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The healthcare system seems to be optimized towards extracting as much money from older people as possible. I just hope we can move the ball forward and try to

The healthcare system seems to be optimized towards extracting as much money from older people as possible. I just hope we can move the ball forward and try to make it good at healthcare instead by the time I get old.

Merrill 7y ago
IIRC about half of medical expenses are incurred in the last 18 months of life. That would be around $1.6 trillion annually.
- ip26 7y ago
  Google suggests it's about 10% (for the last 12 months)
  - Gustomaximus 7y ago
    A quick google and a few articles seemed to agree E.g. "Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan" https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0174 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017....
- mgarfias 7y ago
  I’m checking out before I get there
  - ineedasername 7y ago
    You can't: As long as you live past 1.5 years, you'll always have a "last 18 months" of your life ;)
    - mgarfias 7y ago
      I meant before I get there as in before the costs to keep me alive go eat the hell up
      - ineedasername 7y ago
        But how would you know? You could be a healthy 74-year old and think, "well now is the time, before I go down hill". But you could be cutting off 10 or even 20 years of life in decent health. Or you could wait until you start to get sick, but how would you know it's not just short-term? You could have a case of pneumonia but recover in a month, and again go on for another 10 years. I've seen a fair number of elderly be sick for most of a year and still come out of it: A relative recently passed at 94, but around 86 she had some serious health issues, and her fate was very uncertain. But she beat them, and had another 8 years where she took great joy in seeing multiple great-grand nieces & nephews born, swim in her pool, listen to her read them stories, etc. They were some of her happiest times, but would have never happened if she'd been trying to beat the 18-month decline.
        mgarfias 7y ago
        Because dementia runs in mom's family. Shes getting it and is aware of it, so if I get it I should be aware of it also. At some point its time to pull the plug.
- prepend 7y ago
  That seems normal since so many people die at the end of their life. You wouldn’t expect expensive, life saving procedures to take place in the middle of people’s lives. Since many don’t succeed those costs pile up and count in your stat. But many do succeed do people’s lives are extended.
wwweston 7y ago
On one hand, incentives matter (reward improving care). On the other hand, incentives matter (markets are not known for keeping away from extractive practices). Reward outcomes rather than fee-for-service?
- Gatsky 7y ago
  This is on the money, it’s all about incentives. In Australia there is a public and a private health system. In public, the surgeons are paid a salary which is the same whether they do 1000 or zero operations. In private they are paid per procedure, with zero salary. The probability of getting an operation is very different for the same condition in public and private.
  - refurb 7y ago
    If you’re paid the same whether you do surgeries or not, wouldn’t that incentivizing not doing surgeries? Less stress and less risk for the doctor.
    - Gatsky 7y ago
      No. Doctors are not bureaucrats. They have a 1 on 1 relationship with a patient and they do want to help them (this fact seems lost on many people). You don’t need to incentivize them to do the right thing, it is more that perverse incentives interfere with how things should be, for example performing pointless revascularizations.
    - ineedasername 7y ago
      Except they aren't necessarily paid more for surgery. That is a common misconception. Surgeries take time. Not just for the surgery, but the prep time before and then the aftermath. -For example, a bit of searching shows an appendectomy takes about an hour. Lets add 1/2 hour onto that for prep & cleanup. -Searching indicated about $900 to $1200 is the typical insurance payment to the surgeon. That's $600 to $800 an hour. -Based on my own insurance claims, specialist visits are reimbursed from $200-$300. Average 10 minutes per visit and that works out to $1200 to $1800 and hour. (Non specialist annual "wellness" checkup/physical was reimbursed around $180 for $1080 an hour) Certainly not all surgeries are necessarily the same, so rates may vary and there could be more or less $/hour, although the same goes for office visits. As such, doctors already are paid roughly similar, or close enough that concerns of pushing surgeries for the $$$ probably don't need to be a huge worry.
colechristensen 7y ago
This assumes widespread bad faith, when I think the situation is much different. The healthcare system is biased towards doing something . Patients want there to always be some action taken, and actions are found. Doing nothing seems like giving up.
- prepend 7y ago
  Patients do want to do something. And the fact that doctors and surgeons and lots of other individuals in healthcare make much more money by doing something means there’s lots of inertia to action, even if it’s not the best or even useful. I think the healthcare provider incentive is a more important factor since there is such a power imbalance. I’ve had numerous elective surgical procedures recommended. When I asked for non-surgical therapies I was told there are none. When I researched I found them and found other healthcare providers. I’m pretty young and healthy so the bias for surgeons to recommend surgery seems really strong. Maybe it’s not sinister and it’s just a coincidence that a surgery costs $10-30k and physical therapy costs $1k to someone other than the person who is recommending.
- hestipod 7y ago
  I was advised to have surgery I didn't need and it ruined my life. I will be ending it soon because of all the pain and loss and abandonment and not one of them will care or help prevent that outcome because they got paid. Nobody said "do nothing". They all advised surgery. They advised surgery multiple European doctors later said was never needed and wasn't appropriate. Every one of those doctors attacked when confronted about the outcome and necessity...called me a liar and mental and that the pain and disability was not real. They said I was just trying to get a big payday from them. Everything was about protecting their profits. From the moment I was victimized people started blaming me and trying to discredit me. Doctors, staff, their lawyers, administrators. They never admit fault and will cover each other's back. I have met many people like me...victims of this system. American hospitals and doctors operate for profits not as a public service. They don't get their big houses and fancy cars and status without that precious surgery income. It's very much about bad faith in the American Healthcare Business. People don't want to believe it and think because they haven't had their life taken from them that it's great and people like me are extreme outliers. The number THREE cause of death in America is doctors and hospitals killing people. But nobody cares until it's them. Bad faith is part and parcel with for profit anything and healthcare is one of the biggest for profit cabals on them all in America. Anyone who believes otherwise is just preserving their own income stream or sanity because they need to believe the system will be there for them. As long as "other people" are the victims then for most people it's all fine. I had a life...I had a future...I deserve to live safely and without pain...and I am denied this because they stole my health and means to earn. They made my value zero. Bad faith is their mission statement.
tootie 7y ago
I think that's not a valid conclusion to draw from this. The stent procedure has been considered the gold standard for quite a while and doctors have not had reason to question it until right now.
- astura 7y ago
  They had a reason to question it, the evidence of stent overuse has been piling up for at least a decade. https://www.vox.com/science-and-health/2017/11/3/16599072/stent-chest-pain-treatment-angina-not-effective https://www.vox.com/science-and-health/2017/11/3/16599072/st...

