The original post focuses on the limiting edge case where the only information coming out of the doctor is a single bit: Treatment vs Healthy. I believe the subject can reasonably expect some explanation from the doctor, and then we are in the territory of Interactive Proofs and Arthur-Merlin Games. (https://en.wikipedia.org/wiki/Interactive_proof_system) Actually I'm a bit surprised they were not mentioned in the original post, nor in any of the 127 comments so far. They are the computational complexity models of a situation when a (computationally) all-powerful but unreliable agent has to convince another, (computationally) limited agent. If there's a second greedy doctor, or a greedy detective, we have Multi-prover Interactive Proofs.
The ways to address this problem are “usual and customary[ed- autocorrect] prices”, consumer ratings, information transparency, externalities such as courts to punish fraud and malpractice, and skin in the game.
I have thought about this a lot in the context of real estate- up to recently, agents typically got a fixed commission (generally 3% each for buyer and seller in the places I’ve lived).
There is a moral hazard in that, assuming that the agent can impact my sales price favorably with effort on their part. If they’re helping me buy a house, and they get a percentage, then it’s in their interest for me to overpay. If I’m selling a house, then the margin for increasing the sale price above market value is probably not worth the effort ($300 for every $10k increase in sale price).
My solution (I have not tried it yet) is to structure a sales rep contract such that we agree on a target price for the standard commission, but increase the commission greatly for the sale price amount above the target price. Maybe 3% up to the sale price and 50% above that. That’s what I term “skin in the game”.
Assuming I have done a minimum of homework (looked for agent ratings and avoided bad or inexperienced agents; looked at comparables on Zillow to make sure the proposed sale price is market appropriate, etc.) then I should get a good outcome.
Doctors and state license boards often make it difficult to get informed consumer type information on doctors. Our insane medical system in the US almost never supports price transparency. So we have a long way to go there.
Note one other thing. I am trying to optimize for the best outcome I can assuming limited resources. If you have unlimited resources then you can hire and fire lots of doctors, overpay for performance, and generally do things that are unavailable to mere mortals. Also I am not assuming or eve trying to achieve perfect results (most beneficial result available at the lowest price point). I think that is a fool’s game.
Probable with Realtors (or any other broker): They can value speed a lot more than you do. Getting .5% extra on something might not be worth it, when that would take up 125% of their time, and 25%*normalprofit might exceed 25% extra on one deal.
You have to accurately put your bonus structure >= their normal compensation. That's really hard to do.
>If they’re helping me buy a house, and they get a percentage, then it’s in their interest for me to overpay. If I’m selling a house, then the margin for increasing the sale price above market value is probably not worth the effort
Wait. Surely for the realtor these two scenarios are identical? Every purchase is also a sale. The only difference is in what role you've cast yourself.
The article proposes prepayment options. Why not go to the "other, other obvious" solution, which is results-based payments? In healthcare, that's value-based care. In other industries w/ agent-principle problems, it's called "taking on risk". You're incentivizing results and outcomes, rather than whatever specific actions lead up to those results. It means that the focus is no longer on the activity provided by the agent, but on the desired outcomes from the principle. Pure alignment and it helps filter out those who are good at getting results from those who are good at doing the actions.
> Why not go to the "other, other obvious" solution, which is results-based payments?
There is a story about doctors in ancient China who are paid by their clients only so long as the client is healthy. When they fall sick, the doctor is not paid again until the patient is healthy again. Then the goal is not a cure for a disease but the prevention of disease.
I don't know if any such thing ever really happened but it seems like it might be worth exploring even if only to illuminate the various possibilities.
Well the other option, which is to pay when a problem is found, can lead to over-diagnosis and finding issues where there are none. Its 'taking your car to an unknown mechanic' problem, he _will_ find a problem, and that is a problem too.
Also they have no interest in treating elderly (or anyone all that ill) if it requires any effort at all, as future healthy payments will not cover the expense.
It is easy to see an optimal strategy of never treating anything.
I think this only works if there's a scarcity of patients but it's rarely true that patients are rare. This will probably suffer from the real estate agent problem: in theory, real estate agents are incentivized to get you the best price because they get a cut for their efforts, but in practice it's more lucrative for them to flip more houses than put in the extra effort into your case. Likewise, I suspect doctors will find it easier & cheaper to not care about you and just move onto taking in other healthy patients.
Then doctors filter what patients they take to guarantee these good outcomes. This is already done by some surgeons. Surgery is already a subset of medicine heavily judged on outcomes.
This is featured in the Doctor Strange movie, in fact. IIRC the good doctor is presented with a patient whose case is so difficult that he's one of the only people in the world with a chance at successfully performing the procedure they need—but he turns it down because he thinks the odds would still be too low, and it might hurt his record. I think there might also be a karmic turn with that when his hands get messed up—I wanna say there's a scene or short sequence of the same thing happening to him, at least implicitly.
Cherry picking and lemon dropping does happen in value-based systems, but there has been work to address the issue. No simple answer, but basically you pay doctors more for select patients.
Within the context of the article though, if one assumes greedy doctors, then essentially cooperating doctors can cooperate to refuse treatment N times, where N is an equilibrium between the lemon-picking bonus and never accepting any patients at all (and therefore never having any revenue), in order to get the system to label non-lemons as lemons.
I got the impression that the same phenomenon was present with driving instructors and driving test pass rates. If it's clear after a dozen or so lessons that they might not pass then say that you will stop teaching and suggest a different instructor.
I think that the author is assuming that you, the patient, have no way to assess whether the diagnosis was correct. I think that eliminates what I also thought of as a strategy, which is how this works in real life - some combination of being able to tell, as the patient, when treatment is working, combined with (the threat of) second opinions, and of course all the “human” stuff that the author sets aside about doctors wanting to help people etc.
