It looks like the main reason the ads price for therapy went up is the extra competition - that COVID making the therapy market from in-person to virtual creates the supply to be not constrained by distance, which means suppliers have to compete across greater pool of suppliers, including therapists from cheaper cost of living areas. This naturally creates a downward pressure for the average price, and of course firms like BetterHelp show up to take advantage of this price differential - i.e. they are doing an arbitrage.
So this comes down to therapists living in expensive areas complaining about competition from therapists from cheaper areas. Given there are still people who need/want local therapy, there will be a new price equilibrium but most likely it will be lower than before. No amount of complaining about Google or ads or arbitrage like BetterHelp will make the price stay as before. Nothing much to see here - this looks mostly like a market adapting to a new changed market condition.
Also VC backed online therapy providers are mentioned. Are these sustainable businesses (no one knows) and, crucially, if they fail will they do so before they wipe out independent therapists having used their purchasing power to raise ad prices beyond reach?
In the 90s part of the promise of the web was that it would disintermediate service provision, these economics would seem to act against that possibility. With large aggregator middle men best positioned to profit with large scale small margin offerings.
It is not Google's job to ensure private practice of shrinks is sustainable. Large scale small margin offerings clearly better serve the patients and if Google does not help them they will be in a better position to seek other alternatives like national TV. I do not think small shrinks can even enter those spaces today.
One possibility I see is for many shrinks to come together form a co-operative and compete with vc backed alternatives.
> if they fail will they do so before they wipe out independent therapists
I suspect that this would be at least somewhat balanced by therapists who work for said online therapy providers suddenly needing to work directly with clients again... but I could see that leading to less therapists per capita in areas of high cost of living, like major cities.
But I hadn't really thought about the potential human harm that could be caused by their failure, which is scary to think about.
Kind of like non-profits in 3rd world countries who warp the local economy by providing some things for free, destroying the market for those, and then pulling out of the country after businesses previously filling that role have closed.
Ad prices going up means that more money is being siphoned off by Google from the mental health care service industry.
It's unclear that this is ACTUALLY competition for the service or just competition for the ads. I personally would not do therapy remote unless I had to so any therapist I would be looking for would be local even if I have to do therapy remote in the short term.
Teletherapy is regulated by state... it’ll be interesting to see if there’s a crackdown by states on apps and orgs operating outside their jurisdictions so to speak.
As I understand it, the problem here has little to do with Google. The problem is that the transition to telehealth means that therapists are now competing directly with large national mental healthare providers like BetterHealth and Talkspace mentioned in the article. Those big companies have deeper advertising pockets.
If you want to break up companies to make it easier for independent therapists, those are the ones to break up. Google is just the marketplace.
This is like blaming the sidewalk or the interstate highway system when Wal-Mart causes your local mom and pop store to shut down. Google isn't driving her prices up, competition is.
Generally I agree with your overall points but I have one small reservation about this part:
> If you want to break up companies to make it easier for independent therapists, those are the ones to break up.
It's not clear breaking up BetterHelp and Talkspace will do good at this point.
Fundamentally, it's not efficient or possible for all of therapists in the entire US to compete for everyone's eyeballs independently. It's impossible for consumers to meaningfully compare and "shop" against tens of thousands of therapists, nor tens of thousands of suppliers to compete for tens of millions of consumers. You need some mechanism to funnel this down and organize this market. This is why retailers and various dealers and brokers exist, and BetterHelp and Talkspace are the retailers of therapist service, just like Amazon and Walmart are the retailer for many different goods suppliers.
It would probably be considered a problem if Wal-Mart paid the state/highway department to ensure that major town roads "flow naturally" to Wal-Mart and are better maintained than roads that lead elsewhere.
This is definitely similar to major companies in a specific domain buying the top search result from google for any query within that domain.
The major telehealth bying google ads is Wal-Mart bying 10 large highway billboards. The indie therapist not being able to afford the auction is the mom-and-pop shop not being able to afford those buidboards.
now if the major telehealth would get a dedicated bandwidth and the indie therapist's video calls were getting throttled we would be talking roads etc.
For now it's the 'walmart moving into a small town' scenario but the bloomberg article blames the company that operates the billboards.
A billboard ad is not an explicit and direct "physical" connection to the product the way that a search result is.
Dedicated bandwidth and throttling, to extend my original analogy, would be like the roads going only to Wal-Mart or being difficult in some significant way to take anywhere other than Wal-Mart. It is the same problem only more pronounced.
The first search result you encounter when executing some search is much more similar to the first store you encounter when searching for some store (by taking the easiest or "most natural" path into the shopping district) than it is to viewing a billboard.
Edit -- To clarify what I mean about billboard ads:
A billboard ad is something you see that is unrelated to whatever else you are doing. Yes, a digital "billboard" ad is still a direct connection to the product being advertised but it is also distinctly separate from whatever content or activity it displays alongside.
A search result is the content/activity you have sought out by searching. There could definitely be a grey area if google's design made sponsored search results stand out more or be distinct in some way that causes them to read as some content other than a search result (either by position, border, size, color, etc) but that is very clearly not the case of their current design.
Sponsored search results look exactly the same as non-sponsored search results apart from the "Ad" text displayed with the URL. They are clearly intended to look and function the same as the "normal" content of the page and not intended to be an incidental "secondary" experience alongside your search.
Doesn't seem like a good analogy in either case. The highways are a shared public resource, the 1st page of google is just an ideal place to show an ad.
Google is the closest thing to a "shared public resource" for indexing/searching the Internet that we have.
I agree with you that there are inherent properties of physical transit pathways that make them difficult to compare "one to one" with digital index searches. But I do not think these differences make the two completely incomparable.
