[HN Gopher] The Greedy Doctor Problem
___________________________________________________________________
The Greedy Doctor Problem
Author : ignored
Score : 116 points
Date : 2021-11-18 20:20 UTC (1 days ago)
(HTM) web link (universalprior.substack.com)
(TXT) w3m dump (universalprior.substack.com)
| teekert wrote:
| I think most countries with a civilized, social and sustainable
| healthcare system do this, right?
|
| Maybe this is the kind of market that can never be free, because
| you can never step away from a deal, as the alternative is often
| death. As such perhaps in these matters we should just have some
| faith in humanity. You know, it works for a lot of open source
| software. Capitalism is not a silver bullet, people have a
| consciousness for a reason, use it, have faith in it. You will
| see that that is the exact thing that will make it flourish.
|
| Btw, all "solutions" would piss me off as a doctor that just
| wants to help. The vast majority of people deserve and want to be
| trusted. We work better that way. What a cold piece.
| dasudasu wrote:
| Many countries with universal healthcare still pay by the act.
| In Canada, doctors are mostly independent service providers
| that bill the government directly. This can lead to two
| problems: a) they don't do a whole lot of medical acts because
| it already pays so well that they can afford to slack off
| (e.g., work 3-4 days a week, see very little patients), or b)
| do a lot of unnecessary acts because it goes directly into
| their pockets.
| belval wrote:
| Yep and it's a pretty big issue actually as it creates a lot
| of abuse in the system, doctors mostly interested in smaller
| "easier" acts that they are known to pay well, doctors
| getting referrals from a clinic outside of their
| administrative region (those pay more), and of course
| radiologists working 2-3 days a week because their acts are
| even better remunerated.
|
| Add on top that by being independent, doctors will have their
| own company and be subjected to a much lower tax rate than a
| "normal" person earning 400k$/year.
| rectang wrote:
| It's clear why performing unnecessary medical acts is
| problematic, but what is the issue if doctors being paid by
| the act work 3-4 days a week? Isn't this just piece work and
| you can add more doctors?
| dasudasu wrote:
| Because the supply of medical doctors in most countries
| including Canada is heavily constrained. People are wary of
| opening the flood gates because it is expected that the
| quality of care would drop (not necessarily a good
| argument). Meanwhile, there is a huge access issue with
| long wait times at the ER or for seeing specialists. A
| large proportion of the population has no family doctor.
| dahfizz wrote:
| The median wait time to see a specialist in canada is 78
| days[1].
|
| Yes, in theory you could "just add more doctors". But there
| is clearly already less doctors than there needs to be.
| Policy that encourages doctors to work less exacerbates
| this issue.
|
| You can't just say "add more doctors" as if that helps
| anything. Shortages exist for a reason, and analyzing and
| fixing the system which creates the shortage is the only
| way to resolve the shortage. You can't just tell poor
| people to "make more money" and solve poverty in the blink
| of an eye.
|
| [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292524/
| vanviegen wrote:
| > You can't just say "add more doctors" as if that helps
| anything.
|
| Why wouldn't it?
|
| There are more than enough people who would want to
| become a doctor, and would be capable. _Especially_ if
| the work /life balance would be better. At least in my
| part of the world, it seems that the system is rigged to
| keep the number of docters artificially low.
| dahfizz wrote:
| > Why wouldn't it?
|
| I explained in my comment: There is a shortage of
| doctors. Unless you know 50,000 people with medical
| degrees searching for a job, you are going to have to fix
| the situation that created the shortage rather than just
| wishing more doctors would appear.
|
| This is what dasudasu was doing. They identified a cause
| of the shortage (doctors are encouraged to work 60% of a
| work week) and your response was "so what, more doctors
| will just appear". More doctors have not been appearing.
| klyrs wrote:
| Yeah, that sounds ideal to me. I _hate_ seeing stressed
| out, rushed medical professionals. In part, that 's selfish
| -- they aren't doing their best work. But also, they set a
| terrible example to their patients by ignoring the impact
| of overwork on their own physical and mental health.
|
| Less overwork results in better care, and more jobs. I'm
| all for it.
| [deleted]
| dang wrote:
| Please don't take HN threads into generic flamewar, and please
| particularly keep off the nationalistic flamebait track.
|
| We detached this subthread from
| https://news.ycombinator.com/item?id=29270645.
| throwaway14356 wrote:
| odd that there is no mention of the traditional Chinese model
| where the doctor gets paid only if you are healthy
| Aaargh20318 wrote:
| The article does mention that: "If you pay them whenever you
| are diagnosed as healthy, they will diagnose exactly that."
| goopthink wrote:
| The article proposes prepayment options. Why not go to the
| "other, other obvious" solution, which is results-based payments?
| In healthcare, that's value-based care. In other industries w/
| agent-principle problems, it's called "taking on risk". You're
| incentivizing results and outcomes, rather than whatever specific
| actions lead up to those results. It means that the focus is no
| longer on the activity provided by the agent, but on the desired
| outcomes from the principle. Pure alignment and it helps filter
| out those who are good at getting results from those who are good
| at doing the actions.
| snarf21 wrote:
| This is such an awful take. So if a doctor prescribes a
| medicine and the patient never takes it and the patient dies it
| is somehow the doctor's fault or they don't get paid?
|
| Some doctors are greedy. Some ________ are greedy. There are
| major factors in the waste in our health care system but by and
| large it isn't doctor's fees. There are so many rent seekers
| taking a cut.
|
| There are other models than fee-for-service. They have tried
| population health models where the Provider (Dr, nurse, etc.)
| get $X per person per year. They are incentivized to be more
| preventative where they basically get to keep whatever they
| don't spend on patient care. However, you can lead a horse to
| water but can't make him drink. Ask yourself this: would you
| write web code where you got paid based on how many unique
| visitors viewed the page your wrote?
|
| We can easily fix health care with a few simple changes but
| there is no real appetite to do so. One simple change is to go
| to referenced based pricing. You can't charge more than 1.2 the
| Medicare reimbursement. This change alone would reduce our
| spending by 25%.
| rsj_hn wrote:
| > One simple change is to go to referenced based pricing. You
| can't charge more than 1.2 the Medicare reimbursement.
|
| Agree that this is huge. Price transparency, reference
| pricing. You know "the law of one price" is supposed to be a
| pillar of market economics, so this should be a no-brainer.
| Additionally, don't allow charging more than the insurance
| will pay with the exception of an agreed upon co-pay ahead of
| time. If a hospital accepts insurance, then it shouldn't be
| able to send you a bill later on that the insurance refuses
| to pay. That needs to be worked out between the hospital and
| the insurer. I would also like to see binding quotes before
| any procedure, with no surprise billing.
| sokoloff wrote:
| Most of us have been in a codebase for an issue that turns
| out larger or more complex than first understood. I don't
| want to undergo surgery for cancer X, have the surgeon see
| nearby, related cancer Y and sew me back up and tell me I
| also have cancer Y but that he didn't want to go over the
| estimate.
