Breakdown of Incentive for Doctors Re: Universal Healthcare?

[Patroklos]

Why are we pretending life expectancy and quality of life have only one input?

[madd0ct0r]

Well, either it's not strongly linked, in which case the USA is paying ridiculous amounts for something that is ineffective, or it is strongly linked, in which case the usa's huge spend is making up for an even larger level of unhealthiness. I'm aware of the usa's trailblazing obesity and syndrome X, but no amount of statistical juggling of factors will make health expenditure per capita look reasonably in line with the rest of the developed world.

[Simon_Jester]

So yeah, maddoc is right. Either the US is wasting money on health care which is useless to quality of life in general... or the US is right to spend money on health care but is doing something horribly, horribly wrong.

CATO idiots.

That would be interesting to read as a scatter plot.

[K. A. Pital]

I live to serve.

[Elheru Aran]

So in short terms, that graph basically means the US spends the most per capita, but their life expectancy isn't quite as high as some other nations that spend less? Yet the life expectancy isn't *terribly* different from Singapore-Japan-Switzerland (and I assume most Western nations). The only thing that makes the US stand out so much is the outrageous amount that apparently they're spending.

Also, what the heck are 'International Dollars'? (Honest question, never heard the term before)

[K. A. Pital]

Yeah, it means the US spends like 3 times more than many other nations with a similar life expectancy. Bear in mind the US isn't even remotely as absurdly rich, wages-wise, as Switzerland. International dollars simply mean that this is PPP-adjusted expenses to take into account the purchasing power of local currency.

[Fingolfin_Noldor]

So yeah, maddoc is right. Either the US is wasting money on health care which is useless to quality of life in general... or the US is right to spend money on health care but is doing something horribly, horribly wrong.

Well, many hospitals don't use generics for starters. I know when I was up in the U of Michigan, Ann Arbor, they gave generics at clinics. But that did not hold true in UCF in Florida.

A good portion of the world has no qualms to use generics. Essentially, fuck the big pharma companies.

[Napoleon the Clown]

From what reading I've done on US health care costs, the factors basically come down to massive student loan debt putting the pinch on doctors, no price controls to speak of, extra expenses incurred by dealing with the enormous number of health insurance companies, and a pathological need for the "latest and greatest" in equipment. Obviously, there are other factors involved as well. But those are the biggest ones, based off the stuff I've read. Another contributing factor, historically, has been people not being able to pay for their ER visits. Which pushes the costs off on everyone else. Socialized medicine can help remedy several of these things all on its own. Free college would help as well.

Basically every aspect of US health care is ultimately controlled by a for-profit group. Even if the hospital you go to is not for-profit, the suppliers of their equipment are. Even if everyone on staff went to a not-for-profit school, most will have taken on student loan debts that are for-profit. Drug companies are all for-profit and the only restriction on their products is that they be safe-ish and do what they say. They can charge you as much as they think you'll pay, they can run ads on TV trying to convince you that you must take this pill or you will die. They can send reps to doctors to convince them "Prescribe this to your patients!" and put up ads all over the office for their drugs.

So you get a situation where even the most honest doctors can't do that much to save you money. Getting supplies is expensive. Getting an education is expensive. Malpractice insurance is expensive. Dealing with insurance is expensive. Each insurance company does things different, and if they decide to fight you on an expense it'll take extra time before you see your money. You'll have to pay someone to deal with the insurance company, to deal with the patient that's absolutely livid about the insurance not paying what it's supposed to. Our entire health care system is fucked over by the people that sell them supplies and manufacture our drugs. Because free market.

[Darmalus]

I'd love to know how much of that extra 200% the USA pays winds up in the hands of insurance companies.

Generics are interesting. Most medicines don't cost that much to produce once you know what you are doing, but finding out what you are doing costs billions. So brand names cost loads to make up for research costs, but generics are cheap since they just need to wait for someone else to do the research.

[Elheru Aran]

Bear in mind that in some areas, antibiotics especially, generics can be a problem as drug-resistant bacteria keep evolving resistance to one antibiotic over another. Generic Penicillin isn't going to help if you've got an penicillin-resistant bug, so you have to then bump up to a different antibiotic... which may not be a generic.