I completely disagree that the 1st page of google is "just" an ideal place to show an ad.
While it definitely is an ideal place to show an ad it is also much more than that.
That is like saying a supermarket that can give cash-back at the register is just an ATM.
> Google is the closest thing to a "shared public resource" for indexing/searching the Internet that we have.
Being the closest doesn't mean it's actually close. The 1st page of google is not a "shared public resource" and not just in the physical sense. The roads are collectively owned by society and are designated and maintained for the explicit prerogatives of the public good.
The first page of google is a privately owned webpage that many businesses rely on for increased sales, but it isn't even close to the only resource for society to search/index the web.
> it is also much more than that
Like what?
> That is like saying a supermarket that can give cash-back at the register is just an ATM.
This analogy doesn't fit. Cash-back is a negligible ancillary function of a supermarket while serving up ads is the sole business purpose of google.com.
Analogies might be useful to illustrate an idea, but they are useless as evidence or for supporting reasoning. I find that they weaken arguments, and sticking to the relevant facts keeps discussions on track.
Capitalism doesn't blend perfectly well with issues of Health, so we usually need to step in with some rational rules.
There are special regulations for almost all aspects of Healthcare; so it's not unreasonable that there might be special rules or regulations for ads on Google as well.
The fact that you liken Google to the interstate highway system with 0 irony just shows how far we've fallen from not giving a shit that Google is a natural monopoly in this case.
I share your concerns about monopolies and monopolistic practices, including Google's (which is my employer).
In this specific instance, I don't see that Google's dominance of search is a cause of the problem. Imagine that there were ten search engines all owning 10% of the market. The independent therapist was buying ads on all of them. Then COVID hits and she starts facing ad competition from national telehealth providers on all ten of those ad networks, driving up ad prices.
She will have essentially the same experience, and the exact same article could be written. Maybe I'm missing something, but I don't see how Google's larger marketshare is a large piece of what's going on here. To me, it looks almost entirely like a small business all of a sudden facing much larger competition because of telehealth.
Imagine if one day every restaurant got a free teleportation terminal at their front door. If you run a local barbecue restaurant in your small town, it's going to be a lot harder to stay competitive when everyone nearby can freely choose between you, Franklin in Austin, Joe's in Kansas City, or even just the comparatively larger marketing budget of Smokey Bones.
Like it or not, these independent therapists got dumped into a much larger pond.
The article is so wrong. This is part of the reason why I do not take main stream journalists very seriously. I wish same issue was taken up by some hard core economist.
What is wrong with the article :
- So one small Psychiatrist is losing business to other Psychiatrists.
It is perfectly possible that Ross is an inefficient Psychiatrist here and patients are better served by other Psychiatrists. This is a loss for Ross but barely a "complication". Also it is not clear to me if the market was divided 50-50 between say Google and Bing why would it be any difference. From over 10 years of experience in ad industry I have realized that it is a ruthlessly free market system where the inefficient player will get punished very quickly.
What Google has done here is that opened up a lager pool of customers for the suppliers and that has resulted into fierce competition among suppliers. The customers invariably will benefit here as they have more options.
- The rant about smart campaigns
This is one of the real bad arguments. A couple's councilor is upset that Google is unable to differentiate between a PTSD councilor and couple's Councillor. Will the world be better served if a couple's councilor has to compete with a florist or a nanny ? [That it what yellow pages were].
The article laments that customers have more choice and it is not easy for the suppliers to rely on information asymmetry to make profit. They take some fictional futuristic scenario and compare google against it and blame those problems on Google. But in reality it is a good problem to have.
PS. This is by no means to claim that Google's ad algorithms are perfect, but it is without dispute that they are better than all available alternatives.
- So one small Psychiatrist is losing business to other Psychiatrists.
Perhaps you're approaching this from a technical standpoint because you're a computer person. He's not supposed to represent the entirety of the problem. He's there to illustrate the problem. Journalists do this to "humanize" the story, to make it more understandable by the audience. This is done all the time. If there's space available, several people are added. Or there may have been several examples in the reporter's original writing, but they were cut for various reasons like lack of space.
As an HN reader, you're probably not the audience.
> possible that Ross is an inefficient Psychiatrist
I share your uncertainty about the relevance of Google’s market share. It was however clear to me that Ross is a psychologist, not a psychiatrist, working as a psychotherapist.
> Ellen Ross ... a psychotherapist ... her practice, True North Psychology ... “I’m a fairly good psychologist,” she says.
The exact service on offer is central to the more relevant issue of competition among suppliers. The psychotherapy market is increasingly competitive. Hopefully she’s an efficient psychotherapist as the flood of money into that space is likely to require some adaptation.
In France, they fixed this by not allowing doctors or drugs to advertise. One of the best decisions ever, for a lot of reasons: you cut care cost, and you avoid that kind of third party profiteering.
Looks like there never was a federal law against drug ads in the US. I don't remember seeing any prescription drug ads until maybe the late 80s to mid 90s, when male pattern baldness and ED ads became prolific, starting us down the path towards remedies for diseases of affluence swallowing R&D funding:
I've been growing more concerned lately that today's youth might not be aware that things really were better just a few decades ago. I'm seeing a lot of mental gymnastics to rationalize behavior by big business that I consider indefensible.
Or to rephrase, I think that youth today do know that they are getting screwed, but for whatever reason, they often place blame on the wrong culprits. If we want to get back to the glory days, I feel that we need to revisit fundamental American values like truth, justice, civics, etc etc etc.