|
| When asked for a choice by a medical professional (or a
| home improvement contractor for that matter), I will more
| often than not ask "if you were in my shoes, what would you
| do?" I don't 100% of the time go with what they say, but I
| think it helps me understand their expertise and judgment
| better.
|
| In the surgical case above, if the surgeon would have taken
| it out and given me a single recovery experience and told
| me about the bill when I woke up, I'm probably better off
| for it.
| rsj_hn wrote:
| So in a surgery situation where you are under and
| something else is discovered, then that's a situation of
| unexpected costs. So you look to who is best able to bear
| them and that's who bears them. What exactly is the
| purpose of insurance if they do not cover you from
| unexpected costs? And if there is no insurance (say a
| cash procedure), then the hospital bears the cost and
| bakes the possibility of complications into the price.
|
| Point is, you need clarity of prices rather than the
| situation today where you sign a promise to pay whatever
| costs the hospital decides to charge you, and you may not
| even know what those are until weeks after the procedure.
| There is no meaningful way a market can operate under
| conditions in which blank checks are demanded in order to
| get anything done.
|
| If that can't work, and the hospital insists it cannot
| quote you a cost at all, then go full socialized
| healthcare since obviously no market is possible.
| snarf21 wrote:
| And then you have the current bs where the anesthesiologist
| for your operation at the hospital system that you always
| use is somehow un-affiliated and out of network even if
| everything else in that system is in network.
| kwhitefoot wrote:
| > Why not go to the "other, other obvious" solution, which is
| results-based payments?
|
| There is a story about doctors in ancient China who are paid by
| their clients only so long as the client is healthy. When they
| fall sick, the doctor is not paid again until the patient is
| healthy again. Then the goal is not a cure for a disease but
| the prevention of disease.
|
| I don't know if any such thing ever really happened but it
| seems like it might be worth exploring even if only to
| illuminate the various possibilities.
| themacguffinman wrote:
| I think this only works if there's a scarcity of patients but
| it's rarely true that patients are rare. This will probably
| suffer from the real estate agent problem: in theory, real
| estate agents are incentivized to get you the best price
| because they get a cut for their efforts, but in practice
| it's more lucrative for them to flip more houses than put in
| the extra effort into your case. Likewise, I suspect doctors
| will find it easier & cheaper to not care about you and just
| move onto taking in other healthy patients.
| ryanmcbride wrote:
| It's an interesting idea but the pessimist in me just sees
| this as incentivizing under-diagnosing, running fewer tests,
| etc.
| recursive wrote:
| Running fewer tests is not necessarily bad, especially if
| your baseline is a system where the system is paid per-
| test.
| rileymat2 wrote:
| Also they have no interest in treating elderly (or anyone
| all that ill) if it requires any effort at all, as future
| healthy payments will not cover the expense.
|
| It is easy to see an optimal strategy of never treating
| anything.
| brezelgoring wrote:
| Well the other option, which is to pay when a problem is
| found, can lead to over-diagnosis and finding issues where
| there are none. Its 'taking your car to an unknown
| mechanic' problem, he _will_ find a problem, and that is a
| problem too.
| foolinaround wrote:
| what if the diagnosing and treatment were done by different
| doctors?
| R0b0t1 wrote:
| Really good take, actually. In the extreme case you find that
| doctors actually have no responsibility to their patients. You
| can read board investigations. They are unusually soft on very
| horrible doctors.
| thenoblesunfish wrote:
| I think that the author is assuming that you, the patient, have
| no way to assess whether the diagnosis was correct. I think
| that eliminates what I also thought of as a strategy, which is
| how this works in real life - some combination of being able to
| tell, as the patient, when treatment is working, combined with
| (the threat of) second opinions, and of course all the "human"
| stuff that the author sets aside about doctors wanting to help
| people etc.
| goopthink wrote:
| The thing is, in many cases you don't need to know if the
| diagnosis is correct, so long as the results are
| directionally correct. If the outcome is an improvement in
| health, that meets your threshold for value delivered, hence
| payment rendered. I think there are many cases when you don't
| need to be smarter than the other person to benefit from
| their expertise. You can take it a step further and make the
| distinction between absolute value versus perceived/relative
| value -- if we have a patient with cancer, absolute value
| might mean destroying all cancer cells (which is an absolute
| metric but extremely hard to model). But perceived value
| might be "feeling better". It's important to make this
| distinction particularly in healthcare because absolute
| benefits and relative benefits are _extremely_ important.
| Hospice /end-of-life care is a good example of this (as is
| the cancer example above). Most people would prefer relative
| or perceived comfort as opposed to absolute results that only
| end up prolonging a painful process.
|
| Outside of healthcare, for another example example, you don't
| need to understand engineering and tension dynamics in order
| to appreciate that the second floor of your home support you
| and your roof doesn't cave in on itself. I don't have
| examples on hand, but in medicine we've had cases where
| people do some logical variation of "the right thing for the
| wrong reasons." I.e., rituals that correlate with healthy
| outcomes because there is some not-yet-understood principle
| at play (i.e, you don't need to understand germ theory to
| benefit from cleanliness rituals).
|
| I think this is one of those logical conundrums which falls
| into the trap of "in theory, in practice". The artificial
| constraints around the problem space result in artificial
| logical conundrums.
| IggleSniggle wrote:
| It is a balancing act, to be sure, regarding "feeling
| better" vs "less sick". Hospice care is indeed very
| important. It can go too far in this direction, however,
| and I have real sympathy for docs that get it "wrong" in
| either direction (too much "comfort" or too much "let's
| give you more years").
|
| Notably: the prescription opioid epidemic is a great
| example of how this can go wrong in the opposite direction
| of healthcare providers valuing "relative" benefit vs
| "absolute" benefit.
|
| My spouse is a primary care provider, and there was a
| period a couple decades ago where the prevailing wisdom was
| "if a patient says they are in pain, they are in pain, and
| you treat that pain. We are experts in medicine, but the
| patient is the expert of their own perception." This is
| still a complicated issue today, but there are clearly
| outcomes where we can make people "feel better" all the way
| to an early grave.
|
| For the terminally ill, it seems absolutely appropriate to
| me to let the patient guide whether they wish to accelerate
| their death in exchange for quality of life. But
| "terminally ill" is often not such a black and white
| issue...we are all eventually mortal.
|
| If things like heroin don't inspire a sense of horror or
| dread, then we just aren't speaking the same language. I,
| for one, don't want to live in a world where the human
| priority-at-large is everyone defining "living" as
| maximizing pleasure until their death. For the hedonists, I
| get why this makes a certain nihilistic sense, but I think
| the horror of the reality of it outweighs any momentary
| benefit.
