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A Better Healthcare System


rukawa
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Thought I would start a discussion on healthcare. Buffet brought it up in the annual meeting:

https://www.fool.com/investing/2017/05/07/warren-buffett-healthcare-is-the-real-problem-for.aspx

 

I think the US healthcare system is pretty bad. I am not such a fan of the Canadian system either, although its far better than the US. I am a big fan of the Singapore system and its everyone pays principle. I thought Brad Delong, had a pretty sensible proposal:

http://delong.typepad.com/sdj/2007/06/dealing_with_th.html

 

 

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I think the US healthcare system is pretty bad. I am not such a fan of the Canadian system either, although its far better than the US. I am a big fan of the Singapore system and its everyone pays principle. I thought Brad Delong, had a pretty sensible proposal:

http://delong.typepad.com/sdj/2007/06/dealing_with_th.html

 

I'd be into trying it and seeing if it actually works.  That said, I suspect it wouldn't work because medicine is one of the markets where price signals to consumers don't actually work because consumers are incapable of understanding what medical treatment is required, nor judging the quality of the treatment that is delivered.  Combined with profit-maximization in medicine, the result is overly inflated costs. Munger's heart-surgery example from the Berkshire AGM is a good example of the problem.

 

Nevertheless, it seems worth trying because without experimentation, it's very hard to know what works.  I feel like you almost need 10 states to sign up for 10 different approaches, wait a decade, and see what worked and what didn't.

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That said, I suspect it wouldn't work because medicine is one of the markets where price signals to consumers don't actually work because consumers are incapable of understanding what medical treatment is required, nor judging the quality of the treatment that is delivered.  Combined with profit-maximization in medicine, the result is overly inflated costs. Munger's heart-surgery example from the Berkshire AGM is a good example of the problem.

 

Actually its not just consumers...doctors also are incapable of understanding what treatment is required or judging the quality of treatment delivered:

https://www.theatlantic.com/health/archive/2017/02/when-evidence-says-no-but-doctors-say-yes/517368/

 

The solution is two things:

1) A lot more research into what works and into increasing the operational effectiveness of medicine. Delong does argue for this in his proposal.

2) Strong physician and patient education

 

Anyways Delong was primarily motivated to have price signals because of the large quality increases and cost reductions he saw in laser eye surgery and similar other treatments that are not usually covered by insurance. Its pretty clear that with laser eye surgery price has gone down, quality has increased and productivity has increased.

 

I am also not sure what is casual here. You assume that healthcare is exceptional because of poor consumer information...but it could be exceptional because its covered by insurance and so consumers tend to spend less time researching. Most of the economy consists of products and services that consumers are not experts in.

 

For instance, I am not an expert on audio-visual technology but if I were to buy a tv I would do my research and there would be review sites telling me which products to buy. Same if  bought a car. Why isn't there anything like this for hospitals or for medicine?

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Thank you rukawa  for the Singapore reference. They seem to combine various features that maximize the right incentives.

Why are you not fan of the Canadian system? difficult access? long waits in the emergency room?, long waits for primary and specialized care? others?

Most "successful" countries tend to have a hybrid system (private and public).

I would like to add that specialized care tends to become more expensive (at rates much above GDP/inflation) and my opinion is that this tendency overall, despite what is often mentioned in the mainstream media, has NOT brought proportional health benefits.

 

Another major problem is information asymmetry as Richard Gibbons describes. There is what seems to be a paradigm shift coming with a tendency to focus on evidence-based care. There are now poor incentives built-in the system. The patients want the best care and the treating teams/MDs want to provide the best care but, somehow, the end result ends up often being VERY far from optimal care. In addition to evidence-based medicine and algorithmic based guidelines, perhaps a private/public intermediary could become an option in the future. Just think of the transport logistics providers (C.H. Robinson, Expeditors) and how they really optimized the use of transport ressources and ended up creating value along the way. In the US, there are already some of this in action in the workmans comp "business" space. I submit that this could become a nice opportunity in healthcare as well. There is a potential relative win-win with care obtained/provided being optimized and, at the same time resulting in a profit potential for an asset-light private model based on knowledge and technology acting within the restraints of basic regulations.

There are potential opportunities there.

For those interested, Corvel (CRVL) is worth looking at because it has already a long and profitable operating history (mainly workmans comp) and may be in a position to expand. Many large health insurers have subs that tend to reach similar objectives but these subs tend to be regarded as "cost control" tools and don't seem to be a priority for the parent company. For instance, for those who followed Zenith (before and after it has been acquired by FFH), a component of the business (claims management) deals indirectly with this aspect of "optimal care" but again here, that component is not seen as a dynamic tool to maximize efficiency but more like a cost control unit to keep costs along reserves.

