OK, that’s not the same thing as having increased negotiating power, but I certainly agree that having a lot of cash is an advantage over not having a lot of cash.
BTW, insurance cannot be sold at a loss. Insurance regulators won’t allow it. What insurance companies sometimes do when they’re focused on market share is use aggressive assumptions, but regulators look at these as well. You can get away with doing this a bit, but if you’re too low your rates will be rejected.
OK, I have no opinion as to whether they might or might not gain something out of trying these things or others like it. (Not my area of specialty, at any rate.) I’m just saying I don’t see any apparent way these guys can revolutionize the way the business is done, that’s all.
[It’s unclear to me if these companies intend to go into the insurance business altogether. My vague impression from articles on the subject is that they’re focused on changing the way they provide health coverage to their own employees. But I don’t know, or know if anyone else knows either. :)]
Correction, I recall now that I was unable to determine the case in the question of extended life support.
And, as it’s also commonly suggested, I’ll note that medical malpractice was one thing I investigated and it was not a significant factor. State border limits on insurance regulations also were not.
My suspicion is that they will accelerate moving medicine away from a practice that relies human interaction and trusted relationships and towards a transactional model with more medicine by phone, video, and computer contact with providers working banks, and by generic providers when in person care is needed. I don’t think it will produce the savings they are looking for.
I’m hugely in favor of allowing doctors to bill for “visits” over the phone. Many times an in person visit is called for, but many times it’s not and the doctor does nothing more than ask some questions which could just as easily be done over the phone. And I suspect that this is because doctors don’t like working for free any more than anyone else does, and if the only way they can bill is if it’s an in person visit, then they’ll insist on it. So allowing them to bill for over the phone consults would be a win-win for everyone involved. (I imagine this makes more sense for follow-up visits and the like, as opposed to people calling up at random trying to get prescriptions for things :))
I don’t know of any of them that officially have the video option, but several of Spain’s regions offer “nurse by phone”; you can call a free number to ask what to do and they’ll direct you over the phone or send medical (our UHC doctors and nurses do home visits both for emergencies and for those types of routine care where that’s considered better than making the patient move). The number redirects to a cellphone; I know SiL-the-GP has used it to receive pictures from a caretaker (usually a relative of the patient; I mean someone without medical training, not some sort of nurse’s aide). It’s one of those things people found strange when first offered but now would look at you funny if you remind them it’s only been around for a couple of years.
No question that there are some things that can be done appropriately by a good provider over phone or by way of a video visit. And here are industries emerging to fulfill the demand for those sorts of services, most often staffed by providers who have no existing relationship with the individual, often no access to their past records, and who quality is sometimes quite … variable. So far I’ve seen the quality of care provided by the many of these systems to be horrific. The providers are often trying to over reach what they can properly assess by way of a phone call or video encounter.
I may be on a rant because of the latest this weekend in which a parent called. Her company provides for one of these services so she called them and the provider labelled a rash the child had a the rash that goes with strep throat (no sore throat) and started the kid on antibiotics. First, starting on antibiotics without a confirmatory throat swab is crap, against every guideline that exists for very good reasons. Second when the mother decided that maybe she should give us a call the next day (uncomfortable giving an antibiotic for what she recognized was a sketchy indication, and yes we answer phone calls usually within an hour and do what we can for our established patients over the phone if appropriate, no charge) nothing about the rash sounded like the strep rash. Saw the kid the next day and it was a very very different and more significant condition called Henoch Schonlein Purpura. Nothing at all similar to the strep rash. In person at least there is no way for any qualified child healthcare provider to confuse them.
But that anecdote aside poor quality of care with inappropriate and incorrect prescribing of medicines, especially of antibiotics, does seem to be the baseline of many if not most of these commoditized medical services. Over time that will end up costing all of us lots more. Maybe what they will build will include much better quality control than what is currently mostly available staffed with people more willing to appropriately answer that they cannot manage this one over the phone and that they actually do need to be seen (and not with rigid guidelines that alternatively make everything an emergency either). Our larger group is trying to build our own formalized system. The challenge to doing it well though is more I think than Bezos and the like appreciate.
I had to have a routine eye exam and a field of view test (droopy eye lids). I tried to do it in the same visit, but they said if they did them on the same day my insurance would only reimburse them for one procedure. I had to get a 2nd appt on a different day. More paperwork for them, more inconvenience for me. Madness.
My insurance company here in the states also has a nurse hotline, I have used it a couple times. They helped me decide if a pin office visit was warranted.