|
| In the very abstract, maybe it doesn't really matter one
| way or the other. In the concrete day-to-day reality of it,
| it's absolutely awful to see anyone struggling with any
| kind of addiction, out of control of their own
| lives...sometimes because they got on a treadmill-to-death
| on the _expert_ advice of someone trying to "help them
| out."
| dasudasu wrote:
| Then doctors filter what patients they take to guarantee these
| good outcomes. This is already done by some surgeons. Surgery
| is already a subset of medicine heavily judged on outcomes.
| handrous wrote:
| This is featured in the Doctor Strange movie, in fact. IIRC
| the good doctor is presented with a patient whose case is so
| difficult that he's one of the only people in the world with
| a chance at successfully performing the procedure they need--
| but he turns it down because he thinks the odds would still
| be too low, and it might hurt his record. I think there might
| also be a karmic turn with that when his hands get messed up
| --I wanna say there's a scene or short sequence of the same
| thing happening to him, at least implicitly.
| apyrros wrote:
| Cherry picking and lemon dropping does happen in value-based
| systems, but there has been work to address the issue. No
| simple answer, but basically you pay doctors more for select
| patients.
|
| https://relentlesshealthvalue.com/audios/ep322/
| solatic wrote:
| Within the context of the article though, if one assumes
| greedy doctors, then essentially cooperating doctors can
| cooperate to refuse treatment N times, where N is an
| equilibrium between the lemon-picking bonus and never
| accepting any patients at all (and therefore never having
| any revenue), in order to get the system to label non-
| lemons as lemons.
| ska wrote:
| One potential difficultly here is that good metrics are hard,
| and outcomes for a lot of medicine are hard to evaluate.
| Obviously not true everywhere.
|
| So a potential path will be that the incentives start to line
| up with measurable impact on symptoms short term (easy outcome
| to evaluate) instead of meaningful shift in root causes
| (difficult and/or slow to measure)
| joshuaheard wrote:
| Competition cures greed. Instead of going to one doctor, go to
| three. Go with the doctor that has the best value
| (price/service). If the doctor gets greedy, shop around. Tell the
| doctor you found a lower price, and if he is not competitive, you
| will fire him, and find a new doctor.
| kwhitefoot wrote:
| How many people are in a position to find out which doctor has
| the best value?
|
| Is there even a theoretical possibility that this could be done
| other than after the fact?
| joshuaheard wrote:
| Just like any service provider, there are crowdsourced
| ratings like Yelp.
| Gatsky wrote:
| Substitute 'greedy healthcare organisation' for doctor and you
| have an actual problem not a made up one.
| desktopninja wrote:
| On the streets this is akin to "taking your car to the mechanics
| shop"
| phkahler wrote:
| Here is a story of an actual greedy doctor:
|
| https://abcnews.go.com/Health/whistle-blower-helped-expose-m...
|
| What a nightmare for the people involved.
| evancoop wrote:
| Let us posit that the patient's goal is to remain alive and well
| (maximize quality-adjusted life years). Let us posit that the
| doctor's goal is maximal renumeration. Cannot we simply
| compensate the doctor quarterly as a function of quality-of-life
| during that quarter along with some fixed retainer. Now the
| doctor hopes we remain alive and well as long as possible?
| staticman2 wrote:
| Then the doctor fires you for being unhealthy and finds a
| healthier patient. The patient would have been healthy even if
| he never went to the doctor and the doctor gets credit and
| payment for it.
| jsharf wrote:
| Pay the doctor a fixed amount each month that increases as you
| get older. Sure he makes X right now, but if you live past 100 he
| could making 5X that.
| [deleted]
| cies wrote:
| I leaned once that in ancient China they paid family doctors a
| monthly free, unless someone in the household got sick, then the
| fee was not paid until everyone was healthy again.
|
| Doctors did due diligence on their clients and advised them
| preventive. They did not want sickly households.
|
| Also the incentive is on keeping the whole house in good shape.
|
| I learned the opposite once: never let a capitalist near your
| health care program. They make money when you are sick, and stop
| making money when you are healthy.
| d0gsg0w00f wrote:
| > I learned the opposite once: never let a capitalist near your
| health care program. They make money when you are sick, and
| stop making money when you are healthy.
|
| Wouldn't the same rule apply for IT Sysadmins?
| Aaargh20318 wrote:
| The same applies for everyone who charges an hourly rate,
| they have an incentive to work as slowly as possible.
| skinner_ wrote:
| The original post focuses on the limiting edge case where the
| only information coming out of the doctor is a single bit:
| Treatment vs Healthy. I believe the subject can reasonably expect
| some explanation from the doctor, and then we are in the
| territory of Interactive Proofs and Arthur-Merlin Games.
| (https://en.wikipedia.org/wiki/Interactive_proof_system) Actually
| I'm a bit surprised they were not mentioned in the original post,
| nor in any of the 127 comments so far. They are the computational
| complexity models of a situation when a (computationally) all-
| powerful but unreliable agent has to convince another,
| (computationally) limited agent. If there's a second greedy
| doctor, or a greedy detective, we have Multi-prover Interactive
| Proofs.
| poulsbohemian wrote:
| >The medical professional is greedy, i.e. they want to charge you
| as much money as possible, and they do not (per se) care about
| your health. They only care about your health as far as they can
| get money from you.
|
| I'm not even going to read the rest of the article because the
| premise up front is so flawed. It assumes that doctors alone have
| say over pricing / compensation, and that's just not reality.
| It's much like engineers being blamed for things that rest
| entirely with management. It also makes the same flawed premise
| that I deal with in my profession every day - that I'm so greedy
| and so focused on my own pocketbook that I will screw over my
| clients. Are people motivated by money? Certainly. But a
| professional will put their client above money assuming no other
| perverse incentives.
| spaetzleesser wrote:
| "But a professional will put their client above money assuming
| no other perverse incentives."
|
| After dealing with some surgeons I am not so sure about this
| anymore. They seem to feel very entitled to have big houses and
| nice cars.
| gampleman wrote:
| This comment is like saying that Zeno's paradox is dumb because
| proud Achilles would never consent to a foot race with a mere
| turtle - imagine the insult!
| poulsbohemian wrote:
| Look I understand in making the statement I made that I was
| hanging myself out there for further critique. My points were
| simply that:
|
| 1) The person doing the work often has limited say in the
| cost / compensation model unless they are also an owner.
|
| 2) Yes, there will always be people who prioritize money over
| the quality of their services. But reputation has a way of
| reducing their effectiveness.
| [deleted]
| coding123 wrote:
| For those that thought this was about healthcare, you didn't read
| the entire thing. Actually you should guess by the first example
| showing what looks like an NN setup that this has nothing to do
| with Healthcare.
| samcgraw wrote:
| Very interesting read!
|
| I suppose another such solution, for a patient with a given
| medical condition X, is to have a very large pool of doctors and
| see if any of _them_ have condition X (with similar age,
| background, etc).
|
| Then one could compare how treatment varies when doctors treat
| themselves with the same issue.
|
| "Physician, heal thyself."