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Why are you not fan of the Canadian system? difficult access? long waits in the emergency room?, long waits for primary and specialized care? others?

 

The Canadian system has absolutely no price signals and so tends to ration by controlling supply which leads to long wait lines, low productivity and waste.

 

Mostly the Canadian system suffers from the same problems as the US system except that because we ration our costs are a lot lower. But we still have poor focus on preventative health, physicians in Canada are badly incentivized, treatments often have little scientific basis etc. None of these issues though are as bad as in the US but that's not saying much. Lets provide some statistics:

 

Canada

average lifespan: 81.96 years

average age: 39.8

heatlh (% of GDP): 10.4%

 

US:

average lifespan: 79 years

median age: 37.8

heatlh (% of GDP): 17.1%

 

Singapore

avg lifespan: 82.6 years

median age: 40

heatlh (% GDP): 4.9%

 

Singapore basically spends less than half of what Canada spends and 1/3rd of the US but outcomes are similar. Canada looks good compared to the US but when you compare it to Singapore you realizes its actually pretty bad. Singapore wait times for instance are much much much much much much much much MUCH MUCH lower than in Canada. Singapore measures specialist wait times in minutes, Canada measures wait times in weeks or months. The only exception to this is emergency wait times where Canadian wait times would "only" be 3-4 times longer than Singapore.

 

And to give you some idea of how good Singapore's health system is. Singaporeans biggest complaint about their system are the wait times!! So they are basically complaining about something where they are 2 to 3 orders of magnitude better than Canada.

 

To be honest though given the immense stupidity of healthcare my suspicion is that even Singapore could cut their expenditures in half and improve health simultaneously.

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I have a pretty intimate understanding about healthcare from a provider level in orthopedics. To add a couple points to the discussion that certainly add to healthcare costs.

 

1. Malpractice fears. I myself as well as many others who work in the healthcare field over order tests/admit more then we should, give more meds then we should etc because its not worth getting sued. Id much rather order a CT scan of the head on every patient that walks in the door at the ER that hits their head then have the pt end up with a "bad outcome" If it happens and I didnt do it Im fucked. I then have 2 options, settle for limits of my policy or go to a jury trial and be liable for any amount they see fit. Dont let the BS you hear from politicians fool you. EVERY PHYSICIAN/PA/NP/NURSING HOME/REHAB FACILITY/HOSPITAL over orders tests for this reason. Every day all day long.

 

2. Compliance. How do we make healthcare better if the pt doesn't comply? Very difficult to do. Sicker non compliant pts means more costs, and usually more expensive costs.

 

 

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Why are you not fan of the Canadian system? difficult access? long waits in the emergency room?, long waits for primary and specialized care? others?

 

The Canadian system has absolutely no price signals and so tends to ration by controlling supply which leads to long wait lines, low productivity and waste.

 

Mostly the Canadian system suffers from the same problems as the US system except that because we ration our costs are a lot lower. But we still have poor focus on preventative health, physicians in Canada are badly incentivized, treatments often have little scientific basis etc. None of these issues though are as bad as in the US but that's not saying much. Lets provide some statistics:

 

Canada

average lifespan: 81.96 years

average age: 39.8

heatlh (% of GDP): 10.4%

 

US:

average lifespan: 79 years

median age: 37.8

heatlh (% of GDP): 17.1%

 

Singapore

avg lifespan: 82.6 years

median age: 40

heatlh (% GDP): 4.9%

 

Singapore basically spends less than half of what Canada spends and 1/3rd of the US but outcomes are similar. Canada looks good compared to the US but when you compare it to Singapore you realizes its actually pretty bad. Singapore wait times for instance are much much much much much much much much MUCH MUCH lower than in Canada. Singapore measures specialist wait times in minutes, Canada measures wait times in weeks or months. The only exception to this is emergency wait times where Canadian wait times would "only" be 3-4 times longer than Singapore.

 

And to give you some idea of how good Singapore's health system is. Singaporeans biggest complaint about their system are the wait times!! So they are basically complaining about something where they are 2 to 3 orders of magnitude better than Canada.

 

To be honest though given the immense stupidity of healthcare my suspicion is that even Singapore could cut their expenditures in half and improve health simultaneously.

 

There are as many MRI machines in New Jersey than all of Canada.

