for real? Am I missing something? Sure, people want a
diagnosis and other services from an unregulated, anonymous doctor with a
reputation built by what? Amazon-like reviews? Come on!

~~~
eli5
That's not like that at all. As far as I understand all answers doctors give
are open to the public on the site, so everyone else on the internet,
including other doctors, can read them and say if it's a good answer or a bad
answer. I imagine if this sites starts issuing bad advice, no one would want
to go there. However, as of right now, it appears you are wrong and answers
are getting paid for by willing customers.

Now, this idea may be far from perfect. But comparing it to the existing
system while having a blind faith in it is wrong. In our existing system
patients don't have many options of checking what their doctor tells them;
they are referred to doctors by other doctors and very often have no way of
checking on the reputation (% of successful operations this doctor conducted,
for instance). The current system is very inflexible and not consumer oriented
at all. Consumer interests are sacrificed in the name of their supposed
safety, without first giving said consumers options to decide what they
actually want and consider safe.

~~~
01Michael10
I am not referring to CoinMD so much but this paragraph...

"Imagine a future where renegade doctors shun licensing laws and practice
medicine over the internet. They build up a reputation around an anonymous
identity. Use public key cryptography to sign their diagnosis, reassuring the
patient that it really came from them. It’s not hard to imagine this would
create a demand for anonymous accreditation agencies. These agencies could
issue exams and then use their digital signature to sign the credentials of
doctors who pass the exam. Patients pay for these services in anonymous
currency ― Bitcoin ― and pay fraction of the price they would pay to the
government enforced monopoly."

------
psaintla
So they are hoping people will make medical decisions based on advice from an
anonymous doctor whose credentials you cannot verify and who does not have
prescribing ability? Is this serious?

------
baddox
I think an even better example of potential crypto-anarchist success is legal
advice. It could work largely the same as the medical service this article
describes, but legal advice fits better than medical advice.

------
hershel
Another interesting thing to do is having a high quality medical expert
system(Watson), running outside the u.s.(say africa[1]) with people who we're
taught how to use it(even doctors), with access to video communication with
the patient, with access to his test results - administer advice to him.

Assuming good , mostly automated process and a good expert system - this could
be a way to offer highly accurate second opinion.

And it would be a perfectly legal service from the provider side.

[1]This could be used locally in the country, which is a nice way to
augment/start a country medical system

------
kevingadd
I'm bothered that this article seems to believe that the rise in homeschooling
(in large part by unqualified parents using low-quality textbooks and ill-
considered strategies) is another example of people 'opting out' of some
particular brand of oppression by the State, and that doing so will increase
supply, or something?

As far as I'm concerned, students have a right to a high quality education
because without one their future will be a trainwreck. Just because they're
largely minors doesn't, to me, mean that their parents have the right to deny
them a future in favor of whatever their personal reasons may be. Yes, this is
an infringement on the 'rights' of parents, but I don't think parents have the
right to treat children like property in the first place.

And yes, there are some parents who do a great job homeschooling; I'm sure of
it. I've just never met them, and I was extensively involved in local
homeschooling programs back in my home town, so I interacted with dozens of
homeschooling families, hundreds of homeschooled kids, and visited some of the
organized conventions and programs that involved thousands more. Too many of
these people simply aren't qualified to teach a child from the beginning up to
college age, even if they may have the legal freedom to do it.

As it relates to the article's premise: I also think individuals have a right
to reasonable health because it is integral to their future. A nation full of
sick people is going to be a nation with low productivity and a high tax
burden from running things like emergency rooms. It is in our best interest to
offer everyone affordable access to some basic minimum level of health care,
and to do so in the cheapest possible manner. The author seems to believe that
a comparison shopping website for doctors will deliver affordable health care
to everyone, but I think he ignores a few essential issues that could make it
impossible for such a website to deliver good results:

a) Even now, many people who need health care do not have regular access to
the internet. This is in part due to the huge stretches of rural America, but
it is also due to the fact that we have a huge homeless population and a huge
low-income population, both of whom may not even be able to afford the
equipment necessary to get on the internet. You certainly aren't going to
propose giving them free equipment and internet access so they can go buy
health care on a website.

b) It is arguably impossible to comparison shop for essential health care. You
don't have the time to waste on it and you are emotionally/mentally
compromised by the stress of your impending doom. To a degree, this is correct
- you should be prioritizing your own well-being. It should be the
responsibility of everyone else in the system to try and keep costs for this
essential care to a minimum; instead, a profit-driven health system tries to
maximize profit off this essential care, and deny claims to as many dying
people as possible. Introducing more profit motive into this system does not
seem like it will fix anything.

c) Medical practice over the internet without licenses is simply a recipe for
disaster. I am willing to accept that a licensed doctor could perhaps perform
a subset of their duties over the internet; I occasionally email my doctor
instead of visiting them in person when I need minor adjustments to medicine
doses, and that is fine - both sides are fully informed and no corners are
being cut. However, if you're not even going to license them to verify that
they meet the basest standards of medical competence, you'd be mad to also let
them practice without ever seeing a patient in person. It's just a bad idea.
We have enough issues with malpractice and patients being sold treatments they
don't need as things are; removing licensing and medical standards will make
this worse as both of those problems can be increased by a profit motive.