Another area of medicine that I had not thought of for my earlier post is AI. IBM used Watson as a diagnostic tool and the NYT today has a piece about Chinese companies investing big in medical AI.
That is not correct. The US certainly spends more on R&D, but like the rest of healthcare there is no indication that the increased spending leads to better, or more results. The US results per head of population is pretty much on par with other large nations. A bit of the the UK actually, with their exceptionally cheap system.
No, that is moving the goalposts. This was your original statement:
The study I linked divided waste into several categories, Administrative waste, Operational waste and Clinical Waste, while noting that one source of waste, high US prices for medical goods and services fell outside the article.
Your quote was part of a discussion on the clinical waste, speculating that this may be one of the drivers for clinical waste. It then went on to note that clinical waste seems to be only 2-3 % of total spending.
This means that third-party is not a significant driver of US healthcare costs, far less one of the biggest.
And if the patients were in the US there would have been a significant chance they would have gotten no cancer drugs whatsoever. Which is why the US came out much worse on access. Excellent access for the upper middle class and above does not cancel out problems for the much larger numbers below them.
I did not say there is not rationing outside the US. I said US rationing is worse. My point is that it is wrong to say that other nations control costs through rationing when contrasted to the US, since the US rations far harsher and still have much worse costs.
Its also a comparison based on one of the US strong points, expensive treatment. As noted in one of the papers, there are misaligned incentives in the US system. Shifting treatment from more expensive to less expensive in the US can be undesirable since it represents a loss of profit, whereas it is desirable in the UK.
The methodology of that study seems to be flawed, unless there’s some missing info. Drugs are developed in one country and sold internationally. As long as a company - wherever they’re located - can recoup their R&D costs somewhere, it would be economical for them to develop it.
ISTM that you do, but if you don’t then you don’t. I think it’s clear in context what I’m saying, but if you haven’t figured it out by this time then not much worth in going around in circles about it.
Your claim that the cite says that “clinical waste seems to be only 2-3 % of total spending” is bogus. What it actually says is the following (emphasis added):
So they are very much not claiming that it seems to be only 2%-3% of total spending. It’s hard to imagine how you could have made this claim.
I think the reason the US came out much worse on access in the specific study you cited was because the study defined “access” in a manner geared to produce the results it did. From the study:
If you’re defining access specifically in terms of cost measures, then obviously a country where people pay less out-of-pocket for medical care is going to come in higher. Based on their definition access due to explicit rationing is not included in their measure at all. (Timeliness is less clear, as it’s unclear whether the widespread use of ER as PCP by lower-income people is included in their measures or not - based on their statement about primary care clinicians I would guess not, but I don’t know.)
I’m always amused at these complicated rationalizations for what “really” accounts for America’s outrageous spending on health care when the obvious answer is staring everyone in the face. Sure there are multiple complex factors, but let me net out in simple terms the one that is overwhelmingly dominant.
I have in front of me a slightly dated physician’s fee schedule for medical fees payable in Ontario. A basic GP consult (routine doctor’s visit) is billed at $56.10; a “limited consultation” is $44.65. Now these figures may be a bit dated, but I know that when I forgot and missed a doctor’s appointment, my doctor, who is quite anal about these things, charged me out of pocket. The charge was $45. Note that in these examples and all the ones below, these fees constitute full payment – there are no co-pays, the patient normally owes nothing out of pocket, ever. I would ask Mr. Fotheringay-Phipps to put aside his complex rationalizations and tell us what he pays – his insurance plus co-pays together – for a typical doctor’s appointment.
MRIs are complicated, but to give an idea: head MRI, multislice sequence $71.50, add $19.40 for MR spectroscopy, add $35.85 for each repeat of another plane or different pulse sequence. Among the most expensive is a complex spine MRI, $104.70 and $52.15 per repeat. I would ask Mr. Fotheringay-Phipps what he and his beloved insurance company pay for a typical MRI. From prior discussions, I’ve seen costs mentioned that are on the order of $8000 or more.
Diagnostic ultrasounds are a sum of three components (technical and two professional) and total on the order of around $45 to $100.
I trust this should dispel any mystery about what high US medical costs are really due to, not that I’m expecting Fotheringay-Phipps to respond. And the reasons for these outrageous fees are two-fold. #1, there is not only no effective means of cost control, there is actually an insurance-industry incentive for costs to be high, since their profits are effectively driven off these costs. And #2, the costs have to be high to cover the outrageous overhead and complexity of dealing with insurers.
