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> First off, you won't convince me these folks don't belong in jail. I just dont' think anything less than serious criminal penalties is going to get us anywhere anymore.

Agreed.

Company wise, I’d like to see these things handled like the FDIC handles a bank failure. The Feds come in, wipe out upper management, and have another org take over as caretaker.

Otherwise these fines just get paid out of increased premiums. Which probably makes the folks responsible giggle as they immediately go and do the same thing again.

I would have agreed with the caretakers proposal a year ago. However you can see how it could be abused. Even jail as a remedy is precarious these days.

Business penalties shouldn't be fines but partial government ownership. This

1. hits the management/owners but in a way in keeping with the benefits/protections that corporation provide (government isn't directly coming after owners/management) so we keep a 'do business' friendly regulatory environment. Owners are simply diluted with less ownership and management now have the government operating from within giving the government more visibility.

2. Over time, companies that continue to break the law become government owned. Additional fine percentages should be on a increasing scale.

There needs to be rules about ownership and a time period they are held so the government doesn't just seize business but the current corporate fine structure simply doesn't work.

Personally I’d rather they dictate leadership must change, as well as board members. If the ceo is part of the board remove em they are clearly driving the problem as a conflict of interest.

> In the end - the absolute best of everything is expensive. Very expensive. I doubt a system can afford to have that happen for everyone,

It's not a question of money. If there's one person who's acknowledged as "the best" at something, that puts a hard limit on the number of people who can hire "the best" for that thing in any particular time window. Paying more won't give that one expert more hours in their day.

It’s a matter of money in that we have a finite resource (one person’s time) and in-demand finite resources tend to have a high price.

At a systems level someone pioneering surgery techniques should probably spend most of their time researching and teaching, with surgery being a small portion of their time used to maintain the practical knowledge needed to better teach/research.

Indeed. And one downside of a private healthcare system is that people who don't need the very best, and would be fine with any competent doctor but have the means to pay for the best use up that time, and people who might legitimately need that additional expertise that don't have as much money can't get it.

This is also true of course, but i'm using "best" more colloquially - let's assume it's top 10%.

That would match the rough stratification of doctor salaries (accounting for specialization, etc).

The average primary care family physician earns 350k in the us. The top 10% earn 1.3 million. The top 1% earn 4 million[1].

So enough people are hiring the best, or paying the best, to get a 4x difference and 10x difference in yearly pay.

I chose family PCP's because it seemed more unlikely that the top family PCP should be worth 10x more than the average. Whereas in something like neurosurgery, maybe? It felt at least arguable. Happy to be shown i'm wrong here.

In any case, it seems like this level of stratification would not exist if people weren't trying to get to see the "top" doctors all the time.

[1] There are lots of different data sources, but they all roughly have the same relative stratification even if the exact numbers are different. Since the actual numbers don't really matter to the point i'm making, i didn't try harder. But i will say all the data I find seems a bit of a mess.

But if the insurance isn't going to pay, they shouldn't have pre-approved it.

Of course, but that's sort of orthogonal to the patient base level expectation here.

The point of insurance is that it should not matter. Some providers may charge more, some less, insurance should care about the average. In other countries you may be treated by great doctors and still be covered by statutory insurance.

Patient primary expectation is always to have a doctor they can trust. That can be fixed only when all doctors get the decent money and comfortable work environment and that means several things: the less middlemen the better, the cost of living including housing should be affordable and put them in middle class, the treatment standards should give them enough time and flexibility, etc.

Didn’t, in this case, the insurer care precisely about the average—setting reimbursement at the average rate for people receiving masectomy care in the state?

Doesn’t it say that most people post-masectomy get “a relatively straightforward surgical procedure using implants filled with silicon or another gel,” which, judging by how unusual the article makes out this surgical center to be, seems to have medically reasonable outcomes?

One big argument missing here is why the “natural reconstruction” option is different from the normal option, aside from the patient who explained that “the idea appealed” because she “felt like [she] was taking something foreign out of my body, cancer, and [she] did not want to put something foreign back in.”

So it seems like, faced with this medical need, some people want a procedure that involves “five operations” in a setting “combining the luxury feel of an upscale plastic surgery practice with the mission-driven zeal of a medical clinic,” where instead of the implants the proprietors do “lengthy and complex operations [that] can last up to 12 hours with big medical teams involved.”

It’s true that the latter probably costs more than the average—and it’s more than reasonable that, when it comes to their own care, anybody might prefer the luxury (or just humane) setting and the dozens of hours of painstaking hand-reconstruction.

It’s also obvious (and settled in court) that the insurer got up to some shady business in this particular case (not least the “for me but not for thee” stuff).

In the general case, though, I have a hard time making the case that it’s fair for a patient’s preference alone to be enough to justify bumping the cost by an order of magnitude or two—especially since insurance spreads those costs out among all the other people paying for insurance, not the dastardly execs directly.

If you can afford luxury then pay extra for luxury, fine. But the insurance feels to me like it’s there to meet the basic medical part of the requirements.

The fancy clinic was good enough for them to approve it for their own wives, it seems.

Oh agreed—that seems reprehensible on its surface—not that I imagine it was anything the people involved took lightly.

But in the spirit of, in your professional capacity, taking care of the people you owe a professional duty to before you take care of yourself (in the material sense, at least)…

One imagines these families in particular could afford the difference for the premium care, on their insurance-company-executive salaries.

Fortunately the jury seems to have agreed too.

I agree with the vast majority of what you say.

I will poke at one part:

"Patient primary expectation is always to have a doctor they can trust. "

I don't believe this was the expectation here - trust was not even mentioned. Only credentials were.

I don't disagree it should be the expectation, but it's definitely not in the US and i don't think you'll get there without changing how people think.

Even when it is, trust here seems to be often equated to "how impressive/popular a doctor they are", rather than "how effective a doctor they are" or something sane. At least in the US, the doctors patients trust the most are the ones with the most credentials, awards, etc. It's a popularity contest instead of a baseline competency contest.

If you listen to lots of people in the US talk about choosing and trusting doctors, it's about what school they went to, or what awards they've won, or who else they've treated. Not always, but lots of times. This is not a new thing.

For example - my parents (in their 80's), all of their friends, and heck everyone i've ever met in their community is the same way, and have been for at least 50 years. They don't actually trust doctors who didn't go to harvard, etc.

I think that has to change as well.