The thing is, in many cases you don't need to know if the diagnosis is correct, so long as the results are directionally correct. If the outcome is an improvement in health, that meets your threshold for value delivered, hence payment rendered. I think there are many cases when you don't need to be smarter than the other person to benefit from their expertise. You can take it a step further and make the distinction between absolute value versus perceived/relative value -- if we have a patient with cancer, absolute value might mean destroying all cancer cells (which is an absolute metric but extremely hard to model). But perceived value might be "feeling better". It's important to make this distinction particularly in healthcare because absolute benefits and relative benefits are extremely important. Hospice/end-of-life care is a good example of this (as is the cancer example above). Most people would prefer relative or perceived comfort as opposed to absolute results that only end up prolonging a painful process.
Outside of healthcare, for another example example, you don't need to understand engineering and tension dynamics in order to appreciate that the second floor of your home support you and your roof doesn't cave in on itself. I don't have examples on hand, but in medicine we've had cases where people do some logical variation of "the right thing for the wrong reasons." I.e., rituals that correlate with healthy outcomes because there is some not-yet-understood principle at play (i.e, you don't need to understand germ theory to benefit from cleanliness rituals).
I think this is one of those logical conundrums which falls into the trap of "in theory, in practice". The artificial constraints around the problem space result in artificial logical conundrums.
It is a balancing act, to be sure, regarding "feeling better" vs "less sick". Hospice care is indeed very important. It can go too far in this direction, however, and I have real sympathy for docs that get it "wrong" in either direction (too much "comfort" or too much "let's give you more years").
Notably: the prescription opioid epidemic is a great example of how this can go wrong in the opposite direction of healthcare providers valuing "relative" benefit vs "absolute" benefit.
My spouse is a primary care provider, and there was a period a couple decades ago where the prevailing wisdom was "if a patient says they are in pain, they are in pain, and you treat that pain. We are experts in medicine, but the patient is the expert of their own perception." This is still a complicated issue today, but there are clearly outcomes where we can make people "feel better" all the way to an early grave.
For the terminally ill, it seems absolutely appropriate to me to let the patient guide whether they wish to accelerate their death in exchange for quality of life. But "terminally ill" is often not such a black and white issue...we are all eventually mortal.
If things like heroin don't inspire a sense of horror or dread, then we just aren't speaking the same language. I, for one, don't want to live in a world where the human priority-at-large is everyone defining "living" as maximizing pleasure until their death. For the hedonists, I get why this makes a certain nihilistic sense, but I think the horror of the reality of it outweighs any momentary benefit.
In the very abstract, maybe it doesn't really matter one way or the other. In the concrete day-to-day reality of it, it's absolutely awful to see anyone struggling with any kind of addiction, out of control of their own lives...sometimes because they got on a treadmill-to-death on the _expert_ advice of someone trying to "help them out."
This is such an awful take. So if a doctor prescribes a medicine and the patient never takes it and the patient dies it is somehow the doctor's fault or they don't get paid?
Some doctors are greedy. Some ________ are greedy. There are major factors in the waste in our health care system but by and large it isn't doctor's fees. There are so many rent seekers taking a cut.
There are other models than fee-for-service. They have tried population health models where the Provider (Dr, nurse, etc.) get $X per person per year. They are incentivized to be more preventative where they basically get to keep whatever they don't spend on patient care. However, you can lead a horse to water but can't make him drink. Ask yourself this: would you write web code where you got paid based on how many unique visitors viewed the page your wrote?
We can easily fix health care with a few simple changes but there is no real appetite to do so. One simple change is to go to referenced based pricing. You can't charge more than 1.2 the Medicare reimbursement. This change alone would reduce our spending by 25%.
> One simple change is to go to referenced based pricing. You can't charge more than 1.2 the Medicare reimbursement.
Agree that this is huge. Price transparency, reference pricing. You know "the law of one price" is supposed to be a pillar of market economics, so this should be a no-brainer. Additionally, don't allow charging more than the insurance will pay with the exception of an agreed upon co-pay ahead of time. If a hospital accepts insurance, then it shouldn't be able to send you a bill later on that the insurance refuses to pay. That needs to be worked out between the hospital and the insurer. I would also like to see binding quotes before any procedure, with no surprise billing.
Most of us have been in a codebase for an issue that turns out larger or more complex than first understood. I don’t want to undergo surgery for cancer X, have the surgeon see nearby, related cancer Y and sew me back up and tell me I also have cancer Y but that he didn’t want to go over the estimate.
When asked for a choice by a medical professional (or a home improvement contractor for that matter), I will more often than not ask “if you were in my shoes, what would you do?” I don’t 100% of the time go with what they say, but I think it helps me understand their expertise and judgment better.
In the surgical case above, if the surgeon would have taken it out and given me a single recovery experience and told me about the bill when I woke up, I’m probably better off for it.
So in a surgery situation where you are under and something else is discovered, then that's a situation of unexpected costs. So you look to who is best able to bear them and that's who bears them. What exactly is the purpose of insurance if they do not cover you from unexpected costs? And if there is no insurance (say a cash procedure), then the hospital bears the cost and bakes the possibility of complications into the price.
Point is, you need clarity of prices rather than the situation today where you sign a promise to pay whatever costs the hospital decides to charge you, and you may not even know what those are until weeks after the procedure. There is no meaningful way a market can operate under conditions in which blank checks are demanded in order to get anything done.
If that can't work, and the hospital insists it cannot quote you a cost at all, then go full socialized healthcare since obviously no market is possible.
And then you have the current bs where the anesthesiologist for your operation at the hospital system that you always use is somehow un-affiliated and out of network even if everything else in that system is in network.
One potential difficultly here is that good metrics are hard, and outcomes for a lot of medicine are hard to evaluate. Obviously not true everywhere.
