* I strongly believe that only physicians should be running hospitals. Certainly not administrators whose only education is an MHA and only experience is working for for-profit health companies. Medical decisions need to be made outside of cost considerations. The only factors should be medical science, quality of life, and patient wishes (in that order).
** In stark contrast to asking questions and trying to understand. But I have family members who are the "look everything up and then try to tell my doctor how they're going to treat me" ilk and it's crazy.
*** I don't think the above points are unique to US healthcare other than cost considerations, but that's all I have experience with.*
This is how it is for other professional industries. As an attorney, you can lose your license for sharing any profits with someone who isn't a lawyer. I believe states typically require accounting and engineering firms to either be wholly or two-thirds owned by such professionals as well.
There are plenty of things that could be done better now by non-lawyers with the help of lawyers (look at Rocket law).
What states are these, Canadian states?
In the US, many many many SaaS shops are wholly owned by businessmen / bean counters. It's like, weird, to be an engineer who runs a software company.
> SaaS shop
Now, I get we like to refer to ourselves as Software Engineers, but surely you understand he means actual certified engineering firms, not groups of code monkeys, right? Software is virtually never engineering, you'd have to get to a situation like flight control software before you're doing anything legit
[1] https://www.harborcompliance.com/information/engineering-fir...
- an attitude of "most patients are just trying to wring medications out of you" - an ego-hit of "if I didn't make the diagnosis, I don't want to help" (this applies to both patients coming in with a suspicion of what they have, or getting a diagnosis from another doctor) - burn-out/overworking, where doctors have a hard time managing all the different cases coming at them without dropping the ball here and there
It's not a simple, single-cause problem at all, but just want to provide an alternative point of view about patients who look things up or come in asking about a specific condition or diagnosis.
When I got my ADHD diagnosis after a quarter-century, I went in specifically asking about ADHD because I had seen some flags that made me think I might have ADHD. Contrast that with the people doctors screen out who are trying to get a stimulant prescription despite not needing it, and you have a situation where it's hard for doctors to tell who does or doesn't need meds, and where patients with actual conditions have to fight hard for those to be diagnosed.
Even in cases like POTS, which has no medication involved in treatment, just lifestyle changes, and yet people close to me who have POTS all had an uphill battle getting it recognized by anyone, especially doctors who could diagnose (disclaimer: sample size = 3).
I told my doctor I had already been diagnosed with ADHD because I had a strong suspicion I had it and wanted to see for myself if the medication helped (it helped massively). I think medicine should be accessible for patients who need it but I don't know how to avoid large amounts of patients then taking medications for the wrong thing, which would probably happen if it was a free-for-all. It kinda comes down to the question of having the personal freedom to hurt yourself doing something stupid, which is a balance (a little of that freedom is good, too much probably bad). All-in-all I lean toward the current system of using on experts to make the final decision. Still, I would be really pissed if a doctor prevented me from getting stimulants for something I believe I need, so I am not 100% satisfied with the current system either.
Thanks for mentioning POTS, btw. Despite how many people have it, it's still fairly poorly known about even within the medical community.
I just can't understand this argument. Women already live 5 years longer than men on average. You mean to tell me if the system didn't discriminate so strongly against their best interest they'd live even longer than men?
I have found it helpful to approach it in more of a teamwork-like mentality. Don't just read WebMD and try to diagnose yourself - journal your symptoms, observe the trends, record data. If it seems like it points to a specific condition hop on Google Scholar and look for some legitimate new research the average doctor may not have heard about. Print that out and then when you go in show them and ask questions without attempting to specifically diagnose yourself.
You could be totally wrong but with some background info your doctor is much more likely to accurately diagnose and take you seriously.
The skills need to run a hospital are quite different than those required to be a doctor. I'm not saying hospitals aren't unique - I believe they are and their adminstration is highly specialized. Doctors should inform the administration at every level but it would be a waste of their training and a bad idea for doctors to run everything.
> Medical decisions need to be made outside of cost considerations. The only factors should be medical science, quality of life, and patient wishes (in that order).
Would you be as quick to say "Doctors should work without pay." ?
It's possible to meet the sole criteria of science, quality, and patient wishes with exploding costs. I think the OP's point was that money has to come from somewhere.