I may be misinterpreting your statement here, but if you are implying that the primary reason costs in the US are high is because of waste due to having to deal with insurers, that is mistaken. There have been numerous studies comparing administrative costs in US healthcare to admin costs in other countries, and the consensus seems to be that administrative waste accounts for 10%-12% of all US healthcare spending. Some sample studies:
So eliminating administrative waste in the US healthcare system should reduce spending by about $330B - $400B USD annually. (In 2016, US healthcare spending was $3.3T or 17.9% of GDP). So reducing administrative waste would certainly be helpful, but addressing administrative waste alone would not come anywhere near close to bringing us in-line with other industrialized nations who current sit at around 11% of GDP. There are many sources of inefficiency in the US health care system besides the two you listed, and many of the other sources of inefficiency you have omitted are at least as impactful as the two you did cite.
Piggybacking on jasg, medical diagnostic AI is definitely one area that could be leveraged. Especially if the AI can be tuned to provide probabilistic guidance on the most likely ailments the patient is suffering, so that we can cut down on the amount of testing/“lets try this and see if it works” types of clinical waste, and hopefully reduce the rates of misdiagnosis generally.
Much of which got shot down by the government. I was not impressed by the article. Diagnostics are going to happen all over. Video office visits seem to happen in the US today for those for whom it makes sense - like if you are remote. Refilling prescriptions on line? I do that already. And have for years.
I think any rational analysis of cost differences between the US system and the rest of the OECD countries – because these cost differences are so dramatic – has to acknowledge the impact of the significant structural differences. And by far the most significant structural difference is that virtually all health care funding for those under 65 – and a great deal of it even for those on Medicare – comes from a risk-rated traditional private-sector insurance model which is, relatively speaking, almost completely unregulated. One impact of this is administrative costs. I don’t dispute the numbers and percentages you state for that; some estimates are marginally higher, but by and large I think it’s in line with most such assessments. No, I don’t claim that this is the primary reason costs are so high. I think the lack of an effective means of cost control is a much bigger factor.
Look at the numbers I quoted. Numbers don’t lie. Many US health care costs are truly outlandish compared to average costs in OECD countries which are standardized and regulated, and almost as shocking is the absence of any uniformity or indeed even the ability to determine what those costs even are, because they seem to vary all over the map depending on who the provider is, who the payer is, and apparently the phases of the moon and the direction of the wind. Claiming that Americans just want more health care, or that for some unknown reason there is more clinical waste, are either minor factors or are, in fact, entirely bogus (Americans actually get less health care on average than OECD patients because of out-of-pocket cost disincentives; for instance, off the top of my head, fewer doctor visits and shorter hospital stays).
Fair enough. I somewhat disagree that clinical waste issues are minor factors, I think they are significant, but it is certainly true that lack of cost transparency is a very serious problem. You can’t have an efficient market of any sort without reliable access to pricing information (a drop in-visit at my local clinic is $100 because they post price lists and you pay cash, but I’ll be damned if I know how much a consultation at my primary care provider actually costs). As for Americans getting less health care on average, that depends entirely on how you measure. Yes, we get fewer doctor visits and shorter hospital stays, but we also consume far more drugs (priced at high, semi-arbitrary levels, again, due to lack of cost transparency). And as I posted earlier, I do not personally have access to information regarding overall utilization, but others in this thread have linked to data that hints that perhaps Americans do in fact consume far more of the expensive medical treatments available than other industrialized nations; that is going to have a meaningful cost impact, even if we are using fewer GP-hours and hospital beds.
No. There are wasted administrative costs because we have many businesses and government organizations adminstrating healthcare spending, and that’s further broken down by state, causing more redundancy, but by the same token, the EU doesn’t have a monolithic universal payment scheme for all of its member nations. In this respect, it makes more sense to compare the USA to the EU as a whole. If the impact of having 50 different agencies covering healthcare is a doubling of cost, then why is the EU average spending half as much as the US? If the EU switched to a single payer system, do you think that their healthcare costs would half?
And while some of our groups also earn a profit, the profit margin on healthcare, for insurers, is something like 4%, not 200%.
Logically, it can’t be administration and by simple statistics that you can look up, it’s not health insurance profit.
It’s kind of weird how Americans are dying younger - and bizarrely earlier year-on-year now - than their counterparts in other western countries. Is rationing good for you?
I showed in another thread it’s cheaper to take a weeks vacation, fly to London, rent a AirBnB, do the sightseeing thing, get a MRI, and fly home again.