The FDA has no cost constraints and so maximizes safety instead of QALYs.

Medical equipment and drug manufacturers maximize profit and so fill the highest margin niches first instead of maximizing QALYs.

Radiology and lab services are lucrative and separate themselves from clinical providers to maximize profits instead of QALYs.

Individual physicians and especially surgeons can maximize profits by having their own practices vs. hospital or clinic environments where coordinated care maximizes QALYs.

Hospitals and clinics and especially ERs, cancer treatment, and skilled nursing facilities try to make ends meet with inpatient population and try to hold on to outpatient surgery, radiology, and lab services to make ends meet while providing whatever level of coordinated care they can, but still optimizing for profit over QALYs.

Insurance companies maximize profits by building actuarial plans that stratify patient populations by plan cost, skewing the burden of healthcare costs to the unemployed, underemployed, and low wage earners. A patient becoming uninsured is an economic win for insurance companies and employers. QALYs are proxied by cost/patient/year for anyone managing to stay insured which ignores deductibles, co-insurance and other out of pocket pay.

Medicare and medicaid programs are left to pick up the pieces by trying to piece together effective care with compensation restricted by arbitrary budgets and arbitrary service providers (many specialists, independent physicians, and facilities flatly refuse medicare/medicaid patients).

Actual patients have no clue how any of this works and end up with a pile of bills they try to pay off or if they know the trick they negotiate with the healthcare provider to settle for something slightly above the ~2% face value of debts written off to debt collectors who will hound sick people and their families incessantly.

Maximizing QALYs is hard enough in a centralized single-payer or universal healthcare system. Almost nothing in the U.S. healthcare system is aligned with that goal.

Insurance companies are basically just bill paying services, as almost all employer sponsored healthcare is self-insured by the employer as the risk pool is large enough to take care of the true "insurance" nature of the mutual pooling of risks.

So how do you think insurance companies will react to making it "easier to pay the bill through standardization?"

Chance of movement = zero.

Compare that to insurance being involved recently in my wife's diabetes supplies. My wife is a type 1 diabetic and needs supplies that monitor her blood sugar, we noticed her supplies didn't arrive on the scheduled date, we waited a week to see if they would show up and they didn't. My wife called the company that was supposed to send them, they said our account was in collections? Why, we never received a bill, we never were notified, but in collections we were. We eneded up paying and got that sorted out and waited another week, still no supplies. I'll cut it short and just say it took us 3 weeks being on the phone multiple times a day being bounced around between our insurance, the supplier and her dr, to finally get told we couldn't get the supplies because my wife had gotten a new phone and so the insurance company didn't have enough data to prove that she needed these supplies, and wouldn't reauthorize them. The drama is still ongoing.

Let's get this straight a huge part of the healthcare costs are directly related to insurance and the money and laws tied up in that. We need to get rid of insurance, and the way it works if we honestly want to make any change. Any other effort will only further entrench the confusopoly.

This happens for a reason. A 265 Billion industry (however fragmented) has developed to create/maintain and profit off the complexity. I am extremely pessimistic that they will allow this to be fixed. It might be just too big to fail at this point. However, it might plague "medicare for all" systems too, unless it's completely a separate system somehow. These entities will make every effort to get into the "medicare for all" flows as well.

Even if the particular businesses these professors work with stand to gain from such reform, this sort of approach that thinks we can technocrat our way around the antagonism that is precisely why things like medicare-for-all are so difficult seems incredibly politically naive.

There is an opportunity to allow for procedural specialization so that 'techs' can do a lot of the work normally done by docs and nurses.

'Early detection' is a new, major shift in how medicine works, because the things we get now 'come on slowly in a hidden way'. Allowing for technical specialists to run operationalized testing with standards, clear rules etc. may enable us to get costs down and possibly improve outcomes.

My bet is that someone with very narrow and focused training may be even 'better' at that thing - so long as we can put a nice dotted line around it because of course it's always more complicated than just 'one thing'.

Perhaps requiring 'best price' for all so that individual payers can get the same price as insurers might work, though it's not exactly 'free market' it mostly is. Transparency - so that everything is published and public might work as well.

It may also be worth not billing specifically for low-cost materials used, and just roll it into the type of visit.

The government has deep pockets, and everyone is trying to get as much money as they can from it. Pharmaceutical industries, insurance providers, healthcare facilities, etc.

Pharmaceutical research is important and expensive, but there must be a way for that research to happen without doing stupid shit like making insulin expensive.

Labor costs in healthcare are high, but there must be a way to not make a bag of water with salt not cost $500.

People pay for costs that are completely unrelated for the products and services they are receiving.

And there are still about 14 other layers of the healthcare onion to peel.

Medical talent is kept artificially scarce thanks to the lobbying and control of licensing by the AMA. We should hand control of licensing over to the AARP and the March of Dimes instead.

Hospitals and insurance have perverse incentives because they are separate. But when insurance and provisioning is combined as with Kaiser Permanente, then incentives are aligned and bureaucracy can be streamlined.