So a potential path will be that the incentives start to line up with measurable impact on symptoms short term (easy outcome to evaluate) instead of meaningful shift in root causes (difficult and/or slow to measure)
Really good take, actually. In the extreme case you find that doctors actually have no responsibility to their patients. You can read board investigations. They are unusually soft on very horrible doctors.
The price leverage of the doctor is proportional to how much information the doctor has about how much money you have. If you can't keep it secret, you can add noise proportional to how much information the doctor likely has to cancel it out. The resulting "fair" price will be a function of the net shared information each side if the noise were removed.
Negotiations theory was a pet interest of mine, and I came to believe that in zero sum adversarial bargaining situations like that, the domainant position was the side with the most information, so the best strategy was to use noise to diminish their information, and then use whatever information you retained as arbitrage. If you think of noise in terms of signal entropy, and low entropy as signal, you can figure out whether their gambit is signal or noise by repsonding with noise and gauging the entropy of their response. This is crazy armchair stuff that nobody articultes, but variations of it gets used in bureaucracy and politics all the time, it's basically the game theory of gaslighting.
>The medical professional is greedy, i.e. they want to charge you as much money as possible, and they do not (per se) care about your health. They only care about your health as far as they can get money from you.
I'm not even going to read the rest of the article because the premise up front is so flawed. It assumes that doctors alone have say over pricing / compensation, and that's just not reality. It's much like engineers being blamed for things that rest entirely with management. It also makes the same flawed premise that I deal with in my profession every day - that I'm so greedy and so focused on my own pocketbook that I will screw over my clients. Are people motivated by money? Certainly. But a professional will put their client above money assuming no other perverse incentives.
This article was really trying to illustrate game theory concepts with a story about greedy doctors, but it was unfortunately framed as if it's trying to solve a greedy doctor problem using game theory. It might have fared better using different analogies.
This comment is like saying that Zeno’s paradox is dumb because proud Achilles would never consent to a foot race with a mere turtle - imagine the insult!
It's not that you're wrong, it's that what you write only addresses the title of and first sentences of the article, rather than anything the article is actually trying to say.
This article is about game-theoretical-ideas of how to deal with the principal-agent problem. The "greedy doctor" idea is just a motivating example. You're seemingly taking offense at a knowingly fictional setup. That's akin to not wanting to learn how to solve physics problems about objects in a world where friction is assumed away, because that's not realistic. Umm, what?
> Should you trust someone's advice, when you can't pinpoint their motivation? As a Ph.D. student, I run into this problem around three to five times a week, when interacting with colleagues or my advisor.
Maybe this should be named "The greedy thesis advisor problem"?
This is very different from the Greedy Doctor problem.
Why? Because, generally speaking, the answer to this question is "it doesn't matter". A student will never get a job in academia without their thesis advisor's good word.
If a student is ready to leave and their thesis advisor isn't ready to let them go, their best option -- assuming they have at least a few publications (for CS) -- is to find an industry job and say "Sorry, my hands are tied on the start date and I need a better paying job for personal reasons. I really wish I could write a better thesis but I think there's enough work here at least to graduate."
(BTW: industry is much better than academia. The work is more interesting, the teaching/mentoring is more rewarding, and you'll make enough to retire in your 40s instead of desperately clinging to a job in the increasingly MBA-ified Higher Education Industry until your 80s. The "Academic Life" sucks pre-tenure anyways. If what you want is the so-called comfortable and care-free Full Professor days, just get financial independence in industry first and then go be a professor of practice or even ad junct somewhere for the healthcare and vacation money... which, aside from pay, are both actually low effort and care free!)
The obvious, obvious thing is to simply pay the doctor a fix priced each month wether they diagnose you with something or not. Well above what they would earn elsewhere.
Their incentive then becomes to keep a good relationship with you so you continue to pay them. The best way to do that is to keep you healthy and happy.
For specifically the doctor version of the principle-agent problem, Robin Hanson published an incentive-compatible solution over 25 years ago: http://mason.gmu.edu/~rhanson/buyhealth.html
> To cure health care, give your care-givers a clear incentive to keep you well. Make sure that when you lose, they lose, and just as much. Buy lots of life and disability insurance from your care-givers, and have a third party, unable to act against your life or health, pay you to be the beneficiary.
The quantitative difference is big enough to be qualitative. You have to buy a lot of life insurance, more than people normally get, to make it work. The disinterested third party beneficiary makes this affordable:
> There are, however, two big problems with this approach. The first is that even though my life may be worth $10 million to me, most of the (huge) insurance premium to pay for this insurance would be wasted from my point of view -- there probably is not one person to whom I would want to give this much money when I die. The other problem is moral hazard -- heavy insurance may reduce my incentive to keep myself healthy, and may even create incentives for my relatives to try and hurt me. It might be a problem if I could only give my doctor a 50 percent interest in my life by taking away 50 percent of my own interest, or by giving a minus 50 percent interest to my relatives.
This was also my first idea when I read the problem.
As the payments stop as soon as you die, this is a strong incentive. The only thing I could think of arguing is, that the doc could keep demanding more and more. But that would imply a situation with only one or very few skilled individuals, right?
This assumes that actions that make a patient happy also make them healthy. There’s a risk that pursuing patient happiness can come at the expense of patient health. The doctor may be more inclined to keep a patient from switching doctors to keep getting paid.
That's what I do. It's called "direct primary care". In the last 10 years, I've used two DPC doctors. I loved my first doctor because we had the same philosophies towards health. Last year she started drifting too "mainstream" and I didn't like her style, so I switched and took my money elsewhere. I found a new guy who is really aligned with me and it's been great. It's almost as if having choice and market can work :)
I get the super high-deductible catastrophic with HSA plan from my work, and then I pay $135/mo for my whole family for the DPC doctor (I could pay that $135 with my HSA and have it be on pretax money, but I'd rather invest my HSA pretax right now). The total there is less than any other insurance available to me. If I ever need anything, I just call or email my doc, most of the time we just do a (secure) video chat and I'm done and I don't need to make a trip in. If it is more severe, I can easily get a same-day appointment. He knows me, knows my history, and has an incentive to keep me healthy. The healthier I am, the more I pay him and don't see him.