Merrill 7y ago

IIRC about half of medical expenses are incurred in the last 18 months of life. That would be around $1.6 trillion annually.

ip26 7y ago
Google suggests it's about 10% (for the last 12 months)
- Gustomaximus 7y ago
  A quick google and a few articles seemed to agree E.g. "Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan" https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0174 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017....
mgarfias 7y ago
I’m checking out before I get there
- ineedasername 7y ago
  You can't: As long as you live past 1.5 years, you'll always have a "last 18 months" of your life ;)
  - mgarfias 7y ago
    I meant before I get there as in before the costs to keep me alive go eat the hell up
    - ineedasername 7y ago
      But how would you know? You could be a healthy 74-year old and think, "well now is the time, before I go down hill". But you could be cutting off 10 or even 20 years of life in decent health. Or you could wait until you start to get sick, but how would you know it's not just short-term? You could have a case of pneumonia but recover in a month, and again go on for another 10 years. I've seen a fair number of elderly be sick for most of a year and still come out of it: A relative recently passed at 94, but around 86 she had some serious health issues, and her fate was very uncertain. But she beat them, and had another 8 years where she took great joy in seeing multiple great-grand nieces & nephews born, swim in her pool, listen to her read them stories, etc. They were some of her happiest times, but would have never happened if she'd been trying to beat the 18-month decline.
      - mgarfias 7y ago
        Because dementia runs in mom's family. Shes getting it and is aware of it, so if I get it I should be aware of it also. At some point its time to pull the plug.
prepend 7y ago
That seems normal since so many people die at the end of their life. You wouldn’t expect expensive, life saving procedures to take place in the middle of people’s lives. Since many don’t succeed those costs pile up and count in your stat. But many do succeed do people’s lives are extended.

wwweston 7y ago

On one hand, incentives matter (reward improving care). On the other hand, incentives matter (markets are not known for keeping away from extractive practices). Reward outcomes rather than fee-for-service?

