Greedy Goblin

Wednesday, October 12, 2016

A sad evidence for my health care position

I wrote 7 years ago how health care can't be for-profit. I simplified and repeated it half year ago. The simplest explanation is that free market works to optimize for price and enforce quality by enforcing contracts. If I buy a flatscreen, I choose the best price vs advertised value. Please note that I'm unable to determine the "true" value before the purchase. However the manufacturer is obligated to provide a flatscreen that works and fits the specifications listed in the advertisement or I can force my money back. Health care promises can't be made in good faith and can't be enforced. No doctor can promise you that he can cure you because ultimately everyone is mortal and even the best health care will fail at some point of the life of all of us. All the doctor can promise is "doing his best". Therefore meaningful advertisement cannot be made, so customers cannot choose.

The best analogue of a doctor should be a judge. Plaintiffs and defendants can't pick a judge (in some systems they can reject some jurors but they can never choose one to get in), they are stuck with the solution the judge offers and if they are very unhappy about it, they can only appeal to a higher tier judge but he operates by the same rules. Judges are evaluated by superiors and peers and they are not responsible towards customers (you can't get a judge punished if he mistakenly throws you to jail, you can only get compensation from the state). This is how the health care should work: you go to an assigned doctor and you are stuck with him. You can only appeal to a higher level doctor for second opinion. The doctor should be promoted, counseled or dismissed by peers and superiors, not clients or the legal system.

I was always sure about it, but now I got first hand experience. My cat died today. He had a not treatable - but manageable - illness which got into overdrive when he contracted a trivial infection. This wasn't recognized until it was too late. It could have been recognized by the "all included" blood test which costs about 4 days of minimal wage. I would have paid for it a week ago when the first symptoms appeared. I would have paid for it when I first found the cat a year ago, just to be sure there isn't something lurking behind.

But it wasn't offered to me, because healthy looking cats are usually healthy. Don't get me wrong, I don't blame the vet, I blame the free market system of the "animal health care". He has no right to order a test, he can only recommend. Since 99% of the people don't want to pay for anything that isn't absolutely necessary and some even consider such recommendations "he just want to sell me stuff for profit", he stopped recommending non-surefire stuff long ago to prevent customer dissatisfaction. If he'd tell people to pay for a test that mostly come back negative, he'd be without customers fast. If the system was "he is your district vet, you are stuck with him", he could do that's best for the health of the animals instead of what's best for him to keep customers.

Here I have to make a de-tour to sociality. The medically correct statement every time when an animal with no former medical history enters is "we need a broad scan to assess the current status of this animal. It will cost X. If your animal doesn't worth X for you, of course you can pass". But this is highly offensive for a social as it implies either that he is heartless or that he is poor. So if a vet don't want customers to go to other vets, he doesn't say anything that can be heard like that. The "error" of the vet was that he assumed that I'm one of the socials and didn't offer the test. Don't get me wrong, it's not about me not being poor. No matter how much I wanted to save that cat, there clearly was a financial limit that I wouldn't pass for a cat. But that's exactly what socials don't want. To make the decision of "keep cat safe or keep X". They don't want to be judged, they don't want to feel selfish. They rather stay ignorant, feeling good about themselves and when their pet dies, they just want someone tell them "it wasn't your fault" to keep feeling good about themselves (even if they feel terrible about the pet).

Despite I'm highly trained on a STEM field, ready and able to pay, I couldn't make proper decisions to save a cat. I wouldn't be able to make proper decisions to save myself. The decisions should be made by the doctor who knows better, overruled only by an outranking doctor who knows even more. Customer choices have no place here, therefore there is no place for free market.

On a very important note: I'm not talking about health care finances, but health care itself: what the doctors will do with your body. What I outlined can work both with a "government pays for every patient from tax" or with a "patient pays for everything if he can and left for dead if cannot (supported by free market insurance)" and anything in-between.

I don't need "I'm so sad about your cat" comments. I need you to think about what was written here and to act as a voter when some politician wants to privatize health care or wants to give you more freedom to choose your treatment. You can't choose properly, so you shouldn't. Please note that "I can choose to tell my doctor to do as he sees fit" doesn't protect you from the system, as bad doctors exist and you have to choose your doctor to trust. Since most people are dumb, the doctors prospering in a free market are probably better self-promoters than healers.


Phelps said...

You can hire your own judge. Arbitration is essentially that, and is common in American and especially international commercial disputes.

Anonymous said...

"You can't choose properly, so you shouldn't."

the greatest example of this is the morons who don't vaccinate their children. my government recently had to stop child benefit payments for families that refused vaccinations. just to get them to do the right thing.

Lisk said...

You should check this post out, it's a pretty deep exploration of how what you call 'socials' (and he calls 'guardians') deal with so-called 'priceless' transactions, like saving a life.