And of course the brand name drugs do remain in the control of the company that creates them for a certain period-- something like 20 years? IIRC (could certainly be wrong). So even once a brand name comes out, it's still going to be a while before the generic version comes out, at least in countries which prohibit making generics while the pharma is still holding the rights to that formulation.

[Darmalus]

Bear in mind that in some areas, antibiotics especially, generics can be a problem as drug-resistant bacteria keep evolving resistance to one antibiotic over another. Generic Penicillin isn't going to help if you've got an penicillin-resistant bug, so you have to then bump up to a different antibiotic... which may not be a generic.

And of course the brand name drugs do remain in the control of the company that creates them for a certain period-- something like 20 years? IIRC (could certainly be wrong). So even once a brand name comes out, it's still going to be a while before the generic version comes out, at least in countries which prohibit making generics while the pharma is still holding the rights to that formulation.

Yup, 20 years. The average cost for a new drug is approaching 6 billion, which includes the cost of research programs that get no results. I imagine this rather distorts research, since the accountants aren't even going to let you start research unless you can prove your drug is going to generate at least 300 million in profit per year just to break even.

[Elheru Aran]

Is that just in the US? Do similar circumstances apply to drug research elsewhere? I imagine there's a bit less incentive due to less potential for grotesque amounts of money being made, but on the other hand, less need to *make* grotesque amounts of money...

6 billion is fucking absurd though. I understand developing a drug takes time and money, but come the fuck on. Pharmaceuticals shouldn't be about making money.

[K. A. Pital]

I'd love to know how much of that extra 200% the USA pays winds up in the hands of insurance companies.

[Elheru Aran]

It just skyrockets right there before 2000, doesn't it? Shit. Could you put up some comparables from other countries (if you have the time, of course)?

[Darmalus]

Is that just in the US? Do similar circumstances apply to drug research elsewhere? I imagine there's a bit less incentive due to less potential for grotesque amounts of money being made, but on the other hand, less need to *make* grotesque amounts of money...

6 billion is fucking absurd though. I understand developing a drug takes time and money, but come the fuck on. Pharmaceuticals shouldn't be about making money.

The low hanging fruit has largely been picked dry, and human and animal tries are staggeringly expensive. Unless a chemical/human body modeling software miracle happens it's probably only going to keep going up.

Keep in mind 19 out of 20 new drugs fail and can't be sold. So while any specific drug will only have on average an R&D cost of 300 million, it also has to make up for the R&D costs of the 19 failures too.

http://www.forbes.com/sites/matthewherp ... -medicine/

[Gaidin]

Is that just in the US? Do similar circumstances apply to drug research elsewhere? I imagine there's a bit less incentive due to less potential for grotesque amounts of money being made, but on the other hand, less need to *make* grotesque amounts of money...

6 billion is fucking absurd though. I understand developing a drug takes time and money, but come the fuck on. Pharmaceuticals shouldn't be about making money.

Which interconnected part of healthcare should we let profit then? Wireless engineering? Surgically implanted microprocessors with settings updated via near-field magnetic induction are being developed for both the head and heart and other areas now. How do engineering companies keep going? Assuming approval by both the FCC and FDA, by the way, these things don't get used often. That means we can assume a baseline price of at least five figures just to have a shot at breaking even in a non-profit, forget profit. That's installation. Not down the road maintenance(that's right...batteries go dry...out-patient surgery every few years).

Should we just let companies collapse into bankruptcy because research and development is no longer even gambling on if something can be made to work, because even if it can be made to work, you're just not getting your money back?

But if we let one medical R&D field work... Thing is, the research is just exploding. And across all different fields. It's not going anywhere, and nor is the pricetag for it. Either because we, as noted, lack the simulation capability, or not as many people need it, or both.

Now another question is how much an institute like the NIH would be in backing what might be standard R&D if they had the funding and thus taking some of this load off. But...hell, god knows how you'd shift that around. Or convince the people at large that such funding would be good for them in an indirect fashion.

