6 ms·

Salve Lucrum: The Existential Threat of Greed in US Health Care

51 points by _lx4l 3y ago

mjevans 3y ago
I remember ADs on TV, actual ads, for catheters DECADES ago when I used to watch TV. The greed and grift on government programs isn't new; it's been around for my entire life. Competition is good, for time insensitive fungible things of comparable quality. It can also be good for a reverse dutch auction (within a geographic area) contract price (going rate for the year / timeframe) for a given number of procedures of a sort. I think the ACA (Obamacare) tried far too hard to reach a compromise and fell short. A singe player, taxpayer funded baseline medical care for all organized by by the government as a healthcare provider program is the only answer for a society where we agree everyone should have the right to medically necessary procedures so they can be productive members of society.
- anovikov 3y ago
  It doesn't matter if there's a single payer or not if supply is constrained and demand is skyrocketing. Solution is to make healthcare a branch of public service.
ngngngng 3y ago
I've generally been a very optimistic person, and even when surrounded by "doomers" I've avoided joining them. But I'm increasingly of the opinion that there is no smooth way to solve the problems we've created (and are currently creating). Housing is an example of this, medicine, feels like AI's impact on the economy will go this way. If there were a point where things got bad enough that we finally had the will to push for real change through normal political processes, we would have reached it years ago. Without being too dramatic, I don't see this ending well.
- thejackgoode 3y ago
  I started saying jokingly some time ago “this’ll get fixed after nukes”, I am not completely sure anymore this is a joke.
- worik 3y ago
  Me too. I would add the legal (some mislabel it "justice") system to the mix. With senior lawyers charging multiple thousands an hour, with such terrifyingly high stakes (especially in the criminal legal system) there is zero incentive for swift, and just, outcomes. All the incentives are to prolong the process.
  - worik 3y ago
    And another thing. I studied Finance in a Univerity, and one of my professors taught me a joke. An in-joke: The customer's yacht. It is a joke because the customer cannot afford a yacht once we are through with him.
  - donw 3y ago
    The process is the punishment. And then there's more punishment afterwards.
- mrtesthah 3y ago
  A majority of US citizens agree on the broad strokes of what's needed for political and economic progress; they are merely stymied at every opportunity, and systematically divided through propaganda, by those with extreme amounts of wealth and power. At a certain point in the very near future, it will become necessary to stop heeding the legal and ethical barriers which protect that power.
  - ngngngng 3y ago
    > At a certain point in the very near future, it will become necessary to stop heeding the legal and ethical barriers which protect that power. I really wish I didn't agree with you. The people that said to keep your guns were right.
- gremlinsinc 3y ago
  I feel people could circumvent political control if they banded together... Like imagine if thousands pooled money to build tiny home communities and then rent that out to people for like $140/month/family member. If you have a large family we just stack two tiny homes side-by-side. Or imagine if a bunch of co-ops formed that built SaaS products/etc and used 100% of the money to expand the business, and build mutual aid networks and eventually buy up hospital assets like urgent cares etc... Then charged much more for insured because they can afford to pay, and gave it free to uninsured under certain income limits. Basically a big union of worker co-ops pooling resources to build bigger and better systems that are all aligned. There may even be competitors between the co-ops but they're not competitive to the point of disrupting ecosystems and destroying the planet like unchecked corps like Dupont or something.
DaveExeter 3y ago
The problem is health insurance. If we got rid of health insurance, prices would necessarily drop to levels where patients could simply pay for health services. That's how it used to work. I've seen invoices from the 50s where the cost to deliver a baby is $200. $100 for the doctor, $100 for the hospital. With a 10x inflation adjustment, that's $2,000 total. That was enough money to deliver a baby in the 50s.
- ngngngng 3y ago
  For added context, with really good insurance I've paid about $4000 for both of my children. That's just out of pocket cost, of course I pay very high premiums and my company covers a large portion of the cost themselves. Both of these births were very standard, no complications. The profit margin there is insane.
- worik 3y ago
