And the biggie is that we need to dramatically reduce how often people go to the hospital. That’s by far the biggest expenditure. If you can keep people out of the hospital that’s huge!!
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The janitors are totally negligible relative to the highest-paid people – administrators etc. But for instance at my hospital, cleaning staff gets a minimum wage of $15/hour. Pretty sure that’s not the going rate in other areas, even in this expensive city.
So the higher wages are the most lopsided at the top but they trickle all the way down a little bit too. The janitor can probably still make 15/hour if the administrator and the doctor and the pharma company all agree to bigger pay cuts 
In addition, we would need an effective way to judge when people are at the end of their life and ensure they die out of the hospital with no extraordinary medical attention being provided.
So, cut the pay for the ones who are providing the direct care–brilliant! If the average NFL player makes $2M, then I don’t think the average physician is overpaid. And besides, the amount of money simeone gets paid outside of the government sector is none of your damned business!
Why not get government and horrendous regulation out if the equation, and put medical care back into the private sector? Of course, there would still need to be some government regulation and involvement. But certainly not the micromanagement that exists under the ACA.
@Chris has previously expounded quite well on the concept of the consumer being in charge of his health care decisions, along with transparency in pricing, and how that would drive medical care costs down.
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@docslotnick I tend to agree that doctors are not the most overpaid in our society (to me that honor goes to i-bankers and even computer programmers here in Silicon Valley – and yep, I’m married to one of those).
But I think the point Chris was making is not that every specialist should make a ton less, but that cost inflation isn’t just about insurance company middlemen.
Personally I think the specialties are not compensated the right way – a lot of that has to do with available residency, internship and fellowship programs, which is really not market-driven or driven by healthcare needs. But I don’t think doctors across the board get paid too much. Some def. do (orthopedic surgeons who basically only do spinal fusions come to mind), but many are making less than, say, some dude who helped make an app that allows you get boba tea delivered to your door, which to me just seems dumb.
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@TiaG One of the most important parts of what I wrote in my post, is that it is none of my damned business how much your husband is paid, and it’s none of your or anyone else’s damned business how much ANY doctor is paid. They will be paid what the market demands that they are paid.
This is the type of thinking that drives me crazy, that there should be external adjustments to people’s earnings. The only people who we should have salary concerns about are public employees, because we are their employer.
Enlightened self interest is the cornerstone of our economic system and our society.
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This doesn’t make sense. Knowing what people are paid is hugely important to the functioning of a free market. For a market to function best you need perfect information; even then, people make irrational decisions not predicted by supply/demand, but the worst decisions are made in fields with the highest opacity. If you conceal what others make then the market is not free. Also, it becomes totally impractical. How on earth could people make decisions for their life and career if no one knew what salaries people made???
Also I never said “there should be external adjustments to people’s earnings.” I’m saying as a person, I look at the economy, look at the value each type of career makes, and personally think it’s screwed up – i.e. whatever equilibrium the market has settled on does not actually maximize benefits for society or even those people in those careers. I don’t think the answer is to decree that all i-bankers can only make half of what they currently do. But I do think it’s naive to think that the market is ever truly free anyways, and to be more realistic about the current incentives, laws and distortions that lead to these ridiculous situations.
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I’m maybe a weirdo in that I think most athletes are not overpaid. Agree that boxing is dumb though.
@TiaG You misunderstand what I meant.
There is no problem in people knowing generally how much someone makes, and specifically exactly what they charge. In fact, it is vital for consumers to know how much someone charges for their services.
What is not ok is to try to limit someone’s earnings in an arbitrary manner. It should be solely determined by free market sources.
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Exactly!
yeah I don’t think we should be limiting people’s earnings arbitrarily. I think the big difference is that I think the market is already being manipulated or distorted in an arbitrary (and sometimes non-benevolent/unethical) manner and that it’s impossible to have a truly freely functioning market in our modern society as we have it now. Given that, I think it makes sense for society to consider whether there are ways to unwind some of these distortions or at least counterbalance some of them. Call me crazy, but in a truly free, competitive and enlightened market with perfect information and perfectly rational actors, would anyone have given Juicero $100 million in startup funding, for instance? .
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You can call me crazy, but part of the economic equation is that some ventures will fail. And another is that a sucker is born every minute. It is not government’s business to protect us from ourselves.