Anonymous said...

I am sorry if this is the wrong time to ask, but I really wonder why you of all people would buy a pet. This obviously costs both time and money and returns no measurable value.

Anonymous said...

You can find bioresonance and homeopathy in the free market. Usually they are quite expensive. My mother goes to a homeopathist paying 12k HUF/half an hour (about 40EUR which is 32% of minimum wage per hour). I tried to explain to her why that is utter bullshit, but she wouldn't listen to me, because "How do you know? You are just a physicist!", so I asked my girlfriend who is a phd student at our country's most famous medical university, and appearantly "She doesn't have enough experience, and she and her laboratory are not real doctors but scientists who don't heal."

So yeah. I think you should not be able to decide what you need in health care.

Anonymous said...

so how do you keep the quality up and prvent a tenure problem (long standing people with good contact in their own community that cannot [practically] get removed)?
to me, it sounds similar to the education system:
per default, you are assigned to one set of doctors, and you can change - within reasons. in parallel there are private doctors you can switch over to, but they need a license etc.

as a different aspect, as far as i know, the old socialist system with the policlinic is way more efficient and cheaper than every doctor having to buy + finance their own equipment.
let's look at dentists: every dentist office has to have a x-ray machine. but one x-ray machine can support the needs of a whole bunch of dentists.
private doctors = small offices = lots of x-ray machines = higher cost for patients.

Anonymous said...

What would be the basis for an appeal and does this system include quality of life medicine (p.ex. plastic)?

Gevlon said...

@Phelbs: and that's what make people march on the streets with "no TIPP" signs.

@Anon: I forgot non-vaccination idiots because they are luckily absent in my country. We have awful lot of mystic healers though.

@Lisk: that was a very good read, however it's offtopic here. I'm NOT saying that health care must be off trade because life is sacred, but because we are unable to enforce contract.

@Anon: I didn't buy pet. He just appeared one day and refused to leave.

@Next anon: yep, seeing such things in our own parents is so disappointing. Mine aren't THAT bad, but still buy some "organic and clean" products, at least for non-crippling prices.

@Next anon: quality can be upheld by statistics (patient pool health screenings) and the appeal process. If too many patients appeal the decision of their doctor, he might need some counseling.

Last anon: quality of life medicine is a marketable thing since "quality of life" can be measured by the customer. The appeal process would be like with juries: you are unhappy with your diagnose or treatment and pay the fee of a higher level doctor to reexamine you. If he finds your diagnose or treatment bogus, you get your money back and new treatment.

Anonymous said...


The appeal process would be like with juries: you are unhappy with your diagnose or treatment and pay the fee of a higher level doctor to reexamine you. If he finds your diagnose or treatment bogus, you get your money back and new treatment.

But this is not how appeals work for law, you have to have a reason to appeal - besides beeing not pleased.

"Thus, for an appellate court to hear an appeal from a lower court the aggrieved party must demonstrate to the appellate court that an error was made at the trial level. The error must have been substantial, or material." []

While the wording differs between sources, it comes down to an error, which, by your own assessment, can not be assessed by a layman for medical diagnoses. If it is entirely based on beeing unhappy, the only thing you changed for the first visit is that you get a "better" doctor instead of just a different one as far as most current systems are concerned.

Further visits might just be pro forma as in some systems currently with the GP and its referrals.

Gevlon said...

@Anon: the legal appeal process happens because you are unhappy with the verdict. It's your lawyer who will find a legal reason to appeal.

Similarly, you could hire medical counsels who have some form of medical training with only the laymen's "I'm still not feeling well despite taking the medicine" and he will go through your records and find that the doctor missed a protocol step or didn't do steps which are not in the medical protocol but there are precedents of them working in published cases or failed to rule out a rare disease that fits to the symptoms or simply that your doctor didn't follow the proper conduct (like he was unavailable in his clinic hours so you couldn't get treatment at all). First he will try to mediate, write his criticism to the doctor in order for him to change his behavior and if it fails he presents the case on behalf of the client before the appellate doctor.

Please note that this counsel do NOT perform health care so he can make promises (I will review the case and write an appellate document and represent you), so he can operate on the free market.

Anonymous said...

I have a skin problem. It occured at atumn several years ago and my live has changed totally ever since.

doctors diagnosed it as neurodermatitis and gave me tubes of cortisone salve. the itching goes away and the skin heals but as soon as the tubes got empty it came back. so it'S "treat" not "cure".

every skin doc in a radius of 30km said the exact same thing. my questions about long term treatment with cortisone where unanswered. This was a process over 4 months and finally I found two clinic that try to treat skin stuff WITHOUT cortisone. So I checked myself into that after a month on my own money and my employer luckily got my back. in the clinic they "teached me how to fish" and ever since I can cope with the illness. autmn and winter are still hard but I can cope with it. both clinics head doctors have the same illness as the patients or have family with the same stuff.
I'm from germany the general view on healthcare in comparison to other countys is that they are good and have good quality.