He’s solidly middle class. Not pulling in tons of money. But he doesn’t have crazy stress either. He doesn’t do insurance or Medicare, so his overhead and admin cost are really low.
That’s a good point. I’ll have to ask some friends about overhead. Seems like a weirdly small number though compared to insurance premiums + deductibles, and what doctors usually get per visit when we go for run of the mill fevers for the kids (~$150+ each time).
I agree with the idea of paying the doctor a flat fee every month, but in my variant, the doctor has to repay you the entire sum you've paid to date, with 10% interest, if you succumb to any preventable illnesses; in other words, the doctor now has some real skin in the game. S/he becomes motivated not only to keep you well, but to keep the fees reasonable.
That’s horribly ignorant considering that many diseases have a large genetic component and people are rarely 100% compliant with the things they need to do to prevent a disease. Even when a doctor lets them know how to prevent the disease. How would this work for a disease, for example, like Alzheimer’s where the onset is much earlier in life (40s) but doesn’t manifest until much later in life and has no diagnostic test at age 40? What about hypertension where the majority of it is idiopathic? Would the doctor be blamed for all this despite practicing evidenced based medicine? I’d argue that a lot of diseases are this way and placing the blame on a doctor is a way to shift personal responsibility.
Seconding your view points. If a patient dies from a hypertension related cause (say stroke), and the patient has not followed the strict low salt diet the doctor recommended, does the doctor pay for that? At what point does the doctor stop seeing patients who do not follow their recommendations to the exact letter?
I know you're framing it as patient choice, but it would incentivize doctors to actually want to research new solutions instead of give stale advice that doesn't seem to work.
Do you really think that doctors don't keep up on education? All doctors are required to do continuing education every year to keep up to date on the latest advances. Most I know go to national conferences to learn more about their speciality. Then you have the portion of doctors that conduct research and actively advance medicine. Most doctors I know (anecdotal, I know) are constantly striving to do more, to learn more because they care. Doctors know how much responsibility they have to help people and even save lives.
The advice works if patients listen (which is patient choice). Reducing salt intake and losing weight are simple ways to lower blood pressure and they are also effective.
This is such an oversimplified view of how medicine works. I'm not even sure how to begin a counterargument. In medicine, bad outcomes can occur without being sure of the cause. For example, let's say a patient who currently smokes gets lung cancer. Did the patient get lung cancer from smoking, or is this a sporadic non-smoking related cancer? There's no way to definitively find the answer to that question. But for the sake of discussion, let's say it is due to smoking. Do you fault the patient for smoking and not quitting? Or do you fault the doctor for being unable to convince the patient to quit smoking?
Even for HN this is a pretty shockingly out of touch "I don't know anything about $X but I can figure it out 'from first principles!!1'" type of comment.
Fair point, but if the client does develop a preventable condition, it would be easy to show this is due to dereliction/negligence on the part of the physician, so the insurance would not pay out. If the client came down with a condition and the physician was not negligent, the condition would likely be non-preventable, wherein the refund clause wouldn't apply, anyway. Thus, regardless of outcome, insurance can never pay out, and the physician retains all the liability, i.e. no use for insurance.
Without malpractice insurance, would doctors be incentivized to not take on risky patients? Risky could be defined as litigious (I know this patient has sued another doctor before) or medically difficult to treat (this patient needs this surgery but they are at high risk of poor outcome due to their current state of health).
Having sued a doctor once, you might never be able to get medical treatment again.
Upon reading the responses my earlier comments generated, I suppose I should have disclaimed that I'm seeing this problem as the OP had portrayed it, which is as a thought problem in logic and economics, rather than an actual approach to preventative medicine. As a thought problem, it can be broken into basic, of-necessity simplified elements, e.g. preventable vs. non-preventable illnesses, fee optimization, etc.
The idea of actual healthcare being dependent solely on optimization of greed is, of course, ludicrous.
I had the same thought, but I can think of two problems with it.
1. The doctor's stake is pretty limited.
The old royal court doctor model is the perfect model for this. It's based on the doctor having very few (one?) patient. If the patient dies, not only do you risk your substantial income and high status, but you might even lose your life if the royal family gets suspicious enough.
It's a good solution if you're very rich. Much richer than the average doctor.
2. When you have more than one patient, at some point you probably earn more by treating less.
The less work you spend on each patient, the more patients you can take on. The more patients you can take on, the more you earn. If you simply stop treating patients - "you're perfectly healthy, don't worry" - you can basically take on an unlimited amount of patients and collect their fees until they perish. (This sounds like a caricature of the US insurance system, from my western EU perspective.)
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What about this convoluted system:
- The doctors get paid a recurring fee that starts small and increases the longer you keep a patient around. This counters the problem that patients can just be replaced by a younger and healthier patient.
- The doctors get assigned patients randomly. This addresses the problem that doctors would choose young and healthy patients.
- The doctors can only have a certain number of patients at once. This makes each patient more valuable, and the doctor will be incentivized to actually treat patients, instead of having as many as possible.
Oh wait...
Now, the problem is that a young, ambitious, greedy doctor would be incentivized to cull their set of patients and select for the most viable ones in the long run. This actually incentivizes them to kill off patients with minor defects?
Actually, we are increasingly doing that already in the US. Value-based healthcare, aka Medicare Advantage uses something called risk adjustment. Payments are based on patient demographics and select disease categories (HCC codes) with bundled payments. The intent is to slowly get rid of fee-for-service healthcare.