| loldk wrote:
| This needs to happen. It doesn't have to be a requirement, but
| it needs to be a norm for all doctor's visits. It would save
| insurance companies money guaranteed.
| kuiper0x2 wrote:
| The obvious, obvious thing is to simply pay the doctor a fix
| priced each month wether they diagnose you with something or not.
| Well above what they would earn elsewhere.
|
| Their incentive then becomes to keep a good relationship with you
| so you continue to pay them. The best way to do that is to keep
| you healthy and happy.
| michaelrpeskin wrote:
| That's what I do. It's called "direct primary care". In the
| last 10 years, I've used two DPC doctors. I loved my first
| doctor because we had the same philosophies towards health.
| Last year she started drifting too "mainstream" and I didn't
| like her style, so I switched and took my money elsewhere. I
| found a new guy who is really aligned with me and it's been
| great. It's almost as if having choice and market can work :)
|
| I get the super high-deductible catastrophic with HSA plan from
| my work, and then I pay $135/mo for my whole family for the DPC
| doctor (I could pay that $135 with my HSA and have it be on
| pretax money, but I'd rather invest my HSA pretax right now).
| The total there is less than any other insurance available to
| me. If I ever need anything, I just call or email my doc, most
| of the time we just do a (secure) video chat and I'm done and I
| don't need to make a trip in. If it is more severe, I can
| easily get a same-day appointment. He knows me, knows my
| history, and has an incentive to keep me healthy. The healthier
| I am, the more I pay him and don't see him.
|
| I love the model!
| lotsofpulp wrote:
| I pay $25 to $30 per hour to housekeepers. I question the
| sanity of a doctor charging $135 per month for multiple
| people.
| michaelrpeskin wrote:
| He's solidly middle class. Not pulling in tons of money.
| But he doesn't have crazy stress either. He doesn't do
| insurance or Medicare, so his overhead and admin cost are
| really low.
| ivalm wrote:
| Typical panel size is ~1200 patients. So to get $300k/year
| that's $20.8/person/month.
| [deleted]
| lotsofpulp wrote:
| That's a good point. I'll have to ask some friends about
| overhead. Seems like a weirdly small number though
| compared to insurance premiums + deductibles, and what
| doctors usually get per visit when we go for run of the
| mill fevers for the kids (~$150+ each time).
| [deleted]
| asimops wrote:
| This was also my first idea when I read the problem. As the
| payments stop as soon as you die, this is a strong incentive.
| The only thing I could think of arguing is, that the doc could
| keep demanding more and more. But that would imply a situation
| with only one or very few skilled individuals, right?
| catlikesshrimp wrote:
| Pay a fixed rate.... Like a health insurance plan? That doesn't
| work well in the US
|
| Edit: The smarter person will charge you while you are healthy
| and not treat you when you need it, or underdeliver for the
| expectations.
| winternett wrote:
| >The obvious, obvious thing is to simply pay the doctor a fix
| priced each month wether they diagnose you with something or
| not.
|
| Easy fix... "Just be wealthy!" lol... :|
|
| I've paid for the absolute best insurance I could find this
| year and gone to doctors my entire life that simply don't care.
| I've had everything from colonoscopies to MRIs done and I
| haven't spent more than one day in my entire life in a hospital
| overnight in over 40 years.
|
| Many would say I'm pretty healthy, but who knows?
|
| It usually seems like doctors peddle as much fear as web MD now
| in order to drive me through the service bay of fees every time
| I have an ache or troublesome pain.
|
| If it's any consolation though, my dentist, my auto maintenance
| shop, my lawyer, and even my local supermarket want a constant
| revenue stream out of me because they have a pipeline of
| service that they know they can get a customer hooked on if
| they coordinate their efforts and make their pricing variable
| based on being properly opportunistic.
|
| A lot of the tactics the health care industry regularly uses to
| sell services (and drugs of course too) are from the nefarious
| book of street drug dealers... In a bad economy, the scams and
| opportunism are ripe. Getting a second opinion is often VERY
| EXPENSIVE as well.
|
| Be careful my friends, sometimes it's better to face your fears
| of "WebMD prescribed" death head-on rather than to bankrupt
| yourself, because if you don't die, living broke or in extreme
| debt can be a "silent killer" and harmful mentally and
| physically to you too. Maybe marry a doctor... That might cut
| extreme health care costs... By about 5% if you're lucky... :P
| d0gsg0w00f wrote:
| I think the premise of the article is that this is _more_ of
| a problem when you're wealthy and you want to be "as healthy
| as possible". If you're poor you're only going to pay the
| bare minimum to stay alive so capitalism takes over.
| kiliantics wrote:
| > Easy fix... "Just be wealthy!" lol... :|
|
| Or have all doctors employed by the state on good fixed pay
| mattficke wrote:
| This is basically the Kaiser model. Kaiser's doctors are
| salaried, rather than getting paid per procedure. Works pretty
| well!
|
| (I think the actual answer to the question in the OP is, at
| least in part, to license more doctors. Then the cartel doesn't
| have as much pricing power and medical care is less of a luxury
| good. The rich person should really hire a lobbyist.)
| infecto wrote:
| I had Kaiser for a year and I actually enjoyed it. I saw a
| couple specialist but I never had any major work done so
| perhaps I am biased. It is funny to say it since I believe
| Kaiser originally was one of the opponents of a single payer
| system but using Kaiser kind of felt like what a government
| health care system should be. Very low friction. Oh I need
| blood work or whatever done, walk down the hall. Everything
| felt more convenient.
| hellbannedguy wrote:
| It is so much better than driving office to office while
| not feeling well.
|
| Dealing with ego. Dealing with huge bills even when having
| good insurance.
|
| I sometimes hear people talk about doctors like they are
| going to cure you when you need them. The older I get, the
| more I see the profession as an art.
|
| I remember Lance Armstrong commenting on his cancer
| treatment. He basically said he knew he had the best
| medical care because of his wealth. He said driving from
| doctor to doctor was just depressing/agonizing, and he felt
| it was unnessary.
| spaetzleesser wrote:
| Same here. I enjoyed knowing there is one place where I can
| go and have everything done. They also sent reminders about
| vaccinations and checkups. I have moved away from CA so I
| don't have Kaiser anymore. I generally rarely go to a
| doctor and if I ever get sick I don't even know where to go
| :-(
| lotsofpulp wrote:
| The golden days of the doctor "cartel" (and people in the
| healthcare chain in general) are over.
|
| https://www.beckersasc.com/asc-news/9-cms-pay-cut-for-
| physic...
|
| The 80s/90s/00s were probably the golden years for them, but
| they got in the political spotlight, and combined with the
| decreasing proportion of young to old people, the government
| is going to push down cuts to whoever lacks political power
| to push back. Such as smaller businesses like independent
| doctor offices and pharmacies.