 

Every universal healthcare system I've read of, even those countries whose military budget is almost zero because it leaches its neighbors or NATO's protections, is a healthcare system far worse than what I had available to me 8 years ago. I understand the dilemma with the poor and pre-existing with job loss but I think that should be resolved with Medicaid or SS, even as busted as the two are. What we once had was fine though.

 

MAGA

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Every universal healthcare system I've read of, even those countries whose military budget is almost zero because it leaches its neighbors or NATO's protections, is a healthcare system far worse than what I had available to me 8 years ago. I understand the dilemma with the poor and pre-existing with job loss but I think that should be resolved with Medicaid or SS, even as busted as the two are. What we once had was fine though.

MAGA

 

Singaporeans live 3 years longer than Americans, spend less than 1/3rd of what Americans spend on healthcare and express very high levels of satisfaction with their healthcare. Wait times in Singapore are also vastly superior to the US. BTW, Singaporeans spend as much on their military in proportion to GDP as the US and also force their young into mandatory service where some of them actually die in training (they run themselves to death).

 

Healthcare is an input. HEALTH IS AN OUTPUT. You are confusing the two. You can have a space age healthcare system and yet because you order needless tests, over treat, over medicate and don't wash your hands (poor operational effectiveness)...actually make peoples health worse.

 

 

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I don't think there's a bad healthcare system in the US. It's just really expensive. But I don't think there's much hope of improving it because of economic and political reasons.

 

Firstly economic. Healthcare cost is at 17.1% of GDP. But your cost is someone's income. At 17% it's pretty much the biggest sector of the economy and makes a lot of money. This gives it a lot of money and influence. In turn it will use this influence in order to defeat cost controls so it/they can keep making the money.

 

Secondly political. This is where the public/private ideologies come into play. Because of this when you try to pass something like Obamacare or any other reform it will be heavily flawed from the start because they have to make a lot of compromises just to get it passed. Then the other side will will try its best to make it even crappier so they can get up on a soap box and say "see it doesn't work". Basically healthcare reform fails because nobody wants it to work.

 

Think about it for a second how messed up the ideologies are. Basically from a pure self interest perspective poor states like Alabama and Mississippi should be all in for cheap gov't healthcare and rich states like New Jersey, California, and Maryland should prefer fancy, expensive private care. However in reality their preferences are completely opposite from their self interest.

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Every universal healthcare system I've read of, even those countries whose military budget is almost zero because it leaches its neighbors or NATO's protections, is a healthcare system far worse than what I had available to me 8 years ago. I understand the dilemma with the poor and pre-existing with job loss but I think that should be resolved with Medicaid or SS, even as busted as the two are. What we once had was fine though.

MAGA

 

Singaporeans live 3 years longer than Americans, spend less than 1/3rd of what Americans spend on healthcare and express very high levels of satisfaction with their healthcare. Wait times in Singapore are also vastly superior to the US. BTW, Singaporeans spend as much on their military in proportion to GDP as the US and also force their young into mandatory service where some of them actually die in training (they run themselves to death).

 

Healthcare is an input. HEALTH IS AN OUTPUT. You are confusing the two. You can have a space age healthcare system and yet because you order needless tests, over treat, over medicate and don't wash your hands (poor operational effectiveness)...actually make peoples health worse.

 

Well, I just spent a few minutes seeking a downside to Singapore but can't.

 

3rd richest country in world

tax rate of 0-22%

corp tax 17%

minute # of poor

apparently, a pretty damn good healthcare system

 

No clue. Good for you, Singapore!

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I don't think there's a bad healthcare system in the US. It's just really expensive. But I don't think there's much hope of improving it because of economic and political reasons.

 

Firstly economic. Healthcare cost is at 17.1% of GDP. But your cost is someone's income. At 17% it's pretty much the biggest sector of the economy and makes a lot of money. This gives it a lot of money and influence. In turn it will use this influence in order to defeat cost controls so it/they can keep making the money.

 

Secondly political. This is where the public/private ideologies come into play. Because of this when you try to pass something like Obamacare or any other reform it will be heavily flawed from the start because they have to make a lot of compromises just to get it passed. Then the other side will will try its best to make it even crappier so they can get up on a soap box and say "see it doesn't work". Basically healthcare reform fails because nobody wants it to work.

 

Think about it for a second how messed up the ideologies are. Basically from a pure self interest perspective poor states like Alabama and Mississippi should be all in for cheap gov't healthcare and rich states like New Jersey, California, and Maryland should prefer fancy, expensive private care. However in reality their preferences are completely opposite from their self interest.