I’ve found that my employer-provided health insurance is less than worthless for routine health care. I actually pay less by going to providers who don’t accept insurance — even though I maintain bare-minimum coverage and an HSA. I don’t think I used my health insurance at all this year — at least not enough to come close to meeting the deductible.
My primary care doctor uses this model — I pay $300/yr for basically unlimited access. I have a therapist who I pay $75 a session. I use GoodRX for prescriptions and get better prices than the post-deductible price on my insurance plan.
Basically, I pay less out of pocket by not using my insurance. I also get to choose my doctors, and they treat me as an actual patient rather than a number. Health insurance in the US is a scam.
Yeah, I don't get it. If you have infinite resources, and you absolutely know the doctor is competent (a question omitted here that would make this more interesting) just tie the doctor's fate to yours.
I don't know if overpaying will work, because the marginal value of money goes down the more you have. Once your doctor is rich enough, he won't be overly concerned if you die and the checks stop coming in.
The real answer is the action-movie/not-that-uncommon-in-reality answer: Credibly promise to shoot the doctor if you die, or to shoot the doctor's family members.
If we're trying to handle the case of greedy doctors, why would a doctor accept a very sick patient who is going to require a higher-than average amount of care and probably not live (i.e. pay) as long? If they can't pick their patients, how do you protect the unlucky ones who end up with too many very sick patients?
Right? I can't get over the "meta" point here of what we're here doing: This is not a conceptually difficult problem to fix and a whole lot of countries besides the one I live in have solved it quite easily, but here we are having to contend with it. It's just quite frustrating.
>The obvious, obvious thing is to simply pay the doctor a fix priced each month wether they diagnose you with something or not.
Easy fix... "Just be wealthy!" lol... :|
I've paid for the absolute best insurance I could find this year and gone to doctors my entire life that simply don't care. I've had everything from colonoscopies to MRIs done and I haven't spent more than one day in my entire life in a hospital overnight in over 40 years.
Many would say I'm pretty healthy, but who knows?
It usually seems like doctors peddle as much fear as web MD now in order to drive me through the service bay of fees every time I have an ache or troublesome pain.
If it's any consolation though, my dentist, my auto maintenance shop, my lawyer, and even my local supermarket want a constant revenue stream out of me because they have a pipeline of service that they know they can get a customer hooked on if they coordinate their efforts and make their pricing variable based on being properly opportunistic.
A lot of the tactics the health care industry regularly uses to sell services (and drugs of course too) are from the nefarious book of street drug dealers... In a bad economy, the scams and opportunism are ripe. Getting a second opinion is often VERY EXPENSIVE as well.
Be careful my friends, sometimes it's better to face your fears of "WebMD prescribed" death head-on rather than to bankrupt yourself, because if you don't die, living broke or in extreme debt can be a "silent killer" and harmful mentally and physically to you too. Maybe marry a doctor... That might cut extreme health care costs... By about 5% if you're lucky... :P
I think the premise of the article is that this is _more_ of a problem when you're wealthy and you want to be "as healthy as possible". If you're poor you're only going to pay the bare minimum to stay alive so capitalism takes over.
This is basically the Kaiser model. Kaiser's doctors are salaried, rather than getting paid per procedure. Works pretty well!
(I think the actual answer to the question in the OP is, at least in part, to license more doctors. Then the cartel doesn't have as much pricing power and medical care is less of a luxury good. The rich person should really hire a lobbyist.)
I had Kaiser for a year and I actually enjoyed it. I saw a couple specialist but I never had any major work done so perhaps I am biased. It is funny to say it since I believe Kaiser originally was one of the opponents of a single payer system but using Kaiser kind of felt like what a government health care system should be. Very low friction. Oh I need blood work or whatever done, walk down the hall. Everything felt more convenient.
Same here. I enjoyed knowing there is one place where I can go and have everything done. They also sent reminders about vaccinations and checkups. I have moved away from CA so I don't have Kaiser anymore. I generally rarely go to a doctor and if I ever get sick I don't even know where to go :-(
The 80s/90s/00s were probably the golden years for them, but they got in the political spotlight, and combined with the decreasing proportion of young to old people, the government is going to push down cuts to whoever lacks political power to push back. Such as smaller businesses like independent doctor offices and pharmacies.
The government has already increased supply by letting Nurse Practitioners and Physician Assistants do stuff that doctors used to do, and I suspect a lot more price discrimination is on the way. Expect the average quality of care to fall (may not be a bad thing if overqualified people were treating pink eye), and paying more will result in being seen by someone more qualified.
Increasing the supply doesn't mean the average quality of care will fall.
If I pay doctors $400,000 a year to work 80 hours a week and then double the number of doctors and pay them $200,000 a year to work 40 hours per week, the quality of care would almost certainly improve but costs would be constant. And actually, do we pay doctors a premium for those overtime hours where they're actually probably less effective? If so, our costs would go down as quality of care improves.
In theory, if you want to train twice as many doctors, you have to relax admissions criteria to let in twice as many people, and the new admitees wouldn't have qualified under the previous system.
But what if the limiting factor of admission criteria isn't scoring well but things like crippling amount of debt, archaic culture of hazing and adversity to stupid hours?
Right. Are doctors ubermensch who are the cream of the crop or did they just have a high tolerance for abuse? I’m not sure being ultra-selective gets you people who are fundamentally better doctors nor are the returns gonna be very linear even if they were. I’d much rather have enough well-rested doctors than have more “select” but highly stressed, sleep deprived doctors.
you're kind of assuming that the metrics that the use to admit students are predictive of care quality. thats certainly not true, but who knows how not true?
I'm kind of surprised that med schools haven't dramatically opened up their admissions, like law schools have over the past 20 years. It's such an obvious source of funds for the school.