Or we can like, have even more billionaires and regulatory capture by multinational corporations taking us on an arrow's trajectory towards fascism. I can't even believe I have to write this, but that's how much the US has changed since I was young.
I think what happened in the past with drug and doctor ads is they "red-tided" themselves in the space by making themselves known as the source of disreputable patent medicine quacks such that advertising was shameful. The public, even with the worse transparency learned that they just didn't work. Like how infomercial products are often synonymous with overpriced and/or not working.
Part of why we aren't seeing that reoccur is that while expensive there is FDA regulation and the drugs more or less work even if there may be rightful concerns about side effects. They made sure they actually work so they rake in way more money than any small time quack.
Part of the issue with any return to glory days movement is that tradition is fundamentally a cargo-culted lie via induction. Traditions never were first done because they were tradition. The hard truth is the rot has always been there.
I wouldn’t merge physicians and pharmaceuticals in a conversation about ads.
Ads for the former remain rare in my experience. Supply is tight (imagine an ad to join a 10 month waiting list) and insurance coverage is the critical entry point in searches for a new provider ( that a mental health provider is buying ads is testament to the continued lack of mental health parity / vibrant cash market there ).
Pharma ads are older than the FDA itself which practically grew out of the snake oil market. What many people experience as the explosion in pharma ads is really a broadcast explosion. FDA guidance around balanced reporting of side effects changed in the late 90s such that the brief “this may kill you” was newly possible. Lots written about this, eg:
The impression I get from parts of the Internet that skew towards younger demographics (e.g. Reddit) is that the 30-something crowd realize that they've been given a raw deal and many of them do know that things were better for the median person in the past. They are divided on what the cause of the problem is, however, and far too many of them have latched onto the idea that solution to the cause of quality of life problems caused by the neoliberal revolution (i.e. Reaganism in the US) is to take society even further right into neoliberalism or into blood and soil white nationalism.
Looking younger, the 20-something crowd doesn't seem to have much of a clue about socioeconomic issues and only sees politics through the lens of racial/gender/sexual orientation/gender identity politics. Their indifference to economic issues may be driven by the fact that they aren't yet old enough to have real adult financial responsibilities. The side-effect, however, is that the idea that socioeconomic conditions for the median person were better in the past is outside their scope of understanding.
Sadly, I don't see a solution for either incorrect blame targeting by 30 year olds or indifferent ignorance by 20 year olds. How these people are educated and what they are exposed to by mass culture is determined by the billionaires, and the billionaires are very happy with a status quo that deflects blame for social decay to anyone and everyone but themselves.
I presume the information is disseminated to medical professionals (presumably by official means and not from advertisements) and then the medical professionals determine if the new products or services are appropriate for you.
It’s like my non-technical boss coming into the office and telling me that we should start using technology X that he saw in an advertisement. Typically, with my boss, he sees something at a trade show or a trade magazine or in an email, and becomes convinced that it is the best thing ever for us and will solve all of our problems. Then we have to put forth a lot of effort convincing him that he is wrong (he has never brought us anything remotely useful) without making him feel dumb.
How about he lets us technical people recommend to him the appropriate technologies instead of the other way around?
Awareness can also be an issue -- the experts can't help you if you don't tell them about your problem. And a layperson can't get help from an expert unless they know they have a problem. This can especially be a concern with medical issues that carry social stigma.
There is no public advertising done to the patients. But there is lobbying done to doctors that are the ones that decide what to give to their patients.
Not sure why you're getting downvoted as this is the real answer.
In countries other than America, healthcare is not for profit. It's not to maximize gains, it's to maximize care and allocate available resources for the public good.
Doctors are the ones who prescribe. Imagine: doctors don't even know what a drug costs, and nether do patients. The customers are government health systems, who study the value of a drug, negotiate prices and make it available iff the negotiated price is less than the value it provides. Its true facts that in Europe, healthcare is not a free market. This is how Canada works too.
Patients receive care as needed and don't need to be advertised to because they're not the customers.
Doctors in Canada know the cost. They get frew trips for prescribing certain brands.
Doctors become the customers and sales reps will go directly to them.
But what is covered or not covered are decisions made by governments. Those decisions sometimes forces bad medical practices. On the extreme end a doctor in Toronto was giving a drug to force the baby out of mothers before the due date always on the weekend so he could get overtime. Minor examples are being sent for slightly related tests meds because they are covered vs a more expensive test that would work better but is restricted (the ultra sound vs mri)
Because patients ARE the customer. Drug companies constantly work to make drugs easier to take (long acting forms, or even once a month injections) and have fewer side effects.
ADHD meds are a great example. In America long lasting ADHD meds with fewer side effects were available for literal decades before they were available in certain EU countries.
Modern drug delivery systems that can slowly dose a medicine over 12 hours (!!!) are the direct result of pharmaceutical companies working to improve QoL for the patient.
The doctor, and especially the healthcare system, don't consider the patient's UX to be of that much importance.
This is analogous to having the CTO make a software purchase VS giving user's input.
Should the IT directors and CTO have a majority of the say? Of course. But the end users must be considered or you end up with painful to use software.
> Because patients ARE the customer. Drug companies constantly work to make drugs easier to take (long acting forms, or even once a month injections) and have fewer side effects.
Patients aren't the customer in Europe because they're not buying the drugs. They're consumers, end-users even, but they're not buying them so they're not the customers. Frankly the same is true at any US HMO. The reduction in side-effects is considered by the health system when making purchasing decisions (as side-effects cost the health system money and reduce its ability to provide care on a fixed budget).
And yeah, at a company, the CIO is the decision maker, and the company is the customer. The employees are the end-users. That's why at a big company, employees may not always get to use the tools they want; they're not customers, and they're not making the purchasing decisions.