 

Probably because, first and foremost, AL and MS want gov out of citizens business, while in CA and MD it's the opposite.

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I don't think there's a bad healthcare system in the US.

 

People are not very good at judging the quality of healthcare. They tend to judge it based on inputs: access to doctors/specialists, medications, sophisticated diagnostics.

 

I have a very hard time believing that the US healthcare system is a good one. I define good not based on access to the healthcare, number of MRI machines but rather on its ability to actually improve human health. My reason for believing this is that in the US system there are no monetary incentives for anyone to actually improve health of patients. And additionally there appears to be little concern by anyone as to whether treatments actually work or are effective. The vast majority of things done by doctors don't have scientific evidence backing them up.

 

There is also very little money devoted to operational effectiveness. For instance, a doctor meets a patient and he doesn't wash his hands. He then touches the patient. The patient contracts C. Difficile from contact with the doctor. In the American system there are zero incentives to prevent the scenario I just described from happening and in fact doctors generally are resistant to hand-washing programs. Why are they resistant .... because they don't have time. They get paid by the number of procedures they do and patients they see, not time spent washing hands. When you also consider the fact that many of the procedures doctors perform are contraindicated by research you realize that the system often incentivizes poor health outcomes. The Canadian system is not that different in this regard.

 

The other thing that make me doubt the effectiveness of US healthcare is the fact that the number of iatrogenic deaths (deaths due to the medical system) is estimated at around 200k and interestingly no one appears to care. In a truly good system, that cared about health outcomes, this should be an absolute scandal.

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  • 1 year later...

The US system is far superior in technology, access, and options than the Canadian one. I would not wish the limited features of the Canadian system, the wait times, the state appointed and overworked doctors on anyone. I think something like UK or other parts of Europe have the best system. A hybrid system, with more private clinic options. You can pay cash or get referred via the public system. Faster if you pay cash. Also I'd like to see more options like in the US systems. More technology, more research, more cutting edge treatments. UK has an interesting hybrid mix, Germany and Switzerland too. I quite like these systems.

 

 

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To be different does not automatically mean being inferior as it may just reflect underlying values and historical path-dependency.

From data, it appears that clinical outcomes for the US population are diverging from rising health expenditures.

Looking at what others are doing successfully may be a source of inspiration.

Being great means different things to different people. I submit that a component is the ability to learn from others.

 

There will be reform and this may impact, for better or for worse, private sector firms. Worth thinking about.

If you think of the "system", it may be relevant to discuss the care that will be given to "these people" or what others refer to as ordinary folks.

https://www.newyorker.com/magazine/2009/01/26/getting-there-from-here

 

 

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The US system is far superior in technology, access, and options than the Canadian one.

 

Well, yeah, if you don't actually care that Canada has better outcomes at 2/3rds of the price, doesn't have the massive numbers of underinsured people that USA does, doesn't have the huge number of deaths resulting from underinsurance, and doesn't have nearly the number of medical-related bankruptcies that USA does.

 

That said, if you're really wealthy, then the American system is better for you. If you're playing the genetic lottery (i.e. being randomly assigned into the body of someone that needs healthcare), then the Canadian system is so superior that it's laughable that anyone would suggest otherwise.

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https://www.statnews.com/2018/06/25/how-atul-gawande-landed-extraordinary-impossible-job/

https://www.insurancejournal.com/news/national/2018/06/26/493273.htm

 

Some perspective on the new venture.

Some suggest high deductibles and health savings accounts.

 

Basically a good idea but there are two problems:

1-there is too much (in the sense of unnecessary and potentially harmful) care for some

2-there is not enough care for others

 

To have skin in the game will work if 1- is decreased and 2- is maintained or improved.

Typically, when faced with a cost, people will simply decrease the quantity of care in a non-discriminate way.

https://eml.berkeley.edu/~bhandel/wp/Utilization_BCHK_Web.pdf

 

It appears that present cost sharing schemes don't work.

 

Skin in the game benefits may be conditional on changing the rules of the game.

Getting there, slowly.

 

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I can`t really see how taking out a middleman (that operates at full scale) like CVS or a health insurance with a 3-4% net profit margin changes anything. To me it looks like the pure costs that doctors/hospitals and the pharma industry charge in the US are extraordinary high compared to other countries.

The new venture looks like additional costs for BRK/JPM/AMZN to the benefit of its workers, at least until they operate at full scale.

Am i missing something?