I look at this as a feature, not a bug.
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I concur that we do not live in a free market system. The government decided which banking firms were to be saved and which ones failed during the economic debacle of 2008 /2009. The government, through its “incentives” also decided which solar companies were to be the winners and losers. This is messed up, because as it was pointed out, government money is actually OUR money - collected from taxes. The fact is that a few “elected officials” and their appointed cronies are dictating “rules and guidelines”, essentially preventing a free market.
To the extent possible, I exercise my rights each time I patron a store, or choose to not. For example, it bothers me greatly that the highest compensated employees of Starbucks make so much more than the average “barista”. Therefore, I choose to buy my caffeine from elsewhere. I know that I may be depriving the barista of a revenue source. However, the issue is, I would rather support a barista who works just as hard at another shop (usually a locally owned, mom and pop establishment) who treats their employees more equitably.
Getting back to the point about healthcare. It would be good to have a catastrophic insurance in place, and for those who wish to have elective procedures, cadillac coverage, that ought to be private and by choice.
To share another horror story from my neighbor: She went to her PCP about swelling in her knees. The PCP was somewhat dismissive of her concerns. She went to the ER on one weekend because she felt that her concerns were not being addressed despite two visits to the PCP for the same issue and her request for an MRI. We can all guess that the visit to the ER was likely more costly than visits to the PCP and MRI. Her insurance required that all referrals to specialists be made through a PCP. This is too much regulation. People will find ways to circumvent the system. In this case, the net cost to “society” was likely more than what it needed to be. This is the type of stuff that infuriates me.
In ancient China, the healthcare provider was paid regularly. If a patient became ill, visits were FREE because it was understood that the healthcare provider FAILED to keep his patient healthy. Again, I throw this out there as food for thought.
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The fact is that a few “elected officials” and their appointed cronies are dictating “rules and guidelines”, essentially preventing a free market.
I think regulation has tradeoffs and benefits depending on the arena. I agree healthcare is probably over-regulated, but your horror story is also an example where it’s not government regulation that’s at play – it’s the insurance companies own rules, which evolved to respond directly to market forces. They want to make money and keep costs down – making PCP be gatekeeper is one way to do that. Probably 9 times out of 10 that deters what they consider costly or unnecessary treatments. The tenth time someone like your neighbor goes to the ER, which is hugely expensive.
All this to say I think lots of factors make the market not truly free or efficient (what we really care about, right – that it provides the most efficient allocation of goods and services given the conditions?) I think government regulation is one factor that can reduce efficiency, but too little government regulation can also be a problem. For instance, certain types of basic medical research may never get done if market considerations are the only issue – and yet the initial investment by the government may produce a huge multiplier effect in terms of societal benefits.
My real beef with government intervention is not with it in concept, it’s that nowadays a lot of it doesn’t serve individual people or it is tailored to benefit the powerful at the expense of the weak. For instance, we fund basic research and then once it gets to phase I, a pharma company snaps up the research and keeps its data private, and any drug they eventually develop we have no stake in. So we essentially subsidized the pharma’s early foundational work but then they have no accountability to us the citizens for it.
Or we punish a small, local Chinese bank for financial misdeeds during the financial crisis, while the big lenders who got us into this mess basically get bailed out and their CEOs get off scot free. That type of thing.
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Yes, many CEO’s got off scot free. But the primary movers of our financial crisis, the politicians, got away without any blame. And it’s the same thing with healthcare.
The democrats totally upended and substantially ruined our healthcare system with the ACA.
No, our healthcare system previously was not perfect, and there are some beneficial aspects to the ACA. But they literally shot the fly with an elephant gun, and they apparently bear no blame. Instead it’s all the fault of insurance companies.
That’s what infuriates me.
Regulations is definitely a challenging topic, just like parenting styles. Too permissive a parenting style can lead to undesirable consequences, just as too strict a parenting style can lead to unintended consequences.
Regulations,governmental interventions are possibly necessary to address egregious actions. However, it would appear at times, that some are looking towards the government to provide the solutions to all ills (healthcare, poverty, education, unemployment…etc). Government officials are often so DETACHED from the problems and the realities of the situation that they are not the best people to conceive a solution. Congressional members do not use ACA, neither does Obama. The only President to have sent his child to public school during his presidency, IIRC, was Carter.