We’re “fixing” this by flooding the market with less trained nurse practitioners and PE. Doctors are being gobbled up by regional medical cartels and put where they can maximize billing.
In reality though, the overwhelming majority of cases that walk into a doctors office on any given day do not require an actual MD - NP and PA's are more than capable of handling many, many things that a typical patient needs.
Everybody tends to think they need a 'real doctor', they usually don't. Its good they are there when they are really needed, but do you really need an MD to diagnose a sore throat, adjust your BP meds or many other routine things that are people are seen for everyday?
And still, in many countries, including highly industrialized ones, hospitals are run by doctors. So either US administrators are making their hospitals run a lot better (which does not seem to be the case), or the core incentives each group optimizes for are different.
Why do you think law firms and accountancies are partnerships? Because the best proffesional for managing lawyers/accountants/develipers is such a proffeshional with loads of experience. Thats why we have progression, you gain management skill as you bevome more senior but you still know how the industry works and the people you manage
The issue is if you have someone with a scientific background doing politics, what you have at the end is still a politician. Same thing here. An MD doing hospital administration is an administrator.
Which is not to devalue specialist expertise in these roles. I definitely think you want people with these backgrounds in those roles as well. Just not necessarily exclusively. A career administrator has different skills than a physician, you want people with both, and other, roles working to run a hospital.
The real problem as I see it is probably the incentives, constraints, and pressures they work under, or towards. A physician forced to run a for-profit hospital maximizing returns is going to make a lot of the same decisions as someone with a business background in the same situation. The thing is to change the situation, not put different people into that role and expect them to do it dramatically better.
I think the practical issue is those fields that have similar restrictions basically predate a major societal shift. We now consider the only valid limits on profit and ambition to be market forces. I'm not sure restricting hospitals in this way is less radical than just nationalizing them, in terms of practical politics.
Anyway, again, sure. I'm not informed enough on this subject to know what model would actually work best. I think the problem is the raw exclusive profit motive rather than who specifically is running them, but there are a lot of ways to eliminate that.
Indeed! Whereas a doctor might say yes, give that patient with cancer the treatment they need, the MBA is going to say no, it costs to much, let them die. If the goal is to maximize profit, the MBA is doing a better job. If the goal is to maximize the health of your patients, the doctor is. We must realize that these two goals are fundamentally in conflict with one another.
The question isn't whether a doctor or an MBA should be running a for profit hospital, it's whether we should even have for profit hospitals. If we care about people more than profits, then clearly we should not.
It sucks and no one likes it, but what is the alternative?
Each human life is worth infinity? So we should bankrupt the entire country, spending 10 trillion dollars on a surgery that has a 1% chance to save a 98 year olds life?
Obviously that is an extreme example.. but the point is sound. We only have so many resources, how do they get divided up? Should be spend millions to give 80 year olds 1 more year of life? Do we value life on the reverse of age, so a baby we value at 10 million dollars, but a 90 year old we value at $20,000? What if that 90 year old is your Grandpa?
In my experience, I have had:
1. Doctors that know nothing about a really basic ailment and not have any meaningful guidance or treatment to suggest
2. Doctors that Google something literally in front of me, things that I have already Googled myself, and draw the wrong conclusion because they're looking at results at a glance - when I had searched myself earlier and dug deeper though, it was clear to me the result he was looking at was just plain wrong
3. Doctors that provide very little to no guidance about a wide selection of medications available to treat a problem, leaving me to essentially guess which option of a dozen or more I should go with
4. Doctors that force me to advocate for myself and my condition before they agree to help treat it - so much so that I had to visit 4 different doctors to find one that would, wasting nearly a thousand dollars of office visits with nothing to show for it.
It's no wonder people do their own research and dare to advocate for themselves. Most doctors are fucking worthless.
Keep in mind they also have to do a stupid amount of paperwork these days for every patient and the place they work for may be overscheduling the crap out of them - generally (unfortunately) I always consider my first appointment to be sort of a wash due to this and assume I am not going to really get anywhere until the second time I see them.
However, I think acknowledging when one doesn't know something is a skill many could benefit from improving...
