re: We spend far more on health but have the lowest life expectancy of wealthy nations. Why???

Input > transformation > output

Inputs are patients
Transformation is the system
Outputs are patient outcomes

We have issues with the system, but there’s only so much it can possibly do with inputs that poor

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Diet and exercise. We suck at both.

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Yes…and…

- Poisonous food
- Drug abuse
- Black people shooting each other

Better question might be why is the conumption of cheese driving google's revenue?



Or why does the declning popularity of the name Thomas causing France to use less gasoline?

Processed food
Maintenance medication/polypharmacy
Insurance companies

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Among other things, we reward doctors more for medical procedures than for keeping people healthy

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“healthy” is hard to define and thus a proverbial “slippery slope.” But taking that away, looked at another way, you can view this as penalizing doctor’s for their patients’ decisions. Not really appealing and a good way to get a lot of doctors to stop caring for lower income and lower educated folks.

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keep costs hidden from customers

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This is terrible and should change. Part of the problem is this:
1) there is one cost the clinic/hospital/surgery center is allowed to charge for each of the 10,000+ CPT codes out there. To increase reimbursement rates, the charge is often significantly more than what any payer will pay. IE- procedure X may reimburse $200 from BCBS, $100 from Aetna, $70 from Medicare, $30 from Medicaid, and $400 from Humana (haha). To effectively capture all available dollars, the charge needs to be at least $400 even if you don’t make it from everyone. So you may expect the “blended” or average rate (based on payer mix) of something like $130 or so for this particular procedure. The problem is insurances each have rules. So the BCBS patient may owe $25 up front. The Aetna patient may owe nothing up front but be responsible for 100% of the cost after, and several combinations of copays, coinsurance (which will change throughout the year based on what’s been paid so far). It’s extremely complex, and the vast majority of the reason it is complex is because payers directly reimburse providers, and they each make their own rules for doing so. There’s unlikely to be a solution to this short of:
A) single payer
B) heavily regulated/centralized reimbursement rates
C) reverting back to not using insurance as a direct 3rd party payer and having patients pay directly then file for reimbursement from their insurance company themselves
I’m neither advocating for one of these solutions or for the status quo to stay the same, by the way. Simply sharing experience and pessimism in the buzzword ‘reform.’

The last major reform (ACA) now includes the concept of paying physicians for ‘quality’ of care. But the quality of care is largely numbers on a page that don’t really apply to individuals and don’t really lead to better outcomes. A quick example: December is a month where people often gets colds. People with colds often take cold medicines. Cold medicines often increase blood pressures. Physicians are graded by their payers based on how well they control blood pressure. Sounds great in theory, but they take the last BP of the year and count it as “in” or “out.” So you may be 117/70 and be in the office every other week. But if you take Sudafed, clock in at 145/91 on Sudafed, the doctor loses points/grades/etc. There is no data required on the payers’ part to drive their decisions like this one. They simply get to implement the rules and act on them (and I think any sane person would agree that 25 visits with normal BP and 1 with an elevated pressure induced by medication known to cause it doesn’t mean that doctor does a bad job at controlling blood pressure). Many other metrics work similarly poorly in terms of actually capturing what “healthy” means on a big scale.
They released alternative payment models, which is why these metrics came into existence. Problem is that it is difficult and even risky for physicians to do what is effectively “bet” that they can take care of their patients for less than the average cost and keep some of what would have been paid to the “worse” physicians who spend more. So they’ll hold back newer, sometimes better (over a 30-year life) drugs to save money short term and pocket it. But they can’t do it alone, so they’ll hold jump into large groups of physicians doing this (an Accountable Care Organization). So they’ll hold accidentally created a new middle man of healthcare who takes a substantial cut off the top (the one i am part of is a cool 50%) who incentivizes doctors to spend less and code more, neither of which are really tied to patient outcomes (death at age 20, 30, 80, 90, etc isn’t a metric that is used). It’s all about dollars, not years or quality of years lived.

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spend money on tasks that have nothing to do making patients feel better

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Not sure exactly what this means. But it could mean ‘spending money on tasks that don’t improve health but make patients feel better,’ and that’s true. Healthcare is, sadly, a business that sometimes caters to consumer demands. I try to avoid those scenarios as much as possible and am not a big fan of treatments without particularly well established effects.






Fortunately, it’s still very easy to ignore most of this and just practice good medicine. Not a great business model. Tons of money left on the table. But I can sleep at night with it.

Comparing America's diverse population with mostly white homogenous populations is wrong and misleading. If you want to see how the healthcare system actually compares, like subsets of culture have to be compared to like peers across different countries and healthcare systems.

Anything else is meaningless and worse, misleading.

Replace "healthcare" with "education" and you get pretty much the same results.

The dumbing down and fattening up of America are both planned destructions

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And don’t forget about the gun violence in big cities.

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Once you adjust for US gun violence, our life expectancy jumps significantly into middle of the road (IIRC).