Nearly every doctor will treat it with longterm cortisone. So people get more complications after a decade or two.

I can't immagine my amok potential if I got stuck with one doc and within a apeal-system with doctors that would treat exactly the same.

In the end. After months of research, mails with skin researchers and phone calls and doc visits my knowledge on neurodermatitis and cortesone treatment surpased the knowledge of a regular skin doc. And all it took was a neverending itching and bloody skin to get motivated enough.

Be carful what you wish for.

Slawomir Chmielewski said...

I find the main premise of your argument invalid.
"Patients are not qualified to assess the work done on them a priori, and in some cases even the best treatment fails, therefore free market doesn't work"

How about car repairs? Customers know nothing about the inner workings of their cars and eventually every car will end up on a scrapyard. Which is exactly the same situation as with healthcare.

The real difference is as such: mechanics don't get paid for work that doesn't repair the car (usually they will be paid for diagnostics, no matter the outcome). If we make a contract "After the diagnostics I hereby guarantee to repair the car for X amount of money, but will be paid nothing for my efforts if i fail" then there is little they can do by dishonest marketing practices. In fact, whenever the marketing exceeds the actual quality of service - it's the garage that loses out on it (if they promise and fail to deliver).

Yes, cars are simpler and predictable (that is, a mechanic can know in advance if a car is repairable), but there is always a risk for the mechanics. They have to adjust their prices to reflect the fact that some cars will not be repairable after all and they lose their time for nought. The same can be done with doctors: yes, people die, but a doctor will simply adjust his prices to cover for the possibility. In disputed cases a "medical judge" can be called for assessment. In non-curable deseases (which are only managed long term) there are still verifiable improvements that can be paid for.

Hanura H'arasch said...

@Gevlon: " I didn't buy pet. He just appeared one day and refused to leave."

Yet you did adopt a stray cat, and, as you said yourself, would be prepared to pay a non-trivial amount of money to keep him it healthy. Why?

About health care: what prevents costs from exploding if every doctor wants to do "the right" thing?

Gevlon said...

@Anonymous: in the case of a centrally planned medical system, the doctors you found on your own would have better statistics, better appellate rate, so their methods became the standard, forcing other doctors to adopt. Currently "give cortisone and damn the consequences" doctors are allowed to coexist. Sure, you are right that such transition could be slow and you personally might get stuck with bad doctors until the new protocol is accepted. But your case is not applicable to most people who will never be more informed about anything than a piece of rock.

@Slawomir: ALL cars can be repaired, even decade old rustheaps. Sure, such repair might cost more than buying a new car. But after a price is determined, the outcome is certain: in the hands of a good mechanic, the wreck will be car again.

Anonymous said...

what ilness did your cat have
i wanna check my cat now.. and what i should be looking for in the blood test?

Gevlon said...

@Hanura: I don't know. I can't explain why I found this cat so great.

Costs cannot explode when everyone gets the same treatment, because people/government can't pay for it and death rate goes up. Prices explode when everyone gets as many procedures as he can pay.


Anonymous said...

i want isk banned

Anonymous said...


Sure, you could create/modify a profession ensuring counceling but just some problems with that

- it is s competitive profession, given that people happy with their diagnosis/treatment are very unlikely to use them - you might as well equate them to medical lawyers with going for malpractice
- cost of medical care goes up
- time to a second tier treatment goes up
- low density area logistics

Orson Brawl said...

I'm surprised that the vet would not have checked for FeLV. That and FIV are pretty standard checks in shelters and usually recommended by vets for strays.

Gevlon said...

@Anon: The medical counselor is advising you on health care issues and not legal, increasing your medical knowledge and preferably health knowledge.

The cost of appeal isn't that high, practically the higher tier doctor reads the documentation, orders some tests. I don't see health care cost explosion. Also, the appeal would be rare. Most people don't complain.

@Orson: this is a poor land. People don't pay much for pets. Shelters usually can't even vaccinate pets, just keep them fed until an owner arrives. You (and somewhat I) are privileged people and got used to level of services which is "luxury" for most people on the planet. I guess people in Aleppo are eating their cats to survive.

Anonymous said...


Sure they dont complain currently, they just go to another doctor. Every problem from finding a psychologist that "works for you" (what would an appeal even look like - besidesprocedural nitpicking) or beeing a 70y old rich white lady not liking the new black dentist. What about just thinking your doc is stupid?

The later ones are rather questionable/social problems in itself but ppl will pay up for someone to bail them out.

Gevlon said...