AMA claims the real bottleneck is residency funding, since you cannot practice as a doctor without residency, and for some reason, only the federal government funds residencies, and the feds have not changed funding in many, many years.
Also, increasing class sizes is not without its down sides. Pharmacy schools cashed in and blew up the number of pharmacists in the last 10 years, and now the pharmacists’ employers have so much power in the negotiations due to so much supply of labor, that they can make pharmacists accept metrics which pharmacists know are excessive and unsafe since no one can possibly do the job properly in the time they are expected to check the medications and counsel people in.
A pharmacist family member says the law is to counsel patients, but the reality is anyone who did that would be fired and replaced so, in reality, people are not getting the counseling they deserve when they pick up the medications, and pharmacists are not able to properly double check the doctors.
They constantly try to escape
From the darkness outside and within
By dreaming of systems so perfect
that no one will need to be good.
But the man that is will shadow
The man that pretends to be.
--TS Eliot
Let us posit that the patient's goal is to remain alive and well (maximize quality-adjusted life years). Let us posit that the doctor's goal is maximal renumeration. Cannot we simply compensate the doctor quarterly as a function of quality-of-life during that quarter along with some fixed retainer. Now the doctor hopes we remain alive and well as long as possible?
Then the doctor fires you for being unhealthy and finds a healthier patient. The patient would have been healthy even if he never went to the doctor and the doctor gets credit and payment for it.
Simple version: Payments is contingent on patient being alive.
It's a life-time contract for the doctor, which aligns the incentives... Provided being in the highly quantized state of "alive" is all we care about, i think this is pretty bulletproof. The only place it will fall down is in the moral grey areas where euthanasia usually enters the ring, in which case a more specific criteria of alive may be necessary to prevent prolonged suffering.
However If this is applied to the multidimensional continuum of "health" it gets tricky again. Verifying you are "alive" can be done by your dog; verifying you are "healthy" would require at least as much independent expertise as the greedy doctor, and is an opinionated subject.
Interestingly though, this is kinda, roughly, sortof how public healthcare is supposed to work: everyone who is alive and in working health is capable of contributing economically and paying taxes... which fund the healthcare system, but since it's so indirect this alignment in incentives can only be appreciated at the organisational level trying to increase efficiency. e.g in theory it should encourage preventative healthcare which minimises long term cost while keeping their income stream alive, literally.
Maybe start by actually hiring a doctor, a person you can form a relationship with, rather than a health care system/company. The doctor may charge high fees, but their behavior is more likely to be bound by the relationship, and societal expectations around decency and respect between people. This dynamic does not exist between companies (read health care systems) and the people they supposedly serve, but both internal and external corporate incentives -however well meaning or small when considered alone- come together to extract as much money as possible.
In the US, this model is usually called "concierge medicine." It sounds weird but it's exactly what you want for a GP relationship IF you can handle the fees ($1-2K annually, and that's going to be out of pocket).
The answer is probably from a different area of computer science/game theory: consensus.
This has been practiced by patients for a long time by asking for a second opinion. However, this no longer works, because doctors now all share your medical record, and the second doctor risks getting sued if they disagree, while they bear no risk at all for agreement with the first doctor.
So, the consensus rules have to actively break the model for collusion. I’m not sure how to do this, and actually I think this is a relatively unexamined area of game theory, because most models assume tautological correctness of consensus.
Breaking consensus requires an oracle, which is by definition, a source of truth that operates outside of the consensus model, and cannot be affected by participants. This would be something like a piece of diagnostic equipment that can’t be altered or censored. It also requires a very large incentive for correctly predicting the oracle result against the consensus opinion.
So here is a straw man mechanism:
1. Assume condition can be assessed by a diagnostic test oracle
2. See many doctors, solicit opinions on treatment
3. For each proposed treatment, the doctors bet on the post-treatment test result
4. Choose the treatment with the best most money wagered on a good result
5. Add your service payment to the pool
6. Undergo treatment, take post-treatment diagnostic test
7. Distribute all money to the correct predictors
> How can you design a payment scheme for the medical professional so that you actually get the ideal treatment?
Draw up a contract whereby you are only obligated to pay the doctor while healthy. The doctor loses money as long as your health is suboptimal and therefore it is in the greedy doctor's best interest to do everything they can to keep you healthy.
The same approach can be applied to any service that requires regular intervention to avoid service interruption. If you pay someone every time the service is interrupted, then they’ll be incentivized to do a bad job so it gets interrupted more frequently (e.g. contractors tasked with ensuring traffic lights or electricity supply works all year round in all weather conditions).
Pay a flat rate for continual service. Beyond a certain reasonable/acceptable level of interruption, reduce what you pay them. Eventually if they do enough poor quality work they’ll go out of business - as opposed to the current conventional approach that incentivizes them to do poor quality work.
If this applied to certain goods as well (like electronics) we’d probably be able to get rid of planned obsolescence.
Or the doctor only takes on healthy patients, and refuses to take on anyone with pre-existing conditions.
Also, what happens when people self-select such that only people who often get sick take on these contracts, and people who are normally healthy stick with pay-for-service?
I suppose another such solution, for a patient with a given medical condition X, is to have a very large pool of doctors and see if any of them have condition X (with similar age, background, etc).
Then one could compare how treatment varies when doctors treat themselves with the same issue.
The answer is not to play games with the payment as if it's the only thing you can engage with - it's to check the contents of their work.
P != NP, as far as we've discovered. As a non-doctor, I can still understand medical conditions. What I don't have are the heuristics to diagnose a medical condition. The way I see it, I'm hiring a doctor (or any other skilled knowledge professional) for their ability to generate a proof certificate (in the algorithms sense) that convinces me of their declared diagnosis. Any consultant who asserts "The answer is X" without being able to explain that answer to an intelligent non-domain-expert has not done their job.