In both cases, the end-users and their needs are considered, but ultimately, it's not their names on the invoice and they're not the customers.
> In both cases, the end-users and their needs are considered, but ultimately, it's not their names on the invoice and they're not the customers.
And sub-optimal results thus occur.
What happens with crappy drugs that technically work is that patient adherence is bad and the government + doctors say "well those poor people with mental disorders are just incapable of following the rigorous treatment protocol that we know works." (and you literally end up with people dying on the street)
Maybe now and then some innovation happens to try and improve adherence, but progress is slow. You can see this in the glacial pace that drugs in certain areas of the the mental health space have progressed. For mental health disorders where the patient is making a decision on the drug, each decade sees tons of innovation. Meanwhile for drugs that are "assigned" to a patient, progress is much slower and an untold number of people have suffered as a result.
I'm not saying free market healthcare is a panacea or that people should be able to pick any drug they want, but medicine should be designed to make people's lives easier.
And letting drug companies advertise "this drug is like the current drug you are taking but has 1/2 the side effects and won't cause your hair to fall out so ask your doctor today!" isn't the worst thing in the world. It means patients will demand their health insurance covers the drug, and it means patients will force their doctor to read up on the drug.
Without the patient being a forcing function there is literally zero motive (beyond altruism) for those two things to happen.
Patients do not demand insurers cover anything, they plead, usually in futility. Insurers in the US are goaled on how little care they can provide for the premiums paid, not how much.
> Patients do not demand insurers cover anything, they plead, usually in futility. Insurers in the US are goaled on how little care they can provide for the premiums paid, not how much.
Depends, employees at higher end employers have more say. Since health benefits are "feature" employers have motivation to make their benefits package better to attract employees.
Heck one of Microsoft's defining features as a company used to be their health insurance package. Everything imaginable was covered 100%, no out of pocket costs ever.
I'm still completely confused as to how acupuncture is covered by so many insurers though...
I've not found a single piece of evidence that lobbying by consumers has led to insurers covering a previously excluded treatment. Happy to be proven wrong. I would suggest also that since we're talking about the system in aggregate, the 1% of tech workers probably aren't a representative sample. Not least because they're not the ones negotiating an all-inclusive package. That's the employer.
Again outside of the employer-sponsored program where employers drove the conversations with their massive leverage. This is the crux of the problem: if you organized everyone into a big group, then they have leverage. Otherwise, you're SOL.
You're being downvoted, but I upvoted because it is a legitimate concern. Information dissemination of medicine is a real issue.
People act like "doctor knows best; don't question their wisdom; they have their secret sources of information and you need not concern yourself with that"... yet I as a patient would like to know about all the options on the table available to me so I can do my own research. How do I know an old doctor isn't being biased toward old tried-and-true treatments, and new doctors aren't being biased toward shiny new bleeding-edge treatments?
The same fallacies and biases that affect software developers affect doctors too. Doctors have limited time to think about and research ("debug") my condition, I have a lot of time to research ("debug") my condition.
I'm not saying "advertising" is the correct solution to the information dissemination problem, but surely there could be an alternative solution like some kind of "medicine wiki" that would allow patients to discover medicines related to their conditions.
The FDA has done plenty of research on direct to consumer (DTC) advertising for drugs.[1] It's not like they just said "yeah, that's cool, go ahead".
In a report from 2015, the FDA found that there were benefits (shocking!) and drawbacks to DTC advertizing.
Positives:
- Most physicians agreed that because their patient saw a DTC ad, he or she asked thoughtful questions during the visit.
- Many physicians thought that DTC ads made their patients more involved in their health care.
- The study demonstrated that when a patient asked about a specific drug, 88 percent of the time they had the condition that the drug treated. And 80 percent of physicians believed their patients understood what condition the advertised drug treats.
- Eighty-two percent responded either "very well" or "somewhat" when asked whether they believe that their patients understand that only a doctor can decide whether a drug is right for them.
Negatives:
- 65 percent believe DTC ads confuse patients about the relative risks and benefits of prescription drugs
- Eight percent of physicians said they felt very pressured to prescribe the specific brand-name drug when asked.
> Eighty-two percent responded either "very well" or "somewhat" when asked whether they believe that their patients understand that only a doctor can decide whether a drug is right for them.
That's a huge negative in my mind. Blind faith in doctors is terrible for health.
Patients who have a little bit of knowledge and think that means they can make as informed decisions as professionals are also terrible for health. People tend to dramatically overestimate how much they know about complicated topics like medicine.
That's an interesting research. But it seems it's not making a distinction between the multi-thousands drug for very specific conditions together with Tylenol and other OTC stuff.
DTCs have a point and being involved in your care makes sense. Doctors also get plenty of doctor-targeted specific advertisements/incentives as well (some less ethical than others)
The main issue I see is that ads might be pushing for the "latest" treatment which might not be the most effective or have the best cost-benefit.
It was limited to prescription drug DTC, but yes, you're point about cost-effectiveness is true. That typically falls on the patient and their insurance, but the system doesn't make the ability to take cost into account very easy at all (i.e. you usually find out the cost when paying for the Rx).
This isn't conclusive by itself. Thanks to the Internet, consumers can conduct their own research on what drugs exist to treat their conditions. Do patients in countries where prescription drug advertising is illegal ask fewer questions or have less understanding of or involvement in their healthcare?
You would be stunned at the number of people to whom it would never occur to search the web for drugs, and among those who do try to search, how poorly they do it. The average person is still not very intuitive when it comes to that area.