Hospital consortiums currently carve up monopolies within a given piece of turf. We should break that up, and allow a proliferation of low-cost community clinics for less advanced procedures.

And this hasnt even covered obscene pharmaceutical costs, electronic medical device manufacturers, the diagnostic industry oligopoly, and so on.

Why is every other ad on TV for one of the car insurance companies? Competition, which drives down price. The way to fix US health care is to create a market environment where I can buy health insurance like I can buy car insurance. It's too regionally regulated now. Make the market national. Make it possible for a young, unmarried man to buy into a group policy with other young, unmarried men (with zero benefits for maternity or female-specific illnesses), and let the market sort it out.

Tying insurance to employment has got to be one of the most BALLER moves of Capitalism the world has ever seen. I mean, how much harder could you force your employees to bend over than to tie their literal life and health to working for the company?

GET MY EMPLOYER OUT OF MY FUCKING INSURANCE. People say there's no money for nationalized healthcare. Bullshit. We're already paying it. Give me the money that my company is paying on my behalf -- about $20,000/year -- and let me combine that with my portion -- about $8,000 -- and let me go buy a plan that makes sense for me on the open market.

Do these 2 things, and the market would sort this out in a New York minute.

Nope. More neoliberal capitalist apologetics....

Why not just implement Medicare for All, instead of trying to band-aid the private healthcare market?

- providers (doctors, hospitals) - drug/device companies - lawyers - insurance companies

All of them point to someone else to blame and defend their part of the trough with knives. All have very developed lobbying arms and are fully entrenched in congressional election funding.

I mean, the Bush Administration started part D medicare. Republicans. An entirely new entitlement.

A common accusation of anyone attempting to do a QALY based system would be that they are "sacrificing grandma for the dollar".

The recent COVID crisis is an example where QALY based evaluations (which may well have gone either way) were summarily considered "putting a number on the value of a life".

In that respect, it's not that the institutions are perverted but that the society they are in prefers them this way.

I'm puzzled why the article prefaces one of its rationales with this:

'...“With Medicare for All seemingly off the table, our paper suggests we can still tackle administrative costs through structural changes to the payment process,” said Kevin Schulman, MD, MBA, ...'

Why is that Medicare for All is off the table?

Most people have no idea how captured healthcare is. There's no competition, indeed most healthcare is government granted monopolies already.

Having lived in countries with "free" healthcare, that isn't all it's cracked up to be either. A good example of cost cutting: just make the disease illegal, like ADHD in the UK. If it doesn't exist, nobody can claim medication for it. Problem solved.

Its only partial coverage and the supplemental plans also are partial. Retirees regularly rake up thousands a year in medical expenses on medicare.

If anything we need medicaid for all. Its a total mess with the piecemeal systems that exist, but in PA at least (where I live) medicaid recipients pay like a dollar for basically any service. None of the copay nickle and diming (to the tune of $30 a pop) my grandmother is hounded with constantly.

And even that is a bitter pill. Its giving private insurance companies all the money and power still. The single payer has strong negotiating power but they still have to get someone to insure the citizenry and the cartel of insurers that exist can predate off that and do so eagerly.

This is an underappreciated requirement if we want to significantly lower costs. Drug patents, medical device patents and illogical government regulations imposed by corrupt and incompetent regulators lead to massive costs for patients. Allowing drug to charge hundreds or thousands of dollars for a dose of a drug that costs .50 cents to manufacture is an atrocity. This is doubly true since a large portion of medical research that these patents rely on is done by publicly funded research at universities and research clinics. Patent laws need to be completely rewritten to allow for a decent return on investment while disallowing price gouging.

Medicare for all solves the access problem, but it doesn't do anything for the efficiency problem.

As frustrating and arcane as the current system may be, the government fully in charge for the provisioning (rationing) and financing will only increase 'worthless paper, administrative costs'.

I was able to walk into a fairly large hospital, get a full battery of tests along with a thankfully minor diagnosis and medication for a small amount of money paid up front. The bill was itemized, translated, and I received excellent customer service.

Imagine if auto insurance were eligible to be provided by your company as a tax deductible expense. We would all be buying our gasoline through our car insurance company.

I required a non-elective procedure not covered by my grandfathered pre-ACA insurance back in 2014. I attempted to "shop" the procedure around. It was was not at all easy. I would have rather dealt with insurance.

The healthcare insurance industry absolutely needs to be destroyed.

One day, we'll look back at this debacle similar to cigarettes, big industry manipulating the population and millions of people dying unnecessarily because of it.

It's time to end the suffering.

For historical reference, employer-paid insurance only became prevalent in the US during/after World War II as a way to compete for labor after the government implemented wage controls. When the wage controls were lifted, people had become used to the benefit of employer-paid health care and it stuck.

My sense is the US will never move to the model you describe with young men creating a buying group for very specific policies. Society is simply not going to accept extreme differences in premiums for young, healthy people vs much older, less healthy people.

Provider merges drive up costs.

Health insurance is the buyer of medical care, so when they are monopsony (buyer side monopoly) they drive down costs.