[Fingolfin_Noldor]

Is that just in the US? Do similar circumstances apply to drug research elsewhere? I imagine there's a bit less incentive due to less potential for grotesque amounts of money being made, but on the other hand, less need to *make* grotesque amounts of money...

6 billion is fucking absurd though. I understand developing a drug takes time and money, but come the fuck on. Pharmaceuticals shouldn't be about making money.

Which interconnected part of healthcare should we let profit then? Wireless engineering? Surgically implanted microprocessors with settings updated via near-field magnetic induction are being developed for both the head and heart and other areas now. How do engineering companies keep going? Assuming approval by both the FCC and FDA, by the way, these things don't get used often. That means we can assume a baseline price of at least five figures just to have a shot at breaking even in a non-profit, forget profit. That's installation. Not down the road maintenance(that's right...batteries go dry...out-patient surgery every few years).

Should we just let companies collapse into bankruptcy because research and development is no longer even gambling on if something can be made to work, because even if it can be made to work, you're just not getting your money back?

But if we let one medical R&D field work... Thing is, the research is just exploding. And across all different fields. It's not going anywhere, and nor is the pricetag for it. Either because we, as noted, lack the simulation capability, or not as many people need it, or both.

Now another question is how much an institute like the NIH would be in backing what might be standard R&D if they had the funding and thus taking some of this load off. But...hell, god knows how you'd shift that around. Or convince the people at large that such funding would be good for them in an indirect fashion.

Yeah... but a lot of funding happens to be from the US government. At some point, we should start asking how much do we want to monetise the system, or should it be non-profit as a whole?

[Broomstick]

So yeah, maddoc is right. Either the US is wasting money on health care which is useless to quality of life in general... or the US is right to spend money on health care but is doing something horribly, horribly wrong.

Well, many hospitals don't use generics for starters. I know when I was up in the U of Michigan, Ann Arbor, they gave generics at clinics. But that did not hold true in UCF in Florida.

A good portion of the world has no qualms to use generics. Essentially, fuck the big pharma companies.

Big pharma frequently supplies name-brand drugs to US hospitals at a steep loss, because then, when patients go home, they think "I want what I had in the hospital - the hospital uses it, so it must be the best". That's how Tylenol brand pain reliever got to be the "#1 used by hospitals!" They were supplying it to hospitals at below cost. Catchy line, has made a lot of sales for Tylenol brand over the years.

Source of this information: my dad the pharmacist, my brother-in-law the pharmacist, my niece the pharmacist, and my sister the doctor. Dad also used to work for the drug makers before he went into hospital work, so he's seen both sides of it.

[Fingolfin_Noldor]

Big pharma frequently supplies name-brand drugs to US hospitals at a steep loss, because then, when patients go home, they think "I want what I had in the hospital - the hospital uses it, so it must be the best". That's how Tylenol brand pain reliever got to be the "#1 used by hospitals!" They were supplying it to hospitals at below cost. Catchy line, has made a lot of sales for Tylenol brand over the years.

Source of this information: my dad the pharmacist, my brother-in-law the pharmacist, my niece the pharmacist, and my sister the doctor. Dad also used to work for the drug makers before he went into hospital work, so he's seen both sides of it.

In which case, they often supply hospitals outside the US at an even steeper cost because of collective bargaining. Mind you, if not for generics, I highly doubt it would be supplied below cost.

[PainRack]

Bwahahahahahahaha!!!!!!


Right. Attempts to switch from fees for services where doctors get paid by how much they do to diagnosis/incident basis and the current shift to outcome basis is a 'cancer' in medicine thats driving away doctors because they are now forced to you know, obey evidence based practices and do everything within a fixed budget to get the best outcomes, instead of previously, where there isnt any finanicial incentive to get you better, meaning the free market is incentivised not to get you better or more accurately, spend a lot of time and money NOW so that you wont be sicker later.

We can argue whether which model works better, but if we let physicians charge whatever they want on basis of autonomy, google Susan Lim Singapore.