  Really? An operating theatre cost many thousands of dollars an hour to run, the pre and post care is also very expensive. You may never need them (I hope you do not) but if you do it would almost surely bankrupt you without either socialised medicine (yay - sort of - another story) or insurance.
  - runamok 3y ago
    Most other countries are around what he is talking about ($2.5k to $4k) whereas the US > $10k. https://www.insider.com/costs-giving-birth-around-the-world-2018-7 https://www.insider.com/costs-giving-birth-around-the-world-... Certainly when things go wrong it can get more costly but the US consistently costs 2 to 3x more for everything AND usually has worse health outcomes. US maternal mortality is an embarrassment: https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020... .
  - glass3 3y ago
    The markets don't work if delivering a child leads to bankruptcy. Either people pay for unnecessary procedures or those procedures cost too much.
BigCryo 3y ago
Is that what I find amazing is that Americans, especially older americans, have not caught on to the fact that apparently the government and the insurance companies colluded to make Medicare confusing.. in order to drive senior citizens into the arms of the insurance companies because they can't figure out what's going on with the Medicare situation
- ngngngng 3y ago
  To be frank, you don't have to look long to find ample evidence of our government being a disaster. COVID is fresh in everyone's minds and everything about that situation was horrifically mismanaged. We all know the healthcare situation is terrible but the main politicians that want to change this offer 100% government controlled single payer healthcare as the only solution. That would take us from the least socialized system in the world, to literally the most socialized system in the world. I don't think you have to try very hard to imagine why people are uncomfortable with that. Edit: Never make one slight error on HN or your entire point is invalid, it would be one of the most socialized by the legislative proposals, but not literally the most.
  - worik 3y ago
    > , to literally the most socialized system in the world. Well there is Cuba. The best health system in the world, many say.
    - whitemary 3y ago
      During the heights of the pandemic, the Cuban health system sent over 2,000 doctors to 23 of the most affected countries. No other country sent nearly that many doctors elsewhere, and Cuba is a tiny place!
  - bradleyjg 3y ago
    That would take us from the least socialized system in the world, to literally the most socialized system in the world. Single payer is “less socialist” than the UK system that has many of the healthcare providers working directly for the government. Likewise, the US is not the “least socialist” today. In Nigeria most people just pay out of pocket for healthcare.
mrosett 3y ago
Ok, apologies for a slightly irritated tone, but this touched a nerve. Of course the author is an MD who doesn’t mention the extremely high salaries paid to physicians in this country, instead acting like they’re somehow victims of high healthcare costs rather than the primary beneficiaries: > Perhaps the demoralization of professionals, the conflicted consciences of many executives, and the anger of the public represent potential political energy that, with proper leadership, can become kinetic. > First, health care professionals in all disciplines need to become noisier about the conflict between unchecked greed and the duty to heal. Extortionate drug prices, exploitation of market consolidation, coding games, excessive executive compensation, and promulgation of unnecessary care ought not to be met with silence. Silence is assent. The median salary for a specialist physician in the US is $346k. Orthopedic surgeons clear north of half a million on average. As a result, “physician” is the most common profession profession among the richest 1%. Note that this didn’t happen by accident. Groups like the AMA lobby for policies that keep supply low and salaries high. The one time that legislation threatened to reduce physician salaries, Congress passed the infamous “doc fix” Mind you, residency sucks and many doctors are wonderful, so I mostly don’t begrudge them their pay. But if you’re complaining about the cost of healthcare and mention literally every group except the one you belong to, perhaps you’re being the slightest bit disingenuous. As for the author, he earned $889,484 back in 2009 running a nonprofit. Does that “unchecked greed” cause him to have a “conflicted conscience,” I wonder? Sources: https://www.nshss.org/blog/you-want-to-be-a-doctor-here-is-the-average-salary-for-each-medical-specialty/ https://www.nshss.org/blog/you-want-to-be-a-doctor-here-is-t... https://www.npr.org/sections/money/2014/10/16/356176018/the-most-popular-jobs-for-the-rich-middle-class-and-poor https://www.npr.org/sections/money/2014/10/16/356176018/the-... Page 18 for salary: https://pp-990.s3.us-east-1.amazonaws.com/2011_03_EO/38-3017223_990_201004.pdf?response-content-disposition=inline&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIA266MJEJYTM5WAG5Y%2F20230327%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20230327T051426Z&X-Amz-Expires=1800&X-Amz-SignedHeaders=host&X-Amz-Signature=dbe2858c899da827038cc49c32ef31473442b72e90c42192985acd3641c2f10b https://pp-990.s3.us-east-1.amazonaws.com/2011_03_EO/38-3017...