I wonder how software world has the most sophisticated practices and patterns for architectures, communication, and arbitration, yet we are played by lawyers and doctors like blind children. Once I was looking to address my non-obvious health issue. Insurances, appointments, referrals, hospital, ended up with an obsolete surgical procedure leaving visible incision scars. That was in Germany. Somewhere at the back of my head I was thinking "I'm smart, you're smart, we're pals and I can trust you right?". Now I'm just left with infinite hatred and distrust towards greedy medical frauds.
Or...do something along the lines of what the healthcare world has already come up with: doctors get paid for the quality of care they give, rather than just quantity.
This is exactly what I was waiting to see at the bottom of the article. It's what Medicare is trying to move towards in the US - doctors are paid more if their patients are healthy (as measured by biomarkers, time in hospital, etc.)
Right. And many insurance companies already reward hospitals and doctors more if the diagnosis methods and treatments were appropriately effective.
For example, if the patient with pneumonia is discharged but re-admitted a week later for recurrence of the pneumonia because they weren't given the appropriate antibiotic, or their bed during hospital stay wasn't at a 30-degree angle, etc...then they get less money from insurance.
Or if a particular emergency department physicians keep ordering unnecessary and expensive diagnostic tests, not only may those tests not be reimbursed, but their "score" for quality of care goes down, and so will their personal reimbursement.
I blew half a million of healthcare companies money searching for answers. Which I eventually got.
Entire time desperately trying to find a doctor to work with me. Instead had to educate myself for a couple of years.
I would have loved to just pay a doctor a grand or more a month for a few hours to go over tests and discuss next steps. Would have been drastically cheaper for all involved.
It's more a hospital business set up if anything.
The hospital admin and shareholders treat their staff terribly and keep most of the actual profits.
They end up begrudgingly paying doctors more than the general public but they wouldn't do this if poor - middle class medical students could go to school without signing their financial freedom to the gov. or military.
Which is why the hospital owners have recently started convincing lawmakers to allow them to hire as many 'mid levels' they want instead.
They charge the patients the SAME, since, to the eyes of insurance, the services supplied are basically the same. They just get to KEEP more of the difference for the hospital stakeholders with a PA than with someone with a medical degree.
Doctors are also basically employees to the eyes of these hospitals. Albeit ones with some skills.
But I think they are abused during their residency and 4 - 5 years of being treated like absolute shit and everyone looking at you like a spoiled idiot (but is actually poor since residency salaries basically cover only housing and food) can turn most futures doctors into jaded and disillusioned cogs for the insurance machine.
Hospitals want to get paid by the insurance companies... so will bend over backwards and make it happen to the employees detriment.
Insurance companies PWN us all. So do not get distracted and think bigger picture. Doctors actually don't know the price of anything, they just do their job, and are getting trickle down from the insurance companies... which the hospitals gut through first.
Yeah, doctors had to work to get paid that much, but its the insurance and hospital business aspect that makes the costs sky high. They have lobbied for it to be this way for decades, letting idiot doctors distract us and have become an easy scapegoat. Most doctors have no idea how they get paid, the hospital complicates it on purpose so that idiots on both the doctor and patient sides are clueless and blame anything but the accurate picture.
I must have completely misunderstood the problem because none of the "solutions" proposed occurred to me. Simplifying the goal to be "don't die" why not just pay the doctor a flat rate for every year I'm alive? Then they will (presumably) give me advice that is likely to keep me alive?
For those that thought this was about healthcare, you didn't read the entire thing. Actually you should guess by the first example showing what looks like an NN setup that this has nothing to do with Healthcare.
One obvious solution is to have the diagnosing doctor not be the treating doctor- and the diagnosing doctor doesn't get paid more for a positive diagnosis.
I leaned once that in ancient China they paid family doctors a monthly free, unless someone in the household got sick, then the fee was not paid until everyone was healthy again.
Doctors did due diligence on their clients and advised them preventive. They did not want sickly households.
Also the incentive is on keeping the whole house in good shape.
I learned the opposite once: never let a capitalist near your health care program. They make money when you are sick, and stop making money when you are healthy.
> I learned the opposite once: never let a capitalist near your health care program. They make money when you are sick, and stop making money when you are healthy.
Competition cures greed. Instead of going to one doctor, go to three. Go with the doctor that has the best value (price/service). If the doctor gets greedy, shop around. Tell the doctor you found a lower price, and if he is not competitive, you will fire him, and find a new doctor.
Someone uses “greedy doctor” as an example to talk about an easy to understand version of the Control Problem, and the comments make it into a discussion of healthcare systems.
I’m starting to think most readers on HN don’t really read the articles and go straight into the comment section..
I noticed that when the 'laws of stupidity' article [1] came up here. I'm very familiar with it as I read it when I was young and impressionable, almost all the comments had nothing to do with the substance of the article.
What makes it more poignant is that I typically go straight to the comments myself, assuming that intelligent commentary on an article will convey what the article was about faster than the article itself. Which would probably be a good assumption - if I was the only member of the commentariate to make it.
There’s a tragedy of the commons going on here. The best outcome as a group is if everyone reads the article. The best outcome individually is if you’re the only one that doesn’t read the article, then you get all the informed comments without spending the time to read it personally. The actual outcome is that very few people read the article, and the entire discussion is about the title and how people interpreted it.
I don't think it is true that the best outcome individually is if you're the only one to read the comments. In the wisdom of the crowds formulation the average is closest, but on Hacker News and similar websites there is a popularity contest which biases the responses. The average over a biased sample doesn't have the same mathematical reasoning suggesting it is better than any individuals estimate.
To use a specific example there was once a claim about a board seat for Tesla going to someone that people tend to dislike. The comments were largely in agreement that this would happen and it would happen basically because it was outraging and seemed evil which agreed with the commenters preconceptions. Anyone who posted contrary to this - which I did, quoting a primary source which disagreed with the claim, got downvoted. Ultimately I was right and the board seat didn't go to the 'evil' person.