The best solutions are often crafted by those closest to the problem or the issues. In the case of healthcare, we, the people are the best poised to craft a solution, not the overpaid government or insurance bureaucrats.
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The democrats totally upended and substantially ruined our healthcare system with the ACA.
I guess I just don’t see it. I go to the doctor a lot lately (I’m about 3 days from baby #3) and everything seems pretty much as it was beforehand. I agree there are a lot of things ACA made more bureaucratic. I hate the whole concept of “team” medicine, I think that electronic medical records sound good but that these big EMRs with all their HIPAA regulations are laughably bad, and while I am wholly in support of my doctors practicing evidence-based medicine, I think there can be a lot of debate about what evidence to include, the quality of the evidence, and the guidelines that are being drawn from that. A lot of the weird regulations in it were mandated by public health types based on theories or hypotheses of how certain regulations would change practice, and as those experiments play out, there are a lot of unintended effects which I don’t like.
But overall, my feeling is that Obama’s whole “if you like your insurance you can keep it” has been true for me. And I also see a whole lot more people in my doctors’ office waiting room who simply had no access to care at all before hand, which makes me happy.
So personally, I’m pretty happy with my experience. It’s interesting that I mostly like Obamacare and live in a state that jumped headlong into its implementation, and you hate Obamacare and live in a state that declined to implement the Medicaid expansion and did the absolute minimum necessary to integrate Obamacare mandates into its system. So I wonder if the things you hate are directly attributable to Obamacare, or have to do with some other quirks in Texas’ healthcare system and how it implemented things. I had access to much crappier care when I lived in Texas – although then I was younger and in college and grad school, so I can’t really say what the difference is.
I agree that some of the regulations truly hamper good healthcare and get in the way of practicing wellness healthcare; and rather, at times, encourage unnecessary testing and actually contribute to the escalating cost of healthcare. Another example involved my son, who happened to be below the chart in every way, height, weight…etc.at the time of the incident (he was about 4 years old). The pediatrician recommended a specialist, a pediatric endo, who wished to conduct all types of testing including bone age. We did do the first test, the bone age. However, I inquired as to the test result options after the other tests that were being recommended. While the doctors were making their recommendations based on evidence, I think that their methodology was poor. They ought to have discussed with me in detail whether he and we, the parents would have 1.
wanted to human growth hormone 2. and whether his overall size was consistent with the fact that I’m less than 5 feet and that my husband is about 5 feet 4. Well, I declined further testing, never returned to the pediatric endo. She sent a letter to the pediatrician noting that the mother refused treatment. Is it on my “permanent record” that somehow I am a negligent mother? My son is 19 now and about 5 feet 3 inches, not developmentally delayed, or physically impaired. By not proceeding with the standard protocol of treatments, we probably did not spend $20k to $30k in healthcare costs, whether covered by insurance or personally. It is an individual choice. A few of my neighbors did use human growth hormone for their children. Their personal choice. In my opinion, this is an example of elective procedure, not necessary for saving lives.
The “acid test” in my opinion about wellness, is 1. safety to the patient - will the procedure save the patient from some harm and 2. first do no harm - the procedure ought not to expose patients to potential harm,
Point #2 is most contentious because the technologies, diagnostic tools and medications that are being invented and promoted. Patients are not necessarily provided with full disclosure of pros and cons. It is quite common for PCP and even endo’s to prescribe oral meds before insulin, and in some cases, the anti diabetic sulfonylurea drugs are the most inappropriate drug of choice for the patient. I still push back when my endo asks me to try this new drug. No thanks, the science behind it is insufficiently clear to me as to why it would be good. Whereas, the science behind insulin is pretty clear and well understood, even if it acts rather slowly. The controversy surrounding the necessity of mammograms is another example of weighing the pros and cons of the test. Just my 2 cents.
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I agree – I saw that firsthand with the whole gestational diabetes experience earlier in the pregnancy – They did one big observational study and changed the gestational diabetes screening and diagnostic guidelines, leading to a huge number of women being flagged with the disease. And in the end, there’s no actual clinical data showing that all these extra women being flagged improves outcomes.
One of my big pet peeves is labeling a patient “non-compliant” – because someone doesn’t blindly do what you say about their own body they’re somehow a problem patient?
So I am definitely not arguing that all these various rules, checkpoints, guidelines etc. are perfect.