- malborodog 3y ago
  Link to the 990 dead — should have used archive.org or something.
ars 3y ago
"nor physician practices" And also physicians themselves. The fact that the article conspicuously skips that one ruins their entire narrative. To fix American healthcare a TON of people will lose their jobs, and a ton more will get a pay cut. There's no other way - it's simple math, if healthcare will be cheaper, then someone has to get less money. Just making the government pay for everyone at current rates is simply impossible, there's just not enough money. Costs must go down. Doesn't matter which you prefer: government plans, or private; costs must go down.
doodlebugging 3y ago
>Salve Lucrum, it reads, “Hail, Profit.” This could be the buzzwords for any Texas roofing contractors. The whole idea that systemic greed has created a situation where each patient has become a profit center that can be milked definitely fits the whole health care and senior care industries.
osigurdson 3y ago
I've never really understood the concept of "greed". Is it "greed" to want a yacht and helicopter when so many in developed nations struggle to own a home, a nice car and put their kids in good schools? Is it greed to want a house and a car when 100s of millions live in poverty? Is it greed to live at all given the inevitable harms to plants and animals that one will likely cause over their lifetimes? Therefore, the concept of greed seems fundamentally nihilistic to me. Many people are comfortable with their own level of greed, but uncomfortable with the next "level up" in wealth. In terms of healthcare, I think what is actually needed is more competition and less corruption.
- ravel-bar-foo 3y ago
  Aye. No problem with hospitals, insurance companies, doctors, or drug companies being greedy as long as they provide value. The problem is that over time the value received by the patient is dropping while the value extracted increases (as does the number of middlemen!). We have gotten to the point where the value proposition is highly questionable. I can drive to Mexico (or fly to the Bahamas) and get cheaper care, often even better care. The only thing that makes it worthwhile to stay in the US system is that one's employer shoulders the burden of insurance payments. In other sectors of the economy we call this vendor lock-in.
- pavlov 3y ago
  Corruption is a manifestation of greed. Competition is a mechanism that can regulate greed. We don’t need an absolute scale of greed to make relative judgments about it.
  - osigurdson 3y ago
    So, we just go on, using the word "greed" to elicit a nihilistic emotional response with no definition whatsoever.
- jgil 3y ago
  Greed is not the same as ambition. The difference is in ethical considerations and societal impact. Wanting a basic quality of life isn't a "level up," it's part of the human condition. It's not inherently greedy to seek a comfortable and secure existence for oneself and one's family. Usually, attaining that also benefits society by compound gains with education and productivity. An insurance company allegedly defrauding the US [1] and not even reading claims [2] before rejecting them is pretty clearly greedy IMO. I agree that there should be competition and less corruption, but the focus should be on accessible, high-quality care. [1] https://www.justice.gov/usao-sdny/pr/united-states-files-civil-fraud-lawsuit-against-cigna-artificially-inflating-its https://www.justice.gov/usao-sdny/pr/united-states-files-civ... [2] https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims https://www.propublica.org/article/cigna-pxdx-medical-health...
ravel-bar-foo 3y ago
Vested interests have succeeded in creating a system where the individual has almost no agency, but the individual's interests are not being served. If my primary care provider is too expensive or too inept, I should be able to seek out another. This does not happen, because my insurance company locks me into their network and hides the prices and complication rates. If my healthcare provider denies too many claims, I should find another. This does not happen because either my healthcare provider is selected by my employer, or the claim denial rates are obfuscated. If enough patients or insurance companies complain about drug prices, hospital administrators should negotiate with drug companies. This does not happen because until last year hospital administrators were able to take kickbacks from drug companies. At every level the patient is given minimal information and minimal choice. The only way to be guaranteed affordable care without billing surprises is medical tourism.