@Anon: this is exactly the problem now, doctors who are nice (or even: white) get the clients, regardless of skill, creating a less-then optimal heath care.

The point of the appeal process is that it's a formal complaint about disagreement about the MEDICAL actions of the doctor instead of his niceness or blackness. You - with your counselor - complain about what he did or failed to do objectively instead of you feel about him. This would improve the health care as either he gets a formal feedback to improve his medical performance or you get a (n expensive) lesson about proper health procedures.

Anonymous said...


I see what you want to do, but you are moving the problem. The counselor is interested in making money, the client wants another doctor for emotional/social or whatever reasons and has money, you beeing told that your request is unreasonable takes a few minutes, you beeing involved in an appeal process takes vastly longer therefore more lucrative and given that your counselor - even if it gets shut down - is not a directly involved with your treatment and has to fear a malpractice suit can always side with the client. And the room to argue in medicine is vast, you can order all kinds of tests, p.ex. MS/mercury poisoning have such a wide array of symptoms that you could, even if this is pure insanity, ask for that every time you have some (psychosomatic) symptoms. "0,0139% probability for your age group according to study a? Well after my review of a current meta study for specific age group x this would be 0,893%.."

Therefore my anaolgy, a lawyer will try to reduce your punishment with whatever means available, if it is a simple procedural error or manipulating a jury, if you are worth your salt you go where the victory is.

Although i have to admit seeing the reaction to "Doctor i would like to tape our conversation for future 'counseling' (aka appeal aka malpractice over which you can get fired)" would be very entertaining given that he can, given your ruleset, not deny that, actually this implies that there should be the baseline requirement of recording every word your doctor said to you ever, making this profession even more appealing (try to talk to your medics what they think about beeing dragged to court).

In general i like hierarchical structures, meritocracy etc (which means you got promoted because people dont (successfully) appeal your stuff - which might mean you are really good or just really nice), but on the other hand i also like libertarianism and imposing a rational mindset on people is not only futile but also ignorant given that the justification of logic is based in logic. Most of the time, well in theory, you can walk away from people who don't share your mindset, but forcing "them" into your world, as appealing as it is, will just end up with one or another trump beeing elected.

Gevlon said...

@Anon: you greatly underestimate the emotional/time cost of a formal appeal compared to just walking out and seeing another doctor, which is a current system. Sure, people who feel badly wronged (even when not) will appeal. But no one will appeal if the doctor was just not nice or not caring. Also, it's a crucial point is that you are still stuck with your doctor after a successful appeal, he is just ruled to change your treatment. The only exception if he was found doing something so unprofessional that his superiors remove him from service. Socials don't want to get bad blood with people they need to meet eye to eye.

Another point: I'm NOT dragging them to court. The appeal process is not handled by judges, and - except for extreme misconduct - it is not aimed to punish the doctor, it's aimed to improve him. It's more like the peer review process for scientists. How it goes:
- You think you are poisoned by mercury by the evil government via chemtrail
- The doctor says you are bipolar and should take medicine X
- You pay a counselor to review your case. You pay for his hours even if he finally refuses to represent you. His win rate and representation rate are mandated to be on his door so if he takes every lunatic, first will be low, second will be 100% and people avoid him. So if he don't want to decrease his win rate, he says he can't represent this case.
- He finds that you have some symptoms with mercury poisoning and while the government chemtrail is unlikely, he finds that you could be exposed to mercury at work if your workplace was careless.
- He agrees to represent you and writes this report to your doctor. If the doctor changes his mind, he pays for your counselor - as your costs were his fault - and orders the test.
- If he sticks to his opinion that you are just being bipolar and paranoid, the case will go to appeal.
- A few superior doctors - likely a psychiatrist and a toxicologist review your case from documents (no oral sessions in this process, as only medical facts matters).
- If they rule that mercury poisoning is reasonable, they order the test and the doctor pays the cost. If they rule that it's not, it's yours.
- The cost of this process is merely their hours. This is important. You aren't battling for money, but for better treatment. You won't get money even if you get the test and it comes back positive.

The point is that being appealed is not something doctors have to fear. It's something that they can improve from. They won't get punished (besides the cost of the process). Remember, they WANT to heal people. The only exception from this if the doctor wasn't simply wrong, but violated good practices. In this case if there was a surgeon general's letter to all doctors in your area that multiple mercury poisonings happened and they should look out for it until the source is found. This case
- he'll get a letter of reprimand from the superiors for ignoring the warning, regardless your test. This gets to his personal file and affects his future promotions or in bad or multiple cases can lead to mandatory counselling or even dismissal. You won't know about this.
- if your test get back positive AND the delay increased your medical costs he has to pay it
- only if the delay caused irreparable damage will you become eligible for compensation via legal process