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Comment by testing22321 | Hacker News Reader

Call me crazy, but it’s almost like incentives to make money rather than good patient outcomes may just lead to a whole bunch of unnecessary treatments.

Maybe for profit healthcare is a bad idea?

Surely all developed countries have it wrong.

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As a European, I can assure you we have the same problem. Healthcare providers still get payed by the insurance for the work they do, so there’s both an incentive to bill them for as much as possible and also to upsell special premium services the insurance won’t cover for, like better filling materials, invisible aligners, these kinds of things. As a layman, of course you never know if what they are offering you is really the right way, and asking different doctors for their opinion can also lead to wildly different diagnoses.

Perversely though, there is another incentive for doctors to spend as little time as possible with each patient, because they need to justify all time spent and procedures done to the insurance, which is naturally suspicious of the provider to overbill. Thus, they require tons of documentation the provider has to fill out, and neither that nor just talking to a patient for longer than usual are line items they get paid for, leading to appointments being as short as they can manage - usually rushing in, working through the list a medical assistant prepared, annoyedly answering a question if you can manage to slot it in, and rushing out to the next person.

Having a general sense of ease that a malade won’t ruin me or be a death sentence is a good thing, really, and I cannot imagine living another way. But we haven’t really figured it out yet fully either.

While some of that might be true for some countries with publicly funded dental care, it’s certainly not true for regular healthcare. Doctors are paid fixed salaries, there’s no incentive for them to perform unnecessary procedures. Quite the opposite in fact, departments have strict budgets and so they have a strong pressure to ensure all procedures are medically justifiable, and cheaper / simpler / preventative options have been tried first.

Source: Also a European, spouse is a doctor

Individual doctors working for a clinic are paid a flat salary, true - but the clinics themselves, or the small doctors running their own office are absolutely dependent on accurate billing to the insurances. They have an incentive to optimise their margins, even if patients are not paying directly, and that means both trying to spend as little on care as possible while getting back as much as possible from the insurance providers.

It sounds like you’re describing a country with a public-private hybrid system. Certainly in the UK and the Nordics, the systems I’m most familiar with, there is no “getting back as much as possible from the insurance providers”, as there are no insurance providers. The hospitals are run by the government, funded by regional governments, and have fixed yearly budgets, not treatment dependent billing. The only exception is some privately run GP clinics that may bill per service rendered.

In some countries, healthcare has nothing to do with “insurance”.

People say 'Europe', speak as if their experience is the same across the continent, and anyone with a different experience is somehow not in the Europe they mean. It's very annoying.

European healthcare is run very differently across the continent. 'Insurance' can mean a [state] social insurance institute that the doctor must bill. Some countries would employ the doctor directly as part of a nationalised health system. Some places it might be the municipality or city that would then get some subsidy from central government. Some it is a mix of all of this. 'Free' healthcare might actually mean a few hundred Euros, or literally nothing.

This! We went to a pediatric dentist with my kid on Monday, with a referral from another dentist, both private. After small talk, their first proper question was: "Do you have insurance?". Before I could respond, my wife responded affirmatively. Insurance here in Ireland means private insurance. After an x-ray, we were presented with a menu of treatment options ranging from around €2k to €5k.

Later I requested the clinic to share the x-ray with me and consulted with another pediatric dentist from another EU country. His assessment was completely different, and recommended very minimal intervention.

Sounds like your system is not perfect, but far superior to the US system.

This is the poster child of “don’t let perfect be the enemy of good”

My point was that for the specific critique raised here, the European (or the be exact, the German) healthcare system doesn’t really offer much of an improvement, but suffers from similar problems. The fact that you don’t pay yourself doesn’t change the incentives medical professionals have in terms of getting paid for their work.

Sounds like a shit system then.

In my personal experience, Canada and Australia don’t suffer from this.

The UK has the opposite problem. You don't get overtreated, but you may get undertreated - sometimes it is impossible to find a NHS dentist at all. Indeed, I went private because I literally