51 points by _lx4l 3y ago

I remember ADs on TV, actual ads, for catheters DECADES ago when I used to watch TV. The greed and grift on government programs isn't new; it's been around for my entire life. Competition is good, for time insensitive fungible things of comparable quality. It can also be good for a reverse dutch auction (within a geographic area) contract price (going rate for the year / timeframe) for a given number of procedures of a sort. I think the ACA (Obamacare) tried far too hard to reach a compromise and fell short. A singe player, taxpayer funded baseline medical care for all organized by by the government as a healthcare provider program is the only answer for a society where we agree everyone should have the right to medically necessary procedures so they can be productive members of society.

anovikov 3y ago
It doesn't matter if there's a single payer or not if supply is constrained and demand is skyrocketing. Solution is to make healthcare a branch of public service.

ngngngng 3y ago

I've generally been a very optimistic person, and even when surrounded by "doomers" I've avoided joining them. But I'm increasingly of the opinion that there is no smooth way to solve the problems we've created (and are currently creating). Housing is an example of this, medicine, feels like AI's impact on the economy will go this way. If there were a point where things got bad enough that we finally had the will to push for real change through normal political processes, we would have reached it years ago. Without being too dramatic, I don't see this ending well.

thejackgoode 3y ago
I started saying jokingly some time ago “this’ll get fixed after nukes”, I am not completely sure anymore this is a joke.
worik 3y ago
Me too. I would add the legal (some mislabel it "justice") system to the mix. With senior lawyers charging multiple thousands an hour, with such terrifyingly high stakes (especially in the criminal legal system) there is zero incentive for swift, and just, outcomes. All the incentives are to prolong the process.
- worik 3y ago
  And another thing. I studied Finance in a Univerity, and one of my professors taught me a joke. An in-joke: The customer's yacht. It is a joke because the customer cannot afford a yacht once we are through with him.
- donw 3y ago
  The process is the punishment. And then there's more punishment afterwards.
mrtesthah 3y ago
A majority of US citizens agree on the broad strokes of what's needed for political and economic progress; they are merely stymied at every opportunity, and systematically divided through propaganda, by those with extreme amounts of wealth and power. At a certain point in the very near future, it will become necessary to stop heeding the legal and ethical barriers which protect that power.
- ngngngng 3y ago
  > At a certain point in the very near future, it will become necessary to stop heeding the legal and ethical barriers which protect that power. I really wish I didn't agree with you. The people that said to keep your guns were right.
gremlinsinc 3y ago
I feel people could circumvent political control if they banded together... Like imagine if thousands pooled money to build tiny home communities and then rent that out to people for like $140/month/family member. If you have a large family we just stack two tiny homes side-by-side. Or imagine if a bunch of co-ops formed that built SaaS products/etc and used 100% of the money to expand the business, and build mutual aid networks and eventually buy up hospital assets like urgent cares etc... Then charged much more for insured because they can afford to pay, and gave it free to uninsured under certain income limits. Basically a big union of worker co-ops pooling resources to build bigger and better systems that are all aligned. There may even be competitors between the co-ops but they're not competitive to the point of disrupting ecosystems and destroying the planet like unchecked corps like Dupont or something.

DaveExeter 3y ago

The problem is health insurance. If we got rid of health insurance, prices would necessarily drop to levels where patients could simply pay for health services. That's how it used to work. I've seen invoices from the 50s where the cost to deliver a baby is $200. $100 for the doctor, $100 for the hospital. With a 10x inflation adjustment, that's $2,000 total. That was enough money to deliver a baby in the 50s.