Doctors are not like other proffeshions, they cannot put things right if the opportunity for treatment is missed
Doctors that blatantly lie to your face because they want to push some procedure.
In the end, labor hours of professionals are finite. Even if you don't need to pay doctors, you only have so many, they can only work so many hours, you will need to prioritize who to help in what way, which procedures to do. Same with all the other personnel, the consumable stuff, the devices/scanners/equipment, etc. So someone is going to have to prioritize. It can be just "how much quality of life can we save using the resources we have", regardless of the patient's ability to pay/insurance/citizenship, but some prioritization will need to happen. The policy of the death panels can be changed, but their existence is inevitable.
This is why it makes no sense to have doctors and nurses waste time battling insurance companies over treatments, and hospitals over staffing. Their time is indeed too valuable.
That's not always the case. The reason I stopped writing mobile applications long ago was because the mobile carriers were doing exactly this, and not even providing enough paperwork for you to argue with them about it.
People like to lambast the Apple App Store for being greedy, but the fact of the matter is that people netted 3x as much off Apple that they did from the carriers. They are asking too much money now but their rates were absolutely defensible at the time. It's not a coincidence that we had a gold rush that started almost exactly when the App Store became a viable target.
One might ask what would happen if we joined the rest of the 1st World in providing medical care and marginalized private health insurance. Would it be a similar watershed moment?
A common attitude which may cause:
Health care is extremely costly in the United States. Although the rate of growth in spending has attenuated in recent years, per capita spending on health care is estimated to be 50 to 200 percent greater in the United States than in other economically developed countries. Despite leading the world in costs, however, the United States ranks twenty-sixth in the world for life expectancy and ranks poorly on other indicators of quality.
https://journalofethics.ama-assn.org/article/complex-relatio...
On the other hand, imagine the world where Coca-Cola makes billions on healthy drinks, people are slim and fit until they die, and half of the money spent on treatment of chronic diseases of excess can be used for something else.
This is not unique to the US. Can't really say "but we only have 25% obesity here" and call that any kind of win. Maybe the US leads in this regards (though it varies by region, some areas have European-level obesity rates), but obesity is a worldwide problem.
Strong disagree. This same attitude pervades the military ("only pilots should run the air force") and really all it does is that lower representation of the interests of the other non-pilot 90% of your organization and put a pilot bias on every decision being made.
Anecdotally, this has been true in my experience on complex engineering projects. When the project manager is a mechanical engineer, guess which systems get the most time, money, and priority? Mechanical. And when it's an electrical engineer, the electrical system gets the priority. When it's a software engineer, the software etc. They all recognize the other systems, but availability bias skews their worldview and priorities to the neglect of others.
More than that - hands on healthcare should not be a for profit industry. The need to make profit is fundamentally opposed to providing the best care. As the push for profit increases, more people get sick and die. This goes for long term care as well, which is facing a similar staffing crisis for similar reasons.
I still think it’s better than the other extreme of just showing up and trusting the professionals. That should work in theory, but my experience for myself and those around me is it’s incredibly ineffective. If what you’re dealing with requires the least bit of thought, odds are you’re getting brushed off to the extent you allow.
The real model of US healthcare is essentially apprentice/master, with the patient as apprentice. Apprentice does a lot of the work, not all, some needs to be approved by the master and the apprentice better know how to learn from the master, when to push back, and how to make it seem like it was their idea all along. You can imagine how this falls apart for mental health.
It's really jarring to read an otherwise reasonable comment that drops a whopper like this. Nothing exists outside of cost considerations. The NSA has cost considerations. The Space Shuttle had cost considerations (obviously, not great ones!). The design of nuclear submarines involves cost considerations, however unsettling that may seem. You're telling me that my broken hand needs to be judged outside of cost considerations? Give me a break.
The problem is that there is a lack of "trustworthy" parties to evaluate cost expectations in medicine. The patient often doesn't understand their condition or its treatments, the doctor has a clear perverse incentive to inflate costs, and the insurance company may actually be better off if the patient dies. At least that's the conventional picture. Leftist pundits often complain that the American economy is based on "greed", but a more precise criticism is that there has recently been a trend away from expecting benevolence and for-its-own-sake honesty from anyone under any circumstances, or equivalently an increasing cynicism about human motivations. It remains to be seen whether a medical system can function when nobody expects to trust anyone.