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Can I try with a simple example (based on a true life experience of mine but adjusted for this discussion)?

 

My 16 yr-old daughter was bitten by a deer tick last weekend during a camping experience (risk of Lyme’s disease). What to do?

 

A- consult a naturopath and get a prescription for local clay application and vitamin E pills, total cost about 100$

 

B- consult locally (minute clinic or equivalent) and the result could be a large variety of outcomes, with the most likely result being a 1 to 3 week course of antibiotics, total cost about 200$

 

C- with your Cadillac coverage, obtain first-class medical evaluations and follow-up with specialists, including detailed blood testing (facility owned by…) and a prophylactic (to prevent) 3-week course of antibiotics, total cost about 750$

 

Right answer: none of the above.

 

For this specific presentation, there are validated criteria: area endemic or not, time of tick inside skin, aspect of the tick once completely removed, time delay after bite and tick removed.

 

The right answer is none of the above and was the one that I “influenced” in obtaining: see a relevant first-line physician who, after completing a telephone or on-line consultation with a microbiology specialist, explains that there are two viable choices after the removal of the tick: either do nothing or get one dose of antibiotics to be on the safe side. My total price about 150$ (10,08$ out of pocket for the 200mg dose of doxycycline and the rest from the single payer). Interesting to note that using this option results also in an automatic sharing of the relevant information with public health who continues concurrently to monitor a data base concerning, among others, the risk of Lyme transmission after a tick bite.

 

I guess you could say that A- is cheapest and likely does not change the outcome but I submit that this option leaves a lot of unanswered questions.

 

The middleman here has the potential for an amazing amount of value-add. Outside the box.

 

Right now, I would humbly submit that there are a lot of low hanging fruits.

I remember hearing Jeff Bezos explaining (when his operations were small and when he was directly involved with packaging and delivery) that he wondered how he could relieve knee pain associated with the act of packaging stuff on the floor. As he was considering using knee pads, apparently somebody suggested to use packaging tables and, supposedly, this had a huge impact on productivity.

 

I'm not saying it is going to be easy but it is possible and is there for the taking.

 

Helpful?

 

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I can`t really see how taking out a middleman (that operates at full scale) like CVS or a health insurance with a 3-4% net profit margin changes anything. To me it looks like the pure costs that doctors/hospitals and the pharma industry charge in the US are extraordinary high compared to other countries.

The new venture looks like additional costs for BRK/JPM/AMZN to the benefit of its workers, at least until they operate at full scale.

Am i missing something?

 

What you are missing is the role of the PBMs and others that inflate the costs to CVS, Walgreens, etc. so there is savings there.  There is also savings of what Americans pay for prescriptions vs the rest of the world.  I used to live in a neighborhood where everybody worked for a Pharma company.  As described to me they view the US as their sales engine and accept what the other countries pay.  That would be a major change.

 

That said, I saw a graph of global spending on healthcare going back to the 50s or 60s (before nationalized medicine was common in Europe) and what was surprising was that the US even back then was paying 2x European countries.  Nobody wants to discuss it anymore but tort reform or some change in the legal US system would probably reduce costs by 10-15%.  Have several friends who are family practicioners and they all tell me that they over test everybody because you don't want to be sued for the 1-100/1000 chance you are wrong.  Add in the issues where the doctors own the labs that they refer patients to and its a screwed up system.

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Can I try with a simple example (based on a true life experience of mine but adjusted for this discussion)?

 

My 16 yr-old daughter was bitten by a deer tick last weekend during a camping experience (risk of Lyme’s disease). What to do?

 

A- consult a naturopath and get a prescription for local clay application and vitamin E pills, total cost about 100$

 

B- consult locally (minute clinic or equivalent) and the result could be a large variety of outcomes, with the most likely result being a 1 to 3 week course of antibiotics, total cost about 200$

 

C- with your Cadillac coverage, obtain first-class medical evaluations and follow-up with specialists, including detailed blood testing (facility owned by…) and a prophylactic (to prevent) 3-week course of antibiotics, total cost about 750$

 

Right answer: none of the above.

 

For this specific presentation, there are validated criteria: area endemic or not, time of tick inside skin, aspect of the tick once completely removed, time delay after bite and tick removed.

 

The right answer is none of the above and was the one that I “influenced” in obtaining: see a relevant first-line physician who, after completing a telephone or on-line consultation with a microbiology specialist, explains that there are two viable choices after the removal of the tick: either do nothing or get one dose of antibiotics to be on the safe side. My total price about 150$ (10,08$ out of pocket for the 200mg dose of doxycycline and the rest from the single payer). Interesting to note that using this option results also in an automatic sharing of the relevant information with public health who continues concurrently to monitor a data base concerning, among others, the risk of Lyme transmission after a tick bite.