d) Comparison shopping for long-term health care seems nearly impossible since
in many cases, if you discover the care you are getting is suboptimal, it is
too late to switch - whether because of pre-existing conditions, or because
the care is ongoing and transferring to another provider would put you at
risk. You can't trivially ask to have your dying father moved to an intensive
care unit across town just to save a couple thousand dollars, even if you CAN
do it.

~~~
dragonwriter
> As far as I'm concerned, students have a right to a high quality education
> because without one their future will be a trainwreck. Just because they're
> largely minors doesn't, to me, mean that their parents have the right to
> deny them a future in favor of whatever their personal reasons may be.

Sounds like the solution is to: 1) Define what a "high quality education"
means in terms that it is objectively measurable whether one is being provided
to a child, 2) Assure that children, regardless of education venue (home,
private, or public school) are receiving it.

 _Assuming_ that certain venues do provide a "high quality education" and that
other venues do not -- in any direction -- doesn't seem particularly useful if
that is a genuine concern rather than a superficial rationalization.

~~~
kevingadd
The point is not that homeschooling provides a lower quality education than
public schools (though I would argue that, on average, it does) - the point is
that homeschooling is being done by unqualified people using unverified,
quickly-considered techniques, while public schooling is at least largely done
by people who got teaching certifications and their methods get public
scrutiny.

To me, the amount of criticism public schools receive is an indicator of their
worthiness - people are able to inspect the education and intervene directly
if they feel it is inadequate, and the government has the ability to provide
useful oversight and assist in setting standards. I'm sure there are many
cases where this centralization is to children's detriment, but at least it is
a largely transparent system.

In comparison, the only real transparency provided into a homeschooled child's
education is when they start college and have to find out whether they really
learned enough essential skills and information to be able to compete in a
real educational environment. If the answer is 'no', it's too late to do
anything.

Objective measurements would be great, and so would more rigorous enforcement.
Historically, homeschooling groups are against both.

~~~
baddox
> the point is that homeschooling is being done by unqualified people using
> unverified, quickly-considered techniques, while public schooling is at
> least largely done by people who got teaching certifications and their
> methods get public scrutiny.

But still, you're assuming that unqualified (according to whose
qualifications?) people using unverified (by whom?) techniques are worse on
average than public schools.

It's not easy to agree on what objective measurements comprise "good
schooling," but I think most people will agree that homeschooling and public
schooling both vary wildly in quality if we were to agree upon some objective
measurements. It's not fair to implement policies for either type of schooling
based solely on the _worst_ examples of that type of schooling.

~~~
kevingadd
I think it's reasonable to assume that unless anyone has proven the contrary,
which they haven't. If you were replacing a public school with a private
school, I'd agree that it is unwise to assume the private school is worse.
We're talking about replacing an entire school staff with a couple overworked
parents, though.

Many arguments in favor of homeschooling are about parents' religious freedom
or about how the public school system has failed the children, and in both
cases this does nothing to demonstrate that the parents are going to do a
better job.

I do agree that objective measurements would allow this stuff to be considered
rationally, but historically it's really hard to come up with useful objective
measurements due to all of the different pressures involved.

~~~
baddox
> I think it's reasonable to assume that unless anyone has proven the
> contrary, which they haven't.

I disagree. I think it could go either way, as I have no real scientifically
valid evidence either way, but I think the burden of proof is on the party
advocating using violence to prevent the other party from doing what it wants.

> Many arguments in favor of homeschooling are about parents' religious
> freedom or about how the public school system has failed the children, and
> in both cases this does nothing to demonstrate that the parents are going to
> do a better job.

True, but it also does nothing to demonstrate that the parents are going to do
a worse job.

~~~
kevingadd
Who said anything about violence? I think it's a pretty absurd leap to go from
me expressing a negative opinion on homeschooling directly to me seemingly
dispatching SWAT teams to round up homeschoolers.

~~~
baddox
How then would you implement a policy that prohibits parents from
homeschooling if they don't meet certain qualifications?

------
chiph
You'd want that your physician has more training than just having read some
WebMD articles. How can you be sure?

What about liability in case they're wrong? A coworker lost a relative last
year because the doctor missed an obvious case of septic infection. How do you
take an anonymous physician to court for a mistake like this? Hard to pay
restitution when the injured party dies.

~~~
final_approach
Punishment is just one way of ensuring doctors pay attention. And as many
people find out, it doesn't actually work simply because doctors make mistakes
anyway.

Now, for a price $10 I don't think anyone should expect any kind of liability.
It's advice. If someone gives you a $10 take it as such and go see another
doctor for $100 if you're unsure. To my understanding CoinMD simply provides
what market needs: cheap accessible advice of reasonable quality. If you could
sue doctors there, prices wouldn't be as low.

------
mwnz
I stopped reading when the author implied that the U.S healthcare systems woes
were due to supply and demand. This is a shallow view of a completely broken
system. The supply and demand ratio is comparable to that of other wealthy
nations, yet almost every other wealthy nation has kept their health care
industry in check.

~~~
thomas_eh
this

------
etanazir
MD = Monopoly on Drugs