[PainRack]

From what reading I've done on US health care costs, the factors basically come down to massive student loan debt putting the pinch on doctors, no price controls to speak of, extra expenses incurred by dealing with the enormous number of health insurance companies, and a pathological need for the "latest and greatest" in equipment. Obviously, there are other factors involved as well. But those are the biggest ones, based off the stuff I've read. Another contributing factor, historically, has been people not being able to pay for their ER visits. Which pushes the costs off on everyone else. Socialized medicine can help remedy several of these things all on its own. Free college would help as well.

The real costs is that while demographics for Americans are good, a staggering larger number of baby boomers are getting older.

That means more Americans are likely to get sick and the costs of maintaining good QOL and etc are spiralling upwards as standards change. Some might be mitigated. For example, in the past and currently in India, they use less imaging and rely more on physicals n etc to get information, but those come at other human costs like longer stays and etc.

The current standards are totally different than in the past and these things cost money. In the past,you wouldnt routinely give stockings or anticoagulants post op, but now we do to reduce the risks of complications and shorten stay.

You wouldnt get PT or etc in to mobilise mothers post birth because the idea was let them rest! Say, why are so many women dying from DVT after pregnancies...


The rest comes from the strange economic factors in the US, where labour,equipment,drugs are expensive and despite attempts by HMO to coordinate care to improve outcomes,any impact was temporary.


So now, the government is saying fine. We HIT doctors,hospitals and other service providers in the pocket through the ACA. Its your job now to coordinate this care or you lose money.

Attempts to shift this to patients can choose the best,cheapest care for themselves is nonsense. If compliance was so easy and effective, why the hell is anyone still smoking?

[kc8tbe]

Keep in mind 19 out of 20 new drugs fail and can't be sold. So while any specific drug will only have on average an R&D cost of 300 million, it also has to make up for the R&D costs of the 19 failures too.

This is technically true (although maybe closer to a 10% success rate for drugs that actually make it to phase 1 trials). However, it is also true that pharmaceutical companies have huge profit margins and actually spend more money on marketing than on research & development, see this BBC article from 2014. Also, did you know that the USA the only country besides New Zealand to allow direct-to-consumer pharmaceutical advertising (i.e. "Ask your doctor about Viagra!")?

http://www.bbc.com/news/business-28212223?

[mr friendly guy]

So in short terms, that graph basically means the US spends the most per capita, but their life expectancy isn't quite as high as some other nations that spend less? Yet the life expectancy isn't *terribly* different from Singapore-Japan-Switzerland (and I assume most Western nations). The only thing that makes the US stand out so much is the outrageous amount that apparently they're spending.

Also, what the heck are 'International Dollars'? (Honest question, never heard the term before)

International dollars is the unit used when we use GDP purchasing power parity. To make this short, there are two ways to compare the size of economies. One is GDP nominal and the other GDP purchasing power parity. The first one simply looks at the GDP of two nations, which would be measured in their respective currencies and converted to the US dollar for ease of comparison. PPP tries to convert it but takes into account cost of living and some economists argue its a better marker than simply converting exchange rates. The new unit is called international dollars. To better explain it, lets take a look at the example below.

Lets take three hypothetical nation states, lets say China the Klingon Empire, USSR The Romulan Star Empire and the USA United Federation of Planets. Their economies are measured in Klingon energy credits, Federation EC and Romulan EC respectively. The Klingons trade with the UFP, while the Romulans are isolationists (economically speaking, the believe in autarky and rarely trade outside their borders). The size of the Klingon economy is 1000 Klingon Energy units and the Federations is 1000 UFP energy credits. The average exchange rate for that given year is 1 Klingon EC to 0.5 Federation EC. So on exchange rates basis the Klingon Empire will have an economy of 500 UFP energy credits, or 50% the size of the UFP economy.

Now lets compare the Romulans with the UFP. Unfortunately the Romulans did not trade with the UFP, so there isn't any exchange rate mechanism we can use. However we can have a look at what they can produce based on their GDP. Fortunately with Federation intelligence agents we know the Romulans production capabilities, and if they devoted all their GDP into ship production they can make 30% of the ships the UFP can if the UFP devoted all their GDP to ship building, (assume that all ships between the nations are equivalent in tonnage and capability for ease of comparison). So we say the Romulans have an economy roughly 30% the size of the UFP. This is an example of using purchasing power parity to compare economies.