On top of this, the majority of drug consumers are old people, who (statistically speaking) are far less likely to even use the internet at all. This is why drug advertising can be quite useful for them.
Thoughtful questions like "shouldn't I be using this drug"? Isn't that what the doctor is there for, particularly for a broad enough condition that it is targeted by ads?
Depends on the doctor and specialty. Family medicine covers a massive number of diseases that are treated by thousands of different drugs. Family doctors may, but not always, know about newly approved drugs.
Sure, there are service that collect data for new drugs.
But do you want your doctor prescribing something they’ve glanced at for 5 min?
Take a look at the label for a random drug, it’s often 20 pages or more of data. Doctors, rightfully so, don’t want to prescribe something unless they are well versed in benefits and risks. That takes time and effort.
There is also information disparity in knowing when or if someone should to go to the doctor.
I think Viagra is a good example of this -- it used to be common for people to assume ED was just a part of "getting old" and not a treatable condition that they even could talk to their doctor about.
Canada generally permits advertising that a drug exists to treat a specific condition so long as they don't say which drug it is -- or an ad for a drug, so long as they don't say what condition it treats. Even though both are technically illegal. It's product claim ads (Get Adalimumab today to treat your RA!) that are entirely unwelcome. [1]
> People act like "doctor knows best; don't question their wisdom; they have their secret sources of information and you need not concern yourself with that"... yet I as a patient would like to know about all the options on the table available to me so I can do my own research.
[edit] Nobody's making the case this information should be secret, just that it shouldn't be delivered directly to your face during episodes of Futurama. If you want to know what your options are by all means, pick up the pharmacopoeia.
I made this argument recently -- in Canada, DTC advertising of prescription drugs is illegal, too. Has been for years. There's a reason physicians go through years and years of medical training, and its not least to be able to identify and manage side-effects, drug interactions and perform appropriate diagnostics. You spending 30 seconds watching an ad are not ready to self-prescribe Skyrizi or Oxycontin.
Doing it wrong could lead to death, dependency, or in the case of self-prescribing antibiotics, community issues in the form of antibiotic resistance.
This is something you need to have a minimum basis of knowledge to interpret and understand, and pharma companies are taking advantage of a knowledge gap to push drugs circumventing the professionals. It's people who know more than you taking advantage of the fact you don't to make a buck.
The same argument could be made of drivers licenses, right? Well I know how to drive, so what business does a cop have telling me I need a license or to go to traffic school? The answer is simple: you can harm yourself or others if you don't know what you're doing, and the decision is made at the population level.
Plus we're dreadful at self-administering medicine. 75% of American adults take some form of multivitamin or supplement. Most supplements are useless or harmful [1] and multivitamins are associated with an increase in all-cause mortality [2,3].
Let's leave the medicine to the medical professionals, yeah?
> Let's leave the medicine to the medical professionals, yeah?
Partially disagree. Yes, they are a very important source of information, but ultimately it is your body and information should flow freely both directions so you (the patient) are empowered to make the best possible decision.
Anecdote:
Doctors are not omniscient. One time when my sister was in high school, she went to the doctor because she had a weird rash. My mom researched skin rash images online for hours and concluded it was shingles. When she brought it up to the doctor he laughed and said my sister was far too young for shingles and that it was probably just an allergic reaction to something she ate. He prescribed some topical ointment to see if it helped.
Well, my mom didn't like that and took her to a different doctor who, unprompted, said: "wow, that looks like zoster (shingles)!"
The # of misdiagnosed issues I've had is quite high, including "oh your knee joint is damaged" when actually I had over-developed muscles on one side of my leg that was pulling my knee out of position during certain motions.
My personal trainer took a look and was like "dude, one side of your right leg is jacked, the other side's not, that's your problem".
Heck a few months ago my dentist wanted to give me a root canal because hot food was causing pain in one of my front teeth. I started wearing my night guard again (...) and the problem went away in a week.
And let's not even get into how miserable doctors are at treating acne, when I was a teenager the official medical word was that diet didn't impact acne. Well, turns out, it's been shown through nice detailed studies that milk can inflame acne.
My first blog was detailing an elimination diet to find out what food stuffs made my acne worse, few years later studies started coming out confirming what people had been saying for literally decades, food can impact acne!
Heck to this day if I splurge on cream I'll get a white head or two.
What the doctor did do was prescribe me an antibiotic that I took for 5 years (!!!) that ended up causing low iron and didn't do much of anything for my acne.
On multiple occasions I have asked my doctor about drugs that I had researched on my own (not seen through ads) and my doctor was unaware that the drug even existed.
Doctors have to cover a lot of ground, they don't always have time to learn about every treatment option for every possible human ailment.
I don't think the information should be hidden from you, I just think it should be available on a pull model instead of on a push model, by people with a vested interest in your purchasing their drugs.
I guess my question is - how would a pull model work? Seems hard to escape advertising, because even if a drug ad isn't being pushed to your face while watching TV, researching your condition (on Google for example) would lead to advertisements of available drugs.
You'd need some sort of non-profit repository that indexes all drugs as they become available maybe?
I actually like Canada's compromise, where drug advertisers are allowed to tell you that a drug exists to treat a condition (without telling you what that drug is), or reminding you that a certain drug of a certain name exists, without telling you what it does.
They should. They should know every possible treatment for the condition you have. This includes how to properly ensure they have the right diagnosis even if you have the 1 in a million case and not the typical case everyone else has.
The above probably isn't humanly possible for everything.
>...Let's leave the medicine to the medical professionals, yeah?
That is unfortunately what most people do and it can lead to poor results for the patient:
>...Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S.