|
| The government has already increased supply by letting Nurse
| Practitioners and Physician Assistants do stuff that doctors
| used to do, and I suspect a lot more price discrimination is
| on the way. Expect the average quality of care to fall (may
| not be a bad thing if overqualified people were treating pink
| eye), and paying more will result in being seen by someone
| more qualified.
| Robotbeat wrote:
| Increasing the supply doesn't mean the average quality of
| care will fall.
|
| If I pay doctors $400,000 a year to work 80 hours a week
| and then double the number of doctors and pay them $200,000
| a year to work 40 hours per week, the quality of care would
| almost certainly improve but costs would be constant. And
| actually, do we pay doctors a premium for those overtime
| hours where they're actually probably less effective? If
| so, our costs would go down as quality of care improves.
| ProjectArcturis wrote:
| In theory, if you want to train twice as many doctors,
| you have to relax admissions criteria to let in twice as
| many people, and the new admitees wouldn't have qualified
| under the previous system.
| convolvatron wrote:
| you're kind of assuming that the metrics that the use to
| admit students are predictive of care quality. thats
| certainly not true, but who knows how not true?
| GloriousKoji wrote:
| But what if the limiting factor of admission criteria
| isn't scoring well but things like crippling amount of
| debt, archaic culture of hazing and adversity to stupid
| hours?
| Robotbeat wrote:
| Right. Are doctors ubermensch who are the cream of the
| crop or did they just have a high tolerance for abuse?
| I'm not sure being ultra-selective gets you people who
| are fundamentally better doctors nor are the returns
| gonna be very linear even if they were. I'd much rather
| have enough well-rested doctors than have more "select"
| but highly stressed, sleep deprived doctors.
| ProjectArcturis wrote:
| I'm kind of surprised that med schools haven't dramatically
| opened up their admissions, like law schools have over the
| past 20 years. It's such an obvious source of funds for the
| school.
| dsr_ wrote:
| The med schools are accredited by (a body completely
| governed by) the AMA. Number of seats is part of the
| accreditation.
|
| The AMA does not want more competition and lower income
| per doctor.
| lotsofpulp wrote:
| AMA claims the real bottleneck is residency funding,
| since you cannot practice as a doctor without residency,
| and for some reason, only the federal government funds
| residencies, and the feds have not changed funding in
| many, many years.
|
| Also, increasing class sizes is not without its down
| sides. Pharmacy schools cashed in and blew up the number
| of pharmacists in the last 10 years, and now the
| pharmacists' employers have so much power in the
| negotiations due to so much supply of labor, that they
| can make pharmacists accept metrics which pharmacists
| know are excessive and unsafe since no one can possibly
| do the job properly in the time they are expected to
| check the medications and counsel people in.
|
| A pharmacist family member says the law is to counsel
| patients, but the reality is anyone who did that would be
| fired and replaced so, in reality, people are not getting
| the counseling they deserve when they pick up the
| medications, and pharmacists are not able to properly
| double check the doctors.
| andrelaszlo wrote:
| I had the same thought, but I can think of two problems with
| it.
|
| 1. The doctor's stake is pretty limited.
|
| The old royal court doctor model is the perfect model for this.
| It's based on the doctor having very few (one?) patient. If the
| patient dies, not only do you risk your substantial income and
| high status, but you might even lose your life if the royal
| family gets suspicious enough.
|
| It's a good solution if you're very rich. Much richer than the
| average doctor.
|
| 2. When you have more than one patient, at some point you
| probably earn more by treating less.
|
| The less work you spend on each patient, the more patients you
| can take on. The more patients you can take on, the more you
| earn. If you simply stop treating patients - "you're perfectly
| healthy, don't worry" - you can basically take on an unlimited
| amount of patients and collect their fees until they perish.
| (This sounds like a caricature of the US insurance system, from
| my western EU perspective.)
|
| ---
|
| What about this convoluted system:
|
| - The doctors get paid a recurring fee that starts small and
| increases the longer you keep a patient around. This counters
| the problem that patients can just be replaced by a younger and
| healthier patient.
|
| - The doctors get assigned patients randomly. This addresses
| the problem that doctors would choose young and healthy
| patients.
|
| - The doctors can only have a certain number of patients at
| once. This makes each patient more valuable, and the doctor
| will be incentivized to actually treat patients, instead of
| having as many as possible.
|
| Oh wait...
|
| Now, the problem is that a young, ambitious, greedy doctor
| would be incentivized to cull their set of patients and select
| for the most viable ones in the long run. This actually
| incentivizes them to kill off patients with minor defects?
| pessimizer wrote:
| Yeah, I don't get it. If you have infinite resources, and you
| absolutely know the doctor is competent (a question omitted
| here that would make this more interesting) just tie the
| doctor's fate to yours.
|
| I don't know if overpaying will work, because the marginal
| value of money goes down the more you have. Once your doctor is
| rich enough, he won't be overly concerned if you die and the
| checks stop coming in.
|
| The real answer is the action-movie/not-that-uncommon-in-
| reality answer: Credibly promise to shoot the doctor if you
| die, or to shoot the doctor's family members.
| cfu28 wrote:
| This assumes that actions that make a patient happy also make
| them healthy. There's a risk that pursuing patient happiness
| can come at the expense of patient health. The doctor may be
| more inclined to keep a patient from switching doctors to keep
| getting paid.
| jtbayly wrote:
| Such as doctors that prescribe sleeping meds to rich clients
| that... end up dead.
| khafra wrote:
| For specifically the doctor version of the principle-agent
| problem, Robin Hanson published an incentive-compatible
| solution over 25 years ago:
| http://mason.gmu.edu/~rhanson/buyhealth.html
| shonenknifefan1 wrote:
| > To cure health care, give your care-givers a clear
| incentive to keep you well. Make sure that when you lose,
| they lose, and just as much. Buy lots of life and disability
| insurance from your care-givers, and have a third party,
| unable to act against your life or health, pay you to be the
| beneficiary.
| mattnewton wrote:
| So, basically bundling insurance with the healthcare
| provider, like kaiser?
| khafra wrote:
| The quantitative difference is big enough to be
| qualitative. You have to buy a lot of life insurance,
| more than people normally get, to make it work. The
| disinterested third party beneficiary makes this
| affordable:
|
| > There are, however, two big problems with this
| approach. The first is that even though my life may be
| worth $10 million to me, most of the (huge) insurance
| premium to pay for this insurance would be wasted from my
| point of view -- there probably is not one person to whom
| I would want to give this much money when I die. The
| other problem is moral hazard -- heavy insurance may
| reduce my incentive to keep myself healthy, and may even
| create incentives for my relatives to try and hurt me. It
| might be a problem if I could only give my doctor a 50
| percent interest in my life by taking away 50 percent of
| my own interest, or by giving a minus 50 percent interest
| to my relatives.
| lupire wrote:
| Which doctor is selling disability insurance?