 

I guess you could say that A- is cheapest and likely does not change the outcome but I submit that this option leaves a lot of unanswered questions.

 

The middleman here has the potential for an amazing amount of value-add. Outside the box.

 

Right now, I would humbly submit that there are a lot of low hanging fruits.

I remember hearing Jeff Bezos explaining (when his operations were small and when he was directly involved with packaging and delivery) that he wondered how he could relieve knee pain associated with the act of packaging stuff on the floor. As he was considering using knee pads, apparently somebody suggested to use packaging tables and, supposedly, this had a huge impact on productivity.

 

I'm not saying it is going to be easy but it is possible and is there for the taking.

 

Helpful?

 

Cadillac care here would be getting the correct advice that is backed by evidence and relevant for your scenario. A decision that can be made by the primary care physician, and if they are unable to then they can contact their system's infectious diseases expert - if they were not being killed by productivity metrics it would be a straightforward phone call at the most.

 

Gawande is right when he says that the most expensive device in Medicine is the physician's pen. Someone who doesn't know the evidence or cannot make a decision based on it or communicate it to you then takes you along many wasteful and harmful paths. I have found that medical providers without the right training or expertise or communication skills or intent cost less to employ but a lot more to the system overall.

 

Also, why is a 200 mg one time only dose of Doxycycline costing you $150? Doesn't sound right.

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Can I try with a simple example (based on a true life experience of mine but adjusted for this discussion)?

 

My 16 yr-old daughter was bitten by a deer tick last weekend during a camping experience (risk of Lyme’s disease). What to do?

 

A- consult a naturopath and get a prescription for local clay application and vitamin E pills, total cost about 100$

 

B- consult locally (minute clinic or equivalent) and the result could be a large variety of outcomes, with the most likely result being a 1 to 3 week course of antibiotics, total cost about 200$

 

C- with your Cadillac coverage, obtain first-class medical evaluations and follow-up with specialists, including detailed blood testing (facility owned by…) and a prophylactic (to prevent) 3-week course of antibiotics, total cost about 750$

 

Right answer: none of the above.

 

For this specific presentation, there are validated criteria: area endemic or not, time of tick inside skin, aspect of the tick once completely removed, time delay after bite and tick removed.

 

The right answer is none of the above and was the one that I “influenced” in obtaining: see a relevant first-line physician who, after completing a telephone or on-line consultation with a microbiology specialist, explains that there are two viable choices after the removal of the tick: either do nothing or get one dose of antibiotics to be on the safe side. My total price about 150$ (10,08$ out of pocket for the 200mg dose of doxycycline and the rest from the single payer). Interesting to note that using this option results also in an automatic sharing of the relevant information with public health who continues concurrently to monitor a data base concerning, among others, the risk of Lyme transmission after a tick bite.

 

I guess you could say that A- is cheapest and likely does not change the outcome but I submit that this option leaves a lot of unanswered questions.

 

The middleman here has the potential for an amazing amount of value-add. Outside the box.

 

Right now, I would humbly submit that there are a lot of low hanging fruits.

I remember hearing Jeff Bezos explaining (when his operations were small and when he was directly involved with packaging and delivery) that he wondered how he could relieve knee pain associated with the act of packaging stuff on the floor. As he was considering using knee pads, apparently somebody suggested to use packaging tables and, supposedly, this had a huge impact on productivity.

 

I'm not saying it is going to be easy but it is possible and is there for the taking.

 

Helpful?

 

Wouldn't the cheapest answer be filling out an online form where you upload pictures of the spot for 1-3 days letting a VA (and ultimately a machine learn to identify).  If it looks like an issue then a doctor can consult the pictures and order a script. 

 

That said, you could just move to Western Canada.  2 years ago I stayed at a VRBO with a nice family on Vancouver Island who was selling everything and moving to the US mostly for medical care.  The wife had spent 15 years going to doctors for her issues and finally a visit drove her to Washington.  Within hours it was diagnosed as Lyme disease.  For years Canadians doctors told her it wasn't lyme disease as they do not have many cases.  So they don't know how to diagnose and therefore don't test, creating this cycle of a lack of cases, etc.  I still keep in touch with them and they are finally starting to accept this reality in Canada but its been hard for lots of people.

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