ngngngng 3y ago
For added context, with really good insurance I've paid about $4000 for both of my children. That's just out of pocket cost, of course I pay very high premiums and my company covers a large portion of the cost themselves. Both of these births were very standard, no complications. The profit margin there is insane.
worik 3y ago
Really? An operating theatre cost many thousands of dollars an hour to run, the pre and post care is also very expensive. You may never need them (I hope you do not) but if you do it would almost surely bankrupt you without either socialised medicine (yay - sort of - another story) or insurance.
- runamok 3y ago
  Most other countries are around what he is talking about ($2.5k to $4k) whereas the US > $10k. https://www.insider.com/costs-giving-birth-around-the-world-2018-7 https://www.insider.com/costs-giving-birth-around-the-world-... Certainly when things go wrong it can get more costly but the US consistently costs 2 to 3x more for everything AND usually has worse health outcomes. US maternal mortality is an embarrassment: https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020... .
- glass3 3y ago
  The markets don't work if delivering a child leads to bankruptcy. Either people pay for unnecessary procedures or those procedures cost too much.

BigCryo 3y ago

Is that what I find amazing is that Americans, especially older americans, have not caught on to the fact that apparently the government and the insurance companies colluded to make Medicare confusing.. in order to drive senior citizens into the arms of the insurance companies because they can't figure out what's going on with the Medicare situation

ngngngng 3y ago
To be frank, you don't have to look long to find ample evidence of our government being a disaster. COVID is fresh in everyone's minds and everything about that situation was horrifically mismanaged. We all know the healthcare situation is terrible but the main politicians that want to change this offer 100% government controlled single payer healthcare as the only solution. That would take us from the least socialized system in the world, to literally the most socialized system in the world. I don't think you have to try very hard to imagine why people are uncomfortable with that. Edit: Never make one slight error on HN or your entire point is invalid, it would be one of the most socialized by the legislative proposals, but not literally the most.
- worik 3y ago
  > , to literally the most socialized system in the world. Well there is Cuba. The best health system in the world, many say.
  - whitemary 3y ago
    During the heights of the pandemic, the Cuban health system sent over 2,000 doctors to 23 of the most affected countries. No other country sent nearly that many doctors elsewhere, and Cuba is a tiny place!
- bradleyjg 3y ago
  That would take us from the least socialized system in the world, to literally the most socialized system in the world. Single payer is “less socialist” than the UK system that has many of the healthcare providers working directly for the government. Likewise, the US is not the “least socialist” today. In Nigeria most people just pay out of pocket for healthcare.

mrosett 3y ago

Ok, apologies for a slightly irritated tone, but this touched a nerve. Of course the author is an MD who doesn’t mention the extremely high salaries paid to physicians in this country, instead acting like they’re somehow victims of high healthcare costs rather than the primary beneficiaries: > Perhaps the demoralization of professionals, the conflicted consciences of many executives, and the anger of the public represent potential political energy that, with proper leadership, can become kinetic. > First, health care professionals in all disciplines need to become noisier about the conflict between unchecked greed and the duty to heal. Extortionate drug prices, exploitation of market consolidation, coding games, excessive executive compensation, and promulgation of unnecessary care ought not to be met with silence. Silence is assent. The median salary for a specialist physician in the US is $346k. Orthopedic surgeons clear north of half a million on average. As a result, “physician” is the most common profession profession among the richest 1%. Note that this didn’t happen by accident. Groups like the AMA lobby for policies that keep supply low and salaries high. The one time that legislation threatened to reduce physician salaries, Congress passed the infamous “doc fix” Mind you, residency sucks and many doctors are wonderful, so I mostly don’t begrudge them their pay. But if you’re complaining about the cost of healthcare and mention literally every group except the one you belong to, perhaps you’re being the slightest bit disingenuous. As for the author, he earned $889,484 back in 2009 running a nonprofit. Does that “unchecked greed” cause him to have a “conflicted conscience,” I wonder? Sources: https://www.nshss.org/blog/you-want-to-be-a-doctor-here-is-the-average-salary-for-each-medical-specialty/ https://www.nshss.org/blog/you-want-to-be-a-doctor-here-is-t... https://www.npr.org/sections/money/2014/10/16/356176018/the-most-popular-jobs-for-the-rich-middle-class-and-poor https://www.npr.org/sections/money/2014/10/16/356176018/the-... Page 18 for salary: https://pp-990.s3.us-east-1.amazonaws.com/2011_03_EO/38-3017223_990_201004.pdf?response-content-disposition=inline&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIA266MJEJYTM5WAG5Y%2F20230327%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20230327T051426Z&X-Amz-Expires=1800&X-Amz-SignedHeaders=host&X-Amz-Signature=dbe2858c899da827038cc49c32ef31473442b72e90c42192985acd3641c2f10b https://pp-990.s3.us-east-1.amazonaws.com/2011_03_EO/38-3017...