They counted every death the involved medical care as a medical error death if any sort of imperfection at all was noticed in the case. One of their famous examples was a patient who had a stroke or something and then died "because" he wasn't adequately warned to not go for a jog during recovery, who then had another attack during a jog.
In terms of "debunking" I prefer to see a response from the original authors to make sure the people criticizing a study aren't missing something, but even assuming they are totally correct, they estimate approximately 100,000 deaths that were contributed to by adverse effects of medical treatment.
We can (and should) do better than that. Part of this is that patients have to take some responsibility for their care and get second opinions, read up on the diagnosis they've been given, etc.
+1000. I work for Google, but I'm not American. I cannot understand why pharmaceutical companies are allowed to advertise medications.
1. patient sees ad for drug promising them a normal life full of beer and children, and ample slightly serious sport/exercise.
2. patient calls doctor and excitedly informs doctor about awesome new life changing drug.
3. doctor tells patient why drug is not appropriate.
4. patient gets revenge for crushed dreams by leaving horrible reviews for doctor everywhere they can.
5. oh right it's a business, society tells the doctor, not health care.
6. doctor accepts stupid reality, and prescribes medication.
That moves the money to be spent on SEO instead of going directly to Google, doesn't it? It's less predictable, but unless you do it, you won't be seen, ever, anywhere, by anyone.
> That moves the money to be spent on SEO instead of going directly to Google, doesn't it?
No. In most countries doctors and drugs don't need any SEO, because the doctor is provided by the health service, and the doctor picks the drugs based on clinical indication.
So you don't get any say in which doctor you go to? What about things the public health system doesn't pay for, are they not being done at all?
Germany has a rule for public insurance where you need a referral to specialists from your general physician (but that's not the case for the ~10% that are privately insured), but you can freely choose that doctor, your dentist etc. Since the public option doesn't cover a lot of the latest therapies (... not even glasses unless your eyes are very bad!), there's a secondary market where patients pay privately, or have a special private insurance for certain things.
For MH it's a bit more complicated here in the UK getting therapy through NHS can take months/years.Also, with MH you need to find someone you like and can trust.
Most people I know go private (out of pocket, it's about £20-80 per session in London so on average about £200/mo).
Discovery is done through word of mouth or looking at various schools of therapy and shopping about to find a therapist that works for you.
Here in NYC my out of pocket therapy costs $175 per 45-min session, which is lower than what my therapist charges new clients. It’s a pretty normal rate, many of my friends in therapy pay between $175-225 per session.
Most therapists here don’t accept insurance, many insurance plans don’t cover mental health, and government programs don’t cover it at all.
£20-80 per session sadly sounds like a deal here in the US.
It is, but it varies state to state and the coverage generally isn’t great. You have to hit your deductible before coverage starts and then after that it’s usually a 50% coverage. So if you’re lucky enough to find a therapist that takes insurance, you’re still paying a lot out of pocket.
I just searched what it’d cost me here in NYC to purchase and go through the insurance my therapist does take (in-network): The plan costs about $650/month and I’d have to hit a $5,500 deductible before mental health coverage kicks in. Then it’s a 50% coverage after that. I’d pay about $6700 out of pocket with insurance versus about $7350 without it. This doesn’t include the $7800 I’d have to pay for the plan itself.
I wouldn’t really call that a mental health benefit, it’s easier to just find a therapist you like and just figure out a way to pay for it if you can. Most people can’t and it’s a shame because good therapy is transformative. My life is so much better because of it.
But how is that different than seeing a regular doctor? The issue here seems to be having a high deductible in general. In my case, I have a $1500 deductible too and my guy doesn't take insurance either, but I submit the bill in 2 seconds with an online claim and it counts against the deductible.
> he didn’t even check to see how they did. “I mean, it’s Bing, right?” he says.
Bing and Yahoo are still about 20% of the American market. It is not inconsequential.
I suspect that prices have soared there as well though, simply because the pandemic severely disrupts therapists. In a world of video calls, there is no local market.
There are as many places seeking to sell you therapy as sell you gasoline now.
> pandemic severely disrupts therapists. In a world of video calls, there is no local market.
This is absolutely not true in the United States. Therapists are licensed in each state and it can cause severe professional problems and ethics situation. A counselor cannot technically even see a client telehealth if they are on vacation out of state that week unless the counselor is also licensed in the State the client is vacationing in.
Source: My wife is a licensed practical counselor and regularly studies for her mandatory continuing education credits in the evening. I hear her watching the lectures and answering questions on those exams.
Covid has lead to a changing of guidelines around telehealth both at a state and a federal level. And even if it's not technically allowed it's unlikely that any state will prosecute medical professionals due to the ongoing crisis as it's really bad PR.
Yes, that change came down pretty quick with Georgia Department of Behavioral Health and Developmental Disabilities after the Federal requirements changed. My wife was working from home telehealth for the first time ever for months. Her agency has since shifted back into the clinical environment. But telehealth in this setting went from not allowed for counselors to done for safety of clients and staff.
Private practice may be somewhat different in that State and Federal insurance rules are not at play for private pay, but most sensible counselors will not want to risk their license. You don't have to be prosecuted criminally to lose your ability to practice.
Part of the problem is that since Google is a monopoly they have little incentive to produce good organic search results. It's much better for them if you end up clicking an ad than a search result. And with a dominant position there's not much alternative for businesses or consumers. A competitive search market might force them to come up with better organic results since those are (theoretically) better than ad links.
This problem is amplified by VC funded start ups. They're willing to lose billions in order to gain a dominant market share. How can little ole therapy service compete with VC funded therapy market when they don't care about making money? Eventually little ole therapy service folds and the therapists have to go work for VC funded therapy market. The long term outlook is that we get one (or a handful) of therapy platforms that are just middle men extracting value.