| jrm4 wrote:
| Right? I can't get over the "meta" point here of what we're
| here doing: This is _not_ a conceptually difficult problem to
| fix and a whole lot of countries besides the one I live in have
| solved it quite easily, but here we are having to contend with
| it. It 's just quite frustrating.
| wayoutthere wrote:
| I do this!
|
| I've found that my employer-provided health insurance is less
| than worthless for routine health care. I actually pay less by
| going to providers who don't accept insurance -- even though I
| maintain bare-minimum coverage and an HSA. I don't think I used
| my health insurance at all this year -- at least not enough to
| come close to meeting the deductible.
|
| My primary care doctor uses this model -- I pay $300/yr for
| basically unlimited access. I have a therapist who I pay $75 a
| session. I use GoodRX for prescriptions and get better prices
| than the post-deductible price on my insurance plan.
|
| Basically, I pay _less_ out of pocket by _not_ using my
| insurance. I also get to choose my doctors, and they treat me
| as an actual patient rather than a number. Health insurance in
| the US is a scam.
| lupire wrote:
| Thar only wokrs because you don't need substantial
| healthcare. Like driving a car wothout insurance and not
| getting crashed.
| apyrros wrote:
| Actually, we are increasingly doing that already in the US.
| Value-based healthcare, aka Medicare Advantage uses something
| called risk adjustment. Payments are based on patient
| demographics and select disease categories (HCC codes) with
| bundled payments. The intent is to slowly get rid of fee-for-
| service healthcare.
| bshep wrote:
| This reminds me of something I think i heard ( or something
| similar ) in a movie :
|
| "I'm not going to kill you, but you would surprised how much
| suffering you can live through."
| thebean11 wrote:
| That incentivizes doctors to avoid taking on sick patients, as
| the work/reward ratio is much higher.
| zz865 wrote:
| Or even better pay nothing and get a government run system that
| is smart enough to figure out what is important and what is
| wasteful.
| lupire wrote:
| Thats a wish, not a plan. Medicare just committed to spend
| $250 per person (not per patient) per year on an ineffective
| Alzheimers drug....
|
| https://arstechnica.com/science/2021/11/dubious-56000-alzhei.
| ..
| colinmhayes wrote:
| This type of insurance is called capitated, seeing extensive
| use by medicare and Kaiser Permanente.
| thayne wrote:
| they also have an incentive to keep you alive as long as
| possible since they don't get paid if you die.
| sokoloff wrote:
| Having witnessed the terminal stages of several family
| members, additional days of being undead is not necessarily
| desirable for the patient.
| gwerbret wrote:
| I agree with the idea of paying the doctor a flat fee every
| month, but in my variant, the doctor has to repay you the
| entire sum you've paid to date, with 10% interest, if you
| succumb to any preventable illnesses; in other words, the
| doctor now has some real skin in the game. S/he becomes
| motivated not only to keep you well, but to keep the fees
| reasonable.
| chriscross wrote:
| That's horribly ignorant considering that many diseases have
| a large genetic component and people are rarely 100%
| compliant with the things they need to do to prevent a
| disease. Even when a doctor lets them know how to prevent the
| disease. How would this work for a disease, for example, like
| Alzheimer's where the onset is much earlier in life (40s) but
| doesn't manifest until much later in life and has no
| diagnostic test at age 40? What about hypertension where the
| majority of it is idiopathic? Would the doctor be blamed for
| all this despite practicing evidenced based medicine? I'd
| argue that a lot of diseases are this way and placing the
| blame on a doctor is a way to shift personal responsibility.
| oaktrout wrote:
| Seconding your view points. If a patient dies from a
| hypertension related cause (say stroke), and the patient
| has not followed the strict low salt diet the doctor
| recommended, does the doctor pay for that? At what point
| does the doctor stop seeing patients who do not follow
| their recommendations to the exact letter?
| R0b0t1 wrote:
| I know you're framing it as patient choice, but it would
| incentivize doctors to actually want to research new
| solutions instead of give stale advice that doesn't seem
| to work.
| gwerbret wrote:
| Upon reading the responses my earlier comments generated, I
| suppose I should have disclaimed that I'm seeing this problem
| as the OP had portrayed it, which is as a thought problem in
| logic and economics, rather than an actual approach to
| preventative medicine. As a thought problem, it can be broken
| into basic, of-necessity simplified elements, e.g.
| preventable vs. non-preventable illnesses, fee optimization,
| etc.
|
| The idea of actual healthcare being dependent solely on
| optimization of greed is, of course, ludicrous.
| dstroot wrote:
| The doctor will purchase "refund insurance" and pass that
| cost along in the monthly retainer.
| gruez wrote:
| Yeah that just passes the buck to someone else (the
| insurer), who is incentivized to investigate malfeasance.
| gwerbret wrote:
| Fair point, but if the client does develop a preventable
| condition, it would be easy to show this is due to
| dereliction/negligence on the part of the physician, so the
| insurance would not pay out. If the client came down with a
| condition and the physician was not negligent, the
| condition would likely be non-preventable, wherein the
| refund clause wouldn't apply, anyway. Thus, regardless of
| outcome, insurance can never pay out, and the physician
| retains all the liability, i.e. no use for insurance.
| pc86 wrote:
| How is it "easy" to show negligence?
| catlikesshrimp wrote:
| Some insurance policies must not exist. Malpractice
| policies must not exist.
|
| I am sure if I asked my mates they would all disagree with
| me on this. Bad luck for the patients.
| oaktrout wrote:
| Without malpractice insurance, would doctors be
| incentivized to not take on risky patients? Risky could
| be defined as litigious (I know this patient has sued
| another doctor before) or medically difficult to treat
| (this patient needs this surgery but they are at high
| risk of poor outcome due to their current state of
| health).
|
| Having sued a doctor once, you might never be able to get
| medical treatment again.
| pc86 wrote:
| Which would also disincentivize ridiculous lawsuits that
| you'd almost certainly lose.
| lotsofpulp wrote:
| It would also disincentivize legitimate lawsuits.
| sxg wrote:
| This is such an oversimplified view of how medicine works.
| I'm not even sure how to begin a counterargument. In
| medicine, bad outcomes can occur without being sure of the
| cause. For example, let's say a patient who currently smokes
| gets lung cancer. Did the patient get lung cancer from
| smoking, or is this a sporadic non-smoking related cancer?
| There's no way to definitively find the answer to that
| question. But for the sake of discussion, let's say it is due
| to smoking. Do you fault the patient for smoking and not
| quitting? Or do you fault the doctor for being unable to
| convince the patient to quit smoking?
| pc86 wrote:
| Even for HN this is a pretty shockingly out of touch "I don't
| know anything about $X but I can figure it out 'from first
| principles!!1'" type of comment.
| efsavage wrote:
| If we're trying to handle the case of greedy doctors, why would
| a doctor accept a very sick patient who is going to require a
| higher-than average amount of care and probably not live (i.e.