malborodog 3y ago
Link to the 990 dead — should have used archive.org or something.

ars 3y ago

"nor physician practices" And also physicians themselves. The fact that the article conspicuously skips that one ruins their entire narrative. To fix American healthcare a TON of people will lose their jobs, and a ton more will get a pay cut. There's no other way - it's simple math, if healthcare will be cheaper, then someone has to get less money. Just making the government pay for everyone at current rates is simply impossible, there's just not enough money. Costs must go down. Doesn't matter which you prefer: government plans, or private; costs must go down.

doodlebugging 3y ago

>Salve Lucrum, it reads, “Hail, Profit.” This could be the buzzwords for any Texas roofing contractors. The whole idea that systemic greed has created a situation where each patient has become a profit center that can be milked definitely fits the whole health care and senior care industries.

osigurdson 3y ago

I've never really understood the concept of "greed". Is it "greed" to want a yacht and helicopter when so many in developed nations struggle to own a home, a nice car and put their kids in good schools? Is it greed to want a house and a car when 100s of millions live in poverty? Is it greed to live at all given the inevitable harms to plants and animals that one will likely cause over their lifetimes? Therefore, the concept of greed seems fundamentally nihilistic to me. Many people are comfortable with their own level of greed, but uncomfortable with the next "level up" in wealth. In terms of healthcare, I think what is actually needed is more competition and less corruption.

ravel-bar-foo 3y ago
Aye. No problem with hospitals, insurance companies, doctors, or drug companies being greedy as long as they provide value. The problem is that over time the value received by the patient is dropping while the value extracted increases (as does the number of middlemen!). We have gotten to the point where the value proposition is highly questionable. I can drive to Mexico (or fly to the Bahamas) and get cheaper care, often even better care. The only thing that makes it worthwhile to stay in the US system is that one's employer shoulders the burden of insurance payments. In other sectors of the economy we call this vendor lock-in.
pavlov 3y ago
Corruption is a manifestation of greed. Competition is a mechanism that can regulate greed. We don’t need an absolute scale of greed to make relative judgments about it.
- osigurdson 3y ago
  So, we just go on, using the word "greed" to elicit a nihilistic emotional response with no definition whatsoever.
jgil 3y ago
Greed is not the same as ambition. The difference is in ethical considerations and societal impact. Wanting a basic quality of life isn't a "level up," it's part of the human condition. It's not inherently greedy to seek a comfortable and secure existence for oneself and one's family. Usually, attaining that also benefits society by compound gains with education and productivity. An insurance company allegedly defrauding the US [1] and not even reading claims [2] before rejecting them is pretty clearly greedy IMO. I agree that there should be competition and less corruption, but the focus should be on accessible, high-quality care. [1] https://www.justice.gov/usao-sdny/pr/united-states-files-civil-fraud-lawsuit-against-cigna-artificially-inflating-its https://www.justice.gov/usao-sdny/pr/united-states-files-civ... [2] https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims https://www.propublica.org/article/cigna-pxdx-medical-health...

ravel-bar-foo 3y ago

Vested interests have succeeded in creating a system where the individual has almost no agency, but the individual's interests are not being served. If my primary care provider is too expensive or too inept, I should be able to seek out another. This does not happen, because my insurance company locks me into their network and hides the prices and complication rates. If my healthcare provider denies too many claims, I should find another. This does not happen because either my healthcare provider is selected by my employer, or the claim denial rates are obfuscated. If enough patients or insurance companies complain about drug prices, hospital administrators should negotiate with drug companies. This does not happen because until last year hospital administrators were able to take kickbacks from drug companies. At every level the patient is given minimal information and minimal choice. The only way to be guaranteed affordable care without billing surprises is medical tourism.