And if I’m not mistaken, the audience is now also a lot bigger, right? Would this not imply that this evens each other out? The therapist of the article could just maintain her bid price, not?
Yeah but clearly the ads being bid up are worth it to someone, no? Is the issue that the limited supply is now being taken up by therapists charging more than her, i.e. those who can bear higher costs of advertising?
And if so ... what exactly is the workable alternative? This is all just market forces. The cost of advertising and acquiring new business has been around for much longer than Google.
They aren't even being taken up by therapists charging more than her. They are being taken up by corporations providing online access to therapists for substantially less than she charges. The consumer is actually benefiting.
She charges $250 a session. Lets say she sees 6 patients per day generating $1500 gross revenue a day. She spends $20 a day in ads which works out to around 1.3% of gross revenues spent on advertising. That is an extremely low amount spent on advertising. The US Small Business Administration recommendation for businesses with revenues less than $5 million per year is to spend 7-8% of gross revenues on marketing.
That's a good point and thanks for doing the numbers. Maybe she just has unrealistic expectations of how much is normal to spend on advertising? It sounds like it. She should definitely be able to afford to spend more than a platform like BetterHelp, which is making a lot less per consultation than she is.
isn't adding shelf space analogous to adding more ads? I mean I haven't really kept track but I am always seeing complaints on HN about how many more ads there on google nowadays so they must add some shelf space.
I don't see how either. The total number of searches would remain the same. The total payment from customers for therapy services would remain the same. It would be worth it for therapy companies to spend the same amount of money chasing those customers.
Spending on therapy advertisement would go up during a nation-wide transition to online therapy because far more people are switching therapists — people who previously chose a therapist based on convenience of the office location suddenly no longer have to. There’s also likely more consumption of therapy overall because of unemployment and other COVID-related hardships.
I don't see the direct connection to out mental health crisis in this issue. None of this addresses the mental health care crisis in terms of patient outcomes and patient well being.
Instead, the article talks about how individual therapists are losing out as ad prices rise and newer tech-mediated therapy platforms are gaining attention & market share. (and working for those platforms doesn't pay nearly as well) Also google has a near-monopoly for online advertising, so these therapists have few options if they aren't born natural marketers, and Google customer support is bad. In short, it's bad for therapists.
Nothing much said about this being bad for patients though. It's possible patients have greater access to care with these new platforms.
Paying a skilled therapist with a master's degree $15 an hour is robbery. And they're probably taking folks on as contractors, which means no insurance. That $30 - $50 for a session is a race to the bottom.
How is the market failing to set the appropriate price? A therapist should be able to charge whatever they want, up to the point they can't find anyone willing to pay it.
Side note on billing. My wife's practice is finally hitting it's celing. She needs to either charge more or hire more doctors + get a bigger space.
She is her brand, so we probably won't get more doctors. But we have slowly raised prices from 50$ to 75$ per hour.
Next we are going to stop accepting some government health insurance because they only pay $60/hr. Long term I can see 125$-200$/hr private pay only.
The alternative to her 1 on 1 care is a hospital/clinic where you get 37 minute visits shared with multiple other clients, and have a new doctor every few weeks due to high turnover.
This is kind of a deep question, and not meant to cast aspersions on what you're doing, because it's perfectly rational. The world of private doctors who don't accept patients paying with insurance (government or otherwise) is very interesting to me.
Do you think there's a major difference in expected outcome for the average patient, between your wife's practice and a hospital/clinic?
I can totally grok how a patient would find her services valuable enough to pay a much higher rate, out of pocket; but I'm trying to figure out if the payer's arbitrary cut-offs are rational.
Maybe 60/hr is close to the price-point of exponentially-diminishing returns, from the risk-carrier's perspective?
Obviously, institutional payers are way more conservative with risk than financially-well-off individuals, so maybe they're making mistakes on the margin.
Anyways, hope I'm making sense. It's a fascinating topic.
No insurance hassles - I did medical billing for a bit. The insurance co's basically just run around doctors because they KNOW folks give up. You could absolutely force the $40 extra payment if dr + patient etc proved it out / appealed it - but often not worth it. Also govt billing into central county system for the poor - ugh - the bureaucracy / overhead was a nightmare (always having to recertify to financial need / paperwork this and that - 50% of time was on stuff I'd consider no value add).
For a while I had individual insurance (prior to obamacare). Because it had pretty high deductibles, I would just do a private pay / cash doctor for primary care etc.
Some big wins:
NO discussion about whether something was covered or not! You want to get service, just call.
No crazy surprise bills - yes - I once tried to go to urgent care for something at the main hospital, but NO ONE would tell me what I would be charged as a cash pay client. Yes, it can be expensive to do cash pay, but with a doctor billing by the time you can basically predict / know your cost.
Service - you are paying by the hour. I never felt pressured out the door (no surprise). The service is good to great.
Convenience - I got someone close who used his downstairs as his office. Have a problem, go in and get checked out. Because you don't need the huge billing infrastructure I think you can get away with smaller office sizes. To pay for a full time biller you need a few doctors, who then need a receptionist etc etc.
Yep! There are a large number of benefits for both the provider and the patient, for purchasing elective procedures without involving insurance. It's kind of like how when you get a minor fender bender, it can be easier to settle things directly than to go through insurance. No overhead, like you suggest.
However, it's hard to replace insurance for nonelective/emergency procedures (heart attack, stroke, aggressive cancers).
Insurance-tailored billing systems are really geared towards non-elective procedures (that's where all the money is). When they encroach on the "normal" stuff, it feels invasive.