Now someone notes that the cost of living in the Klingon Empire is lower, and that taking exchange rates might not be an ideal way of comparison. Lets say we look at Klingon ship building. Sure their economy in nominal terms is only 50% of the UFPs, but ship building is much cheaper. We now find that for every 100 ships the Federation churns out, the Klingons can churn out 101 ships (again assume equivalent ships). So in purchasing power parity terms, the Klingons have an economy 1% bigger than the Federation.

Now I have only used one metric (shipbuilding) but economists use numerous metrics when converting an economy into PPP terms, and I used one metric just to illustrate the point.

The numbers I have used in economy size roughly corresponds to the relationships between China, the US in 2014, and the USSR to the US during cold war times. When you convert a nations GDP to purchasing power parity, the units change from US dollars to international dollars. For the US their economy in USD and international dollars stay the same in numbers. So if the US economy is 18 trillion USD its 18 trillion international dollars. For other nations like China, they can change quite a bit (going up) while the EU goes down reflecting its higher cost of living (so it has a larger number in GDP nominal than in GDP purchasing power parity).

Presumably the graph uses international dollars instead of USD, to take into account cost of living expenses. Two countries could spend the equivalent in USD in health budget, but the one with lower cost of living, the money would go further, while the one with the higher cost would have the opposite effect.

[Me2005]

Bear in mind that in some areas, antibiotics especially, generics can be a problem as drug-resistant bacteria keep evolving resistance to one antibiotic over another. Generic Penicillin isn't going to help if you've got an penicillin-resistant bug, so you have to then bump up to a different antibiotic... which may not be a generic.

Add to the problem: I saw a (PBS?) report on how pharmaceutical companies are no longer pursuing antibiotics research. It's too expensive for them to do, and the use isn't frequent enough to ever recover the substantial cost. So we're getting super bugs with no foreseeable cure.

To some of the OP issues: The whole system is busted as-is, and the government isn't helping by passing laws requiring more interference. If we want to go socialized, I think we'd need to treat medical professionals as essentially military forces.

[biostem]

I think there are a couple of factors that affect where the "good" doctors go:

1. If someone becomes a doctor "just" to get rich, then I think they are destined to not put their patients first, (unless doing so directly benefits their income). I fully admit that this can be a strawman position - realistically, I expect doctors to at least be ethical enough to realize that they must care for their patience at least a little.

2. Malpractice is a huge issue - yes, doctors should absolutely be held accountable for negligence or simply cutting corners, but frivolous lawsuits need also be strongly deterred/punished. No treatment is 100% effective, and a person may not get the result they want, even with the best doctor(s).

3. The "society" or "culture" of medicine needs to be overhauled - there is a tendency to over prescribe medications, (partly due to people wanting a magic bullet for their ailment, and partly due to pharmaceutical companies wanting to bolster their bottom line). There are also issues with medical workers, like nurses or orderlies, working way too many hours, or facilities being short staffed, which in turn can lead to mistakes being made, thus impacting #2 above.

4. You can also partly address this issue via some reform in the law - like maybe require doctors who have a private practice to serve X amount of hours in a regular hospital, or to otherwise retain some association thereof. You can also offer something like merit-based free medical schooling - have special pre-med entrance exams, and if the test takers do well enough, offer free medical schooling, provided they maintain their strong performance and agree to serve in a state or other municipal hospital for X number of years.

I do not think, though, that you can ever remove the problem - there's always going to be "somewhere else" where someone's skills can garner them more profit. The best you can do is to make *not leaving* as attractive as possible. Overbearing laws or regulations can retain doctors to only a small degree, and even then, you'll run into situations where things like bedside manner suffer because of said doctors being dissatisfied with the situation they've found themselves in. I don't know if it's even possible, but is there some way that, as part of their education, a doctor's sense of caring or attachment for the place they're in, could be bolstered? I don't really see how you can make doctor's not care about getting better pay or the like - they are human, after all...