| pay) as long? If they can't pick their patients, how do you
| protect the unlucky ones who end up with too many very sick
| patients?
| bullen wrote:
| I would say doctors are the politicians of natural sciences, they
| only act after the fact.
|
| What you need is someone that tells you what do (or most likely
| not to do) before you get sick.
|
| Herein lies the very big problem, if you don't get sick doctors
| have no job!
| efitz wrote:
| The ways to address this problem are "usual and customary[ed-
| autocorrect] prices", consumer ratings, information transparency,
| externalities such as courts to punish fraud and malpractice, and
| skin in the game.
|
| I have thought about this a lot in the context of real estate- up
| to recently, agents typically got a fixed commission (generally
| 3% each for buyer and seller in the places I've lived).
|
| There is a moral hazard in that, assuming that the agent can
| impact my sales price favorably with effort on their part. If
| they're helping me buy a house, and they get a percentage, then
| it's in their interest for me to overpay. If I'm selling a house,
| then the margin for increasing the sale price above market value
| is probably not worth the effort ($300 for every $10k increase in
| sale price).
|
| My solution (I have not tried it yet) is to structure a sales rep
| contract such that we agree on a target price for the standard
| commission, but increase the commission greatly for the sale
| price amount above the target price. Maybe 3% up to the sale
| price and 50% above that. That's what I term "skin in the game".
|
| Assuming I have done a minimum of homework (looked for agent
| ratings and avoided bad or inexperienced agents; looked at
| comparables on Zillow to make sure the proposed sale price is
| market appropriate, etc.) then I should get a good outcome.
|
| Doctors and state license boards often make it difficult to get
| informed consumer type information on doctors. Our insane medical
| system in the US almost never supports price transparency. So we
| have a long way to go there.
|
| Note one other thing. I am trying to optimize for the best
| outcome I can assuming limited resources. If you have unlimited
| resources then you can hire and fire lots of doctors, overpay for
| performance, and generally do things that are unavailable to mere
| mortals. Also I am not assuming or eve trying to achieve perfect
| results (most beneficial result available at the lowest price
| point). I think that is a fool's game.
| treeman79 wrote:
| I blew half a million of healthcare companies money searching for
| answers. Which I eventually got. Entire time desperately trying
| to find a doctor to work with me. Instead had to educate myself
| for a couple of years. I would have loved to just pay a doctor a
| grand or more a month for a few hours to go over tests and
| discuss next steps. Would have been drastically cheaper for all
| involved.
| durnygbur wrote:
| I wonder how software world has the most sophisticated practices
| and patterns for architectures, communication, and arbitration,
| yet we are played by lawyers and doctors like blind children.
| Once I was looking to address my non-obvious health issue.
| Insurances, appointments, referrals, hospital, ended up with an
| obsolete surgical procedure leaving visible incision scars. That
| was in Germany. Somewhere at the back of my head I was thinking
| "I'm smart, you're smart, we're pals and I can trust you right?".
| Now I'm just left with infinite hatred and distrust towards
| greedy medical frauds.
| Vecr wrote:
| This problem appears to be highly contrived, why are there only
| two options (healthy or treat), why is the detective a clone of
| the doctor, why can't anyone use a true quantum random number
| generator, and how exactly are the two doctors supposed to act in
| lockstep as actual agents?
| sampo wrote:
| > Should you _trust_ someone 's advice, when you can't pinpoint
| their motivation? As a Ph.D. student, I run into this problem
| around three to five times a week, when interacting with
| colleagues or my advisor.
|
| Maybe this should be named "The greedy thesis advisor problem"?
| throwawaygh wrote:
| This is very different from the Greedy Doctor problem.
|
| Why? Because, generally speaking, the answer to this question
| is "it doesn't matter". A student will never get a job in
| academia without their thesis advisor's good word.
|
| If a student is ready to leave and their thesis advisor isn't
| ready to let them go, their best option -- assuming they have
| at least a few publications (for CS) -- is to find an industry
| job and say "Sorry, my hands are tied on the start date and I
| need a better paying job for personal reasons. I really wish I
| could write a better thesis but I think there's enough work
| here at least to graduate."
|
| (BTW: industry is much better than academia. The work is more
| interesting, the teaching/mentoring is more rewarding, and
| you'll make enough to retire in your 40s instead of desperately
| clinging to a job in the increasingly MBA-ified Higher
| Education Industry until your 80s. The "Academic Life" sucks
| pre-tenure anyways. If what you want is the so-called
| comfortable and care-free Full Professor days, just get
| financial independence in industry first and then go be a
| professor of practice or even ad junct somewhere for the
| healthcare and vacation money... which, aside from pay, are
| both _actually_ low effort and care free!)
| recursivedoubts wrote:
| They constantly try to escape From the darkness outside and
| within By dreaming of systems so perfect that no one
| will need to be good. But the man that is will shadow
| The man that pretends to be. --TS
| Eliot
| hereme888 wrote:
| Or...do something along the lines of what the healthcare world
| has already come up with: doctors get paid for the quality of
| care they give, rather than just quantity.
| snegu wrote:
| This is exactly what I was waiting to see at the bottom of the
| article. It's what Medicare is trying to move towards in the US
| - doctors are paid more if their patients are healthy (as
| measured by biomarkers, time in hospital, etc.)
| Eliezer wrote:
| Conditional prediction markets on future health/QoL observables
| if visiting alternative doctors.
| BerislavLopac wrote:
| The ideal solution is to move to a country with a great public
| health care (say, Denmark or Switzerland).
| zip1234 wrote:
| Countries with public health care have problems with health
| care as well. It is not a silver bullet. The incentives are
| different but it is still an incentive driven system.
| spaetzleesser wrote:
| Very true. But it seems these countries try to keep the
| system accessible and affordable for patients. The US system
| seems designed to keep profits for providers, instances and
| employers while the patient has to pay without having having
| any market power. From a cost and transparency perspective I
| think it would be hard to design a worse system than the US
| system.
| gruez wrote:
| Isn't that just handwaving the problem away? eg. "high
| corruption? the ideal solution to move to a country with a
| great civil service"
| BerislavLopac wrote:
| Generally speaking, absolutely. But the original problem
| statement begins with "you are very rich", which changes the
| rules a bit.
| skeeter2020 wrote:
| Very rich people will do far better in a private or blended
| system than a country with only a public system. Your best
| approach would be to triage your own health requirements:
| (1) spend as much as needed on preventative & health
| components, (2) pay a retainer or monthly fee to a private
| health network, (3) pay cash immediately for any rare,
| critical or emergent needs. You can get #1 in lots of
| countries, #2 in fewer and #3 in a handful including but
| not restricted to the US. As a Canadian, if you are super-
| wealthy you need to likely leave the country for #3.
| dang wrote:
| Please don't take HN threads on generic tangents. This isn't a
| substantive response to the article; it just points towards a
| version of the same discussion people have been repeating for
| years.