Advocating for the insurance infrastructure, there is a preponderance of medical waste out there. Doctors prescribe blood tests, urine samples, or MRI scans even though they aren't medically-necessary, just because the hospital group needs to make some money. When the patient is paying, they are on the lookout for medical waste, because they don't want to pay.
Of course, this means that there will be false negatives from the insurance carrier, when they try to clamp down on medical waste. The only loser in this game is the patient.
There seems to be a lot to unpack, so sorry if this is jumping around but I tried to provide lots of details.
My wife has worked at those places and the difference in patient outcomes is night and day. Sure some people will get better regardless, but there's something special about people saying a 3 year old injury has 0/10 pain. At a big name company, they get people "good enough".
She's one of those people that would prefer to be a Physical Therapist rather than a business owner.
As a side note, many of her patients came from that 60$/hr insurance because most places don't accept it. It seems like it's a stepping stone. Knowing her, they will be grandfathered in.
Something I didn't mention is how often she does free work/eat the cost because insurance will deny payment for services that were approved but later deemed "not necessary". (Despite the person being unable to work) It's complicated because a phone call, or Physician, or patient can sometimes fix this.
I think there is a lot to unpack here, yes! Thank you for responding :)
I wonder how much of the outcome difference is due to selection bias, so to speak.
For example, your patients are more likely to have better outcomes, because the fact that they are willing to pay OOP for your services implies that they are bullish regarding the valuation of their physical health, which means they are likely proactive in seeking preventative care, solving health problems earlier rather than letting them fester, etc.
Similarly, I'd imagine that the better doctors probably self-select into your wife's situation, because they want to work with active patients and they want to capitalize on their skills and passions. It's a feedback loop where good-follows-good.
Good income -> good outcome, if you will.
But tragically, this implies that good doctors are less likely to be found in the big hospitals, where the people who need healthcare "most" are in need of them. "Most" used here in a marginal sense, where the needy, insurance-using patient receiving 1 hour of your wife's attention provides 10x value in terms of QoL-adjusted life expectancy, than the average proactive OOP patient.
So, we're kind of bound to have a two tier system, with this set of incentives.
In your wife's case, it seems that the price cap of insurance will prevent 10x patients from seeking her out, exacerbating the tiers. But, you can't really blame any of the individual actors in this equation (payer, patient, or provider), it's the incentives that are wacky.
I know of some doctors who "volunteer" some of their time working at a hospital/clinic, in addition to their private practice. Like, one day a week or something like that. If your wife feels guilty about her role in this dance, she might consider doing this, in addition to grandfathering-in the insured folk.
Anyways, I don't really have a point, just thinking out loud. Thank you for your perspective, curious to hear anything more on this topic you'd like to share.
You can only help 40 people per week without cutting down on the care. Another benefit for private pay is that you don't have to spend time on insurances or calling physicians for a prescription.
I talk a big game about raising prices but I know my wife has done free services for disabled children. She's a sucker, and we claim it's advertising/marketing.
Hospitals and big name clinics would never do this.
Isn't Google Maps search free for users and providers?
Doesn't high ad pricing mean there is a glut of supply for the service in question?
The article subject seems upset that someone else gets the customers, but that's not a problem for anyone. If the subject got the customers, that wouldn't be "fair" to their competitors.
A higher priced ad means that the provider is charging extra for the service. Those charges are passed directly to the consumer. If you have a business that is small niche of larger area you will be priced out of ads by larger, higher charging competitors. This squeezes out small and creative organizations and leaves the overall market with a few cookie cutter services that charge much more than the value of the product or service. Consumers without a lot of discretionary income can't find a service to use. Small businesses cease to exist.
Competition for a limited resource (ad space, land, wireless spectrum) selects for companies with higher margin. In one understanding, higher profits mean the business is providing higher value. In another, it means the business is sucking up excess value that could be had by upstream consumers.
Ad space can be seen as land rented out a user request at a time.
Having more competitors to Google will help only a little bit. There's only so many user request x ad space x keyword units to be split among the companies. So the total amount of "land" advertisers bid for remains constant, so prices will be roughly similar. The only difference will be that Google will command a smaller cut of the auctioned price. I doubt that will make as much of a difference as an influx of entrants to the bidding market. Some Google keywords are 10s or 100s of dollars; the Google cut isn't driving hat, but the value of a new customer acquisition.
When there was more competition for Google, and when ads and links for other Google products didn't take up half the page of search results, there was much, much more eye ball space, even though there were many fewer eyeballs. I'm not going to make the case for causation vs. correlation here, but this is part of the often mentioned general deterioration of the Internet.
In addition to the higher ad costs leading to higher costs for the consumer and the resulting funneling of those consumers to only a handful of outfits, a major point from the article is the "Smart Campaigns". Google is exploiting small businesses' lack of marketing expertise to push them, often persistently, to using automatic, algorithm based targeting instead of manual keyword targeting. The result is that a lot of the money they put up for advertising goes into a black hole devoid of useful exposure due to the useless keywords that the algorithm picks for them.
They're not just being outbid by larger outfits, but are being lead to believe that they can compete with said outfits by using Google's "Smart Campaigns". Google gets the money from both, but one is being relegated to space that leads to nothing.
So this comes down to therapists living in expensive areas complaining about competition from therapists from cheaper areas. Given there are still people who need/want local therapy, there will be a new price equilibrium but most likely it will be lower than before. No amount of complaining about Google or ads or arbitrage like BetterHelp will make the price stay as before. Nothing much to see here - this looks mostly like a market adapting to a new changed market condition.