Gatsky 7y ago
This is on the money, it’s all about incentives. In Australia there is a public and a private health system. In public, the surgeons are paid a salary which is the same whether they do 1000 or zero operations. In private they are paid per procedure, with zero salary. The probability of getting an operation is very different for the same condition in public and private.
- refurb 7y ago
  If you’re paid the same whether you do surgeries or not, wouldn’t that incentivizing not doing surgeries? Less stress and less risk for the doctor.
  - Gatsky 7y ago
    No. Doctors are not bureaucrats. They have a 1 on 1 relationship with a patient and they do want to help them (this fact seems lost on many people). You don’t need to incentivize them to do the right thing, it is more that perverse incentives interfere with how things should be, for example performing pointless revascularizations.
  - ineedasername 7y ago
    Except they aren't necessarily paid more for surgery. That is a common misconception. Surgeries take time. Not just for the surgery, but the prep time before and then the aftermath. -For example, a bit of searching shows an appendectomy takes about an hour. Lets add 1/2 hour onto that for prep & cleanup. -Searching indicated about $900 to $1200 is the typical insurance payment to the surgeon. That's $600 to $800 an hour. -Based on my own insurance claims, specialist visits are reimbursed from $200-$300. Average 10 minutes per visit and that works out to $1200 to $1800 and hour. (Non specialist annual "wellness" checkup/physical was reimbursed around $180 for $1080 an hour) Certainly not all surgeries are necessarily the same, so rates may vary and there could be more or less $/hour, although the same goes for office visits. As such, doctors already are paid roughly similar, or close enough that concerns of pushing surgeries for the $$$ probably don't need to be a huge worry.

colechristensen 7y ago

This assumes widespread bad faith, when I think the situation is much different. The healthcare system is biased towards doing something . Patients want there to always be some action taken, and actions are found. Doing nothing seems like giving up.

prepend 7y ago
Patients do want to do something. And the fact that doctors and surgeons and lots of other individuals in healthcare make much more money by doing something means there’s lots of inertia to action, even if it’s not the best or even useful. I think the healthcare provider incentive is a more important factor since there is such a power imbalance. I’ve had numerous elective surgical procedures recommended. When I asked for non-surgical therapies I was told there are none. When I researched I found them and found other healthcare providers. I’m pretty young and healthy so the bias for surgeons to recommend surgery seems really strong. Maybe it’s not sinister and it’s just a coincidence that a surgery costs $10-30k and physical therapy costs $1k to someone other than the person who is recommending.
hestipod 7y ago
I was advised to have surgery I didn't need and it ruined my life. I will be ending it soon because of all the pain and loss and abandonment and not one of them will care or help prevent that outcome because they got paid. Nobody said "do nothing". They all advised surgery. They advised surgery multiple European doctors later said was never needed and wasn't appropriate. Every one of those doctors attacked when confronted about the outcome and necessity...called me a liar and mental and that the pain and disability was not real. They said I was just trying to get a big payday from them. Everything was about protecting their profits. From the moment I was victimized people started blaming me and trying to discredit me. Doctors, staff, their lawyers, administrators. They never admit fault and will cover each other's back. I have met many people like me...victims of this system. American hospitals and doctors operate for profits not as a public service. They don't get their big houses and fancy cars and status without that precious surgery income. It's very much about bad faith in the American Healthcare Business. People don't want to believe it and think because they haven't had their life taken from them that it's great and people like me are extreme outliers. The number THREE cause of death in America is doctors and hospitals killing people. But nobody cares until it's them. Bad faith is part and parcel with for profit anything and healthcare is one of the biggest for profit cabals on them all in America. Anyone who believes otherwise is just preserving their own income stream or sanity because they need to believe the system will be there for them. As long as "other people" are the victims then for most people it's all fine. I had a life...I had a future...I deserve to live safely and without pain...and I am denied this because they stole my health and means to earn. They made my value zero. Bad faith is their mission statement.

tootie 7y ago

I think that's not a valid conclusion to draw from this. The stent procedure has been considered the gold standard for quite a while and doctors have not had reason to question it until right now.

astura 7y ago
They had a reason to question it, the evidence of stent overuse has been piling up for at least a decade. https://www.vox.com/science-and-health/2017/11/3/16599072/stent-chest-pain-treatment-angina-not-effective https://www.vox.com/science-and-health/2017/11/3/16599072/st...