It absolutely did, and great ones too. The program was too costly and never lived up to the original expectations of fast and easy access to orbit.
Falcon 9 + Dragon is the first American human-rated launcher and ship that can be labeled as somewhat cost effective.
I think this is exacerbated by doctors a lot of the time. I'm in Canada so it's obviously a very different system, but visits to a GP often have strict time limits and "one issue only" rules. When you can only talk about one symptom, and you only have 5 minutes to explain it, it's natural to try and do homework first to see what you're going to use your limited time on.
Can you elaborate on your rationale? I ask because I've worked in hospitals run by a cadre of physicians and it was not run well. Anecdotal, obviously, so I'm curious on your thoughts on what they provide.
My worry is that it can lead to an unbalanced technocracy. It's like saying a politician needs to come from [industry x] to govern [industry x]. Technical competence is a necessary, but insufficient criteria when managing a multifaceted problem. The risk is that the front-line physician priorities would always become the organization's top priority. In reality, a hospital administrator has to manage competing priorities across many different domains.
This actually isn't necessarily true when you learn how billing codes work. Most insurance companies pay out at a fixed rate per billing code based on your plan. That doesn't change. What does change is that hospitals can retroactively apply new additional billing codes.
This happened to us once for an ER visit where we got 3 additional surprise bills over 6 months because the hospital retroactively applied new billing codes to our visit.
The doctors and specialists gave me every treatment under the son to no avail.
Then I did my own research and read I should try OTC psuedophredrine. It worked like a charm. Now every time I catch a cold (and when I got Covid), I pop psuedophredrine for a few days and I am good.
Yes, psuedophredrine is suggested to treat Covid if you have virus induced asthma.
Second anecdote: I have relatively mild cerebral palsy. As I’ve gotten older, my affected foot tightens up especially in the winter. My neurologist said it was physical and not neurological. I went on vacation and was drinking more alcohol than I usual do. I noticed I was walking without pain. I did my research when I got home and found a prescription muscle relaxant with the fewest side effects and ask my doctor about it. He prescribed it to me.
He didn’t bother telling me that I should get blood work done to check for liver problems. I had to bring it up to him.
I can now walk without pain and run when properly conditioned.
If you look up possible treatments /side effects and your personal history you will be in a better position to engage and weight options. If you blindly accept everything you will end up on the most profitable treatment plan plan insurance allowed.
(Disclaimer: I have been on the design team for several hospitals, including El Camino and San Francisco General, in the bay area - and I have a family of doctors and nurses in my family - my brother was head of the Veteran Administration for the state of Alaska, and is currently CMO for a large health provider (he is a doctor)
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That said, the "running" of a hospital isa hell of a lot more than medicine (when we are specifically talking to the running of -- but this comment was made in relation to costs/efficiencies as far as outcomes, patient treatment, insurance etc...)
Hospitals are really complex ecosystems and should be thought of more like an aircraft carrier than an other form of business.
The costs within the realm of a hospital are ridiculous - as are the methods and manner in which hospitals raise money.
Insurance is cancer to be sure, but there are so many other factors that go into the operational costs of a hospital - and I don't just mean ngoing care and operations - systems and technology and medicine evolve. People are people and regardless have the same hierachy of needs in any environment.
You have every single actor as an enemy of the hospital bottom line:
New tech, $$
Older nursing pop $$
Current nursing/doctor market salaries $$
Maintenance for existing systems $$
Insurance billing code lock-in $$
Competing hospitals for doctors and nursing staff $$
California $$
Corruption $$
Utilities and related redundant infra to ensure life systems
The ridiculous cost to upgrade
The list goes on and on...
(The cheapest hospital project I worked on was hundreds of millions of dollars)
etc...
Hospitals are really expensive to run, and it requires a hell of a lot more skills than simply being a "doctor" to run one.
This is precisely why I think we will never be able to effectively treat healthcare as a "free market" with tools like HSAs, posted price sheet, etc. The end user can never know the true cost of their procedure until it's long over (sometimes years later) and often don't get to choose at all.