This isn't intended to be a critique of me getting downvoted. Instead I'm trying to point out that if you read all the comments the consensus in the comments doesn't approximate the correct answer. So what do you have to do? You have to go primary sources in order to be able to get an unbiased estimator. Maybe the comments link to one, which is nice, but notice: you can't rely on the comments alone. Which means it was the people who read the primary sources, not the people who read the comments, which get the best outcome individually.
Unfortunately, the people who are doing this aren't becoming popular for doing this when it helps them. Quite the opposite. When this is effective, it is effective entirely because it is not in line with the popular opinion.
"Please don't sneer, including at the rest of the community."
It's a particularly low-value form of comment, and also very common, I think mostly because we try to secure our identity in opposition to others. Since this mechanism appears to work the same way in everyone, such comments are repetitive and extremely tedious.
Point taken! Just for reference though it wasn't a sneer at all. I love HN and think this format where people get into a broader discussion about the general themes implied by the article, rather than stick narrowly to the actual text of the story, has been a successful one.
Please don't take HN threads on generic tangents. This isn't a substantive response to the article; it just points towards a version of the same discussion people have been repeating for years.
Such massive generic topics are like black holes that suck in unsuspecting threads that fly too close. Solution: consciously steer clear.
Very rich people will do far better in a private or blended system than a country with only a public system. Your best approach would be to triage your own health requirements: (1) spend as much as needed on preventative & health components, (2) pay a retainer or monthly fee to a private health network, (3) pay cash immediately for any rare, critical or emergent needs. You can get #1 in lots of countries, #2 in fewer and #3 in a handful including but not restricted to the US. As a Canadian, if you are super-wealthy you need to likely leave the country for #3.
Countries with public health care have problems with health care as well. It is not a silver bullet. The incentives are different but it is still an incentive driven system.
Very true. But it seems these countries try to keep the system accessible and affordable for patients. The US system seems designed to keep profits for providers, instances and employers while the patient has to pay without having having any market power. From a cost and transparency perspective I think it would be hard to design a worse system than the US system.
For all the faults of the US system, one can get some of the best medical care in the world in the US. It is very clear there is a lot of waste and excess cost due to the reasons you mentioned, but it isn't so bad as it is made out.
I think most countries with a civilized, social and sustainable healthcare system do this, right?
Maybe this is the kind of market that can never be free, because you can never step away from a deal, as the alternative is often death. As such perhaps in these matters we should just have some faith in humanity. You know, it works for a lot of open source software. Capitalism is not a silver bullet, people have a consciousness for a reason, use it, have faith in it. You will see that that is the exact thing that will make it flourish.
Btw, all "solutions" would piss me off as a doctor that just wants to help. The vast majority of people deserve and want to be trusted. We work better that way. What a cold piece.
Many countries with universal healthcare still pay by the act. In Canada, doctors are mostly independent service providers that bill the government directly. This can lead to two problems: a) they don’t do a whole lot of medical acts because it already pays so well that they can afford to slack off (e.g., work 3-4 days a week, see very little patients), or b) do a lot of unnecessary acts because it goes directly into their pockets.
Yep and it's a pretty big issue actually as it creates a lot of abuse in the system, doctors mostly interested in smaller "easier" acts that they are known to pay well, doctors getting referrals from a clinic outside of their administrative region (those pay more), and of course radiologists working 2-3 days a week because their acts are even better remunerated.
Add on top that by being independent, doctors will have their own company and be subjected to a much lower tax rate than a "normal" person earning 400k$/year.
It's clear why performing unnecessary medical acts is problematic, but what is the issue if doctors being paid by the act work 3-4 days a week? Isn't this just piece work and you can add more doctors?
Because the supply of medical doctors in most countries including Canada is heavily constrained. People are wary of opening the flood gates because it is expected that the quality of care would drop (not necessarily a good argument). Meanwhile, there is a huge access issue with long wait times at the ER or for seeing specialists. A large proportion of the population has no family doctor.
Yeah, that sounds ideal to me. I hate seeing stressed out, rushed medical professionals. In part, that's selfish -- they aren't doing their best work. But also, they set a terrible example to their patients by ignoring the impact of overwork on their own physical and mental health.
Less overwork results in better care, and more jobs. I'm all for it.
The median wait time to see a specialist in canada is 78 days[1].
Yes, in theory you could "just add more doctors". But there is clearly already less doctors than there needs to be. Policy that encourages doctors to work less exacerbates this issue.
You can't just say "add more doctors" as if that helps anything. Shortages exist for a reason, and analyzing and fixing the system which creates the shortage is the only way to resolve the shortage. You can't just tell poor people to "make more money" and solve poverty in the blink of an eye.
> You can't just say "add more doctors" as if that helps anything.
Why wouldn't it?
There are more than enough people who would want to become a doctor, and would be capable. Especially if the work/life balance would be better. At least in my part of the world, it seems that the system is rigged to keep the number of docters artificially low.
I explained in my comment: There is a shortage of doctors. Unless you know 50,000 people with medical degrees searching for a job, you are going to have to fix the situation that created the shortage rather than just wishing more doctors would appear.
This is what dasudasu was doing. They identified a cause of the shortage (doctors are encouraged to work 60% of a work week) and your response was "so what, more doctors will just appear". More doctors have not been appearing.
No, what I said is that there appears to be a structural problem causing a lack of docters, which we need to fix, as it causes high work pressure (and rather high earnings). I don't think doctors working 60+ hour weeks is the type of solution to the shortage we should aim work.
This problem appears to be highly contrived, why are there only two options (healthy or treat), why is the detective a clone of the doctor, why can't anyone use a true quantum random number generator, and how exactly are the two doctors supposed to act in lockstep as actual agents?