|
| Such massive generic topics are like black holes that suck in
| unsuspecting threads that fly too close. Solution: consciously
| steer clear.
|
| https://hn.algolia.com/?dateRange=all&page=0&prefix=true&que...
|
| https://news.ycombinator.com/newsguidelines.html
| jeffrogers wrote:
| Maybe start by actually hiring a doctor, a person you can form a
| relationship with, rather than a health care system/company. The
| doctor may charge high fees, but their behavior is more likely to
| be bound by the relationship, and societal expectations around
| decency and respect between people. This dynamic does not exist
| between companies (read health care systems) and the people they
| supposedly serve, but both internal and external corporate
| incentives -however well meaning or small when considered alone-
| come together to extract as much money as possible.
| ubermonkey wrote:
| In the US, this model is usually called "concierge medicine."
| It sounds weird but it's exactly what you want for a GP
| relationship IF you can handle the fees ($1-2K annually, and
| that's going to be out of pocket).
| mindslight wrote:
| The answer is not to play games with the payment as if it's the
| only thing you can engage with - it's to check the contents of
| their work.
|
| P != NP, as far as we've discovered. As a non-doctor, I can still
| understand medical conditions. What I don't have are the
| heuristics to diagnose a medical condition. The way I see it, I'm
| hiring a doctor (or any other skilled knowledge professional) for
| their ability to generate a _proof certificate_ (in the
| algorithms sense) that convinces me of their declared diagnosis.
| Any consultant who asserts "The answer is X" without being able
| to explain that answer to an intelligent non-domain-expert has
| not done their job.
| jmull wrote:
| Not sure this is all that useful or interesting as thought
| experiment...
|
| That the Doctor is greedy is in the premise, but why would anyone
| settle for a greedy doctor at all?
| motohagiography wrote:
| This seems like a mutual information problem.
| (https://en.wikipedia.org/wiki/Mutual_information)
|
| The price leverage of the doctor is proportional to how much
| information the doctor has about how much money you have. If you
| can't keep it secret, you can add noise proportional to how much
| information the doctor likely has to cancel it out. The resulting
| "fair" price will be a function of the net shared information
| each side if the noise were removed.
|
| Negotiations theory was a pet interest of mine, and I came to
| believe that in zero sum adversarial bargaining situations like
| that, the domainant position was the side with the most
| information, so the best strategy was to use noise to diminish
| their information, and then use whatever information you retained
| as arbitrage. If you think of noise in terms of signal entropy,
| and low entropy as signal, you can figure out whether their
| gambit is signal or noise by repsonding with noise and gauging
| the entropy of their response. This is crazy armchair stuff that
| nobody articultes, but variations of it gets used in bureaucracy
| and politics all the time, it's basically the game theory of
| gaslighting.
| Zababa wrote:
| Here's my solution: each day you rate how you feel from 1 to 100,
| 100 being the best. The doctor is paid how you feel * something
| fixed.
| staticman2 wrote:
| One obvious solution is to have the diagnosing doctor not be the
| treating doctor- and the diagnosing doctor doesn't get paid more
| for a positive diagnosis.
| bparsons wrote:
| Pay doctors a fair salary in a properly resourced, publicly owned
| system.
|
| This is cheaper, and produces better outcomes than the
| alternative.
| xondono wrote:
| Someone uses "greedy doctor" as an example to talk about an easy
| to understand version of the Control Problem, and the comments
| make it into a discussion of healthcare systems.
|
| I'm starting to think most readers on HN don't really read the
| articles and go straight into the comment section..
| darkerside wrote:
| They might as well have used abortion as an example. The choice
| of analogy distracts from the content of the article itself.
|
| Edit: Part of the problem is that the analogy is such an
| amateur caricature as to be offensive. I am not a doctor.
| CPLX wrote:
| Welcome to Hacker News, a popular discussion forum where
| vigorous conversations are initiated using the text of recent
| headlines.
| dang wrote:
| " _Please don 't sneer, including at the rest of the
| community._"
|
| It's a particularly low-value form of comment, and also very
| common, I think mostly because we try to secure our identity
| in opposition to others. Since this mechanism appears to work
| the same way in everyone, such comments are repetitive and
| extremely tedious.
|
| https://news.ycombinator.com/newsguidelines.html
| CPLX wrote:
| Point taken! Just for reference though it wasn't a sneer at
| all. I love HN and think this format where people get into
| a broader discussion about the general themes implied by
| the article, rather than stick narrowly to the actual text
| of the story, has been a successful one.
| SuoDuanDao wrote:
| I noticed that when the 'laws of stupidity' article [1] came up
| here. I'm very familiar with it as I read it when I was young
| and impressionable, almost all the comments had nothing to do
| with the substance of the article.
|
| What makes it more poignant is that I typically go straight to
| the comments myself, assuming that intelligent commentary on an
| article will convey what the article was about faster than the
| article itself. Which would probably be a good assumption - if
| I was the only member of the commentariate to make it.
|
| [1]http://harmful.cat-v.org/people/basic-laws-of-human-
| stupidit...
| ashtonkem wrote:
| There's a tragedy of the commons going on here. The best
| outcome as a group is if everyone reads the article. The best
| outcome individually is if you're the only one that doesn't
| read the article, then you get all the informed comments
| without spending the time to read it personally. The actual
| outcome is that very few people read the article, and the
| entire discussion is about the title and how people
| interpreted it.
| JoshCole wrote:
| I don't think it is true that the best outcome individually
| is if you're the only one to read the comments. In the
| wisdom of the crowds formulation the average is closest,
| but on Hacker News and similar websites there is a
| popularity contest which biases the responses. The average
| over a biased sample doesn't have the same mathematical
| reasoning suggesting it is better than any individuals
| estimate.
|
| To use a specific example there was once a claim about a
| board seat for Tesla going to someone that people tend to
| dislike. The comments were largely in agreement that this
| would happen and it would happen basically because it was
| outraging and seemed evil which agreed with the commenters
| preconceptions. Anyone who posted contrary to this - which
| I did, quoting a primary source which disagreed with the
| claim, got downvoted. Ultimately I was right and the board
| seat didn't go to the 'evil' person.
|
| This isn't intended to be a critique of me getting
| downvoted. Instead I'm trying to point out that if you read
| all the comments the consensus in the comments doesn't
| approximate the correct answer. So what do you have to do?
| You have to go primary sources in order to be able to get
| an unbiased estimator. Maybe the comments link to one,
| which is nice, but notice: you can't rely on the comments
| alone. Which means it was the people who read the primary
| sources, not the people who read the comments, which get
| the best outcome individually.
|
| Unfortunately, the people who are doing this aren't
| becoming popular for doing this when it helps them. Quite
| the opposite. When this is effective, it is effective
| entirely because it is not in line with the popular
| opinion.
| dfxm12 wrote:
| HN doesn't want to talk about the control problem, HN wants to
| discuss health care. -\\_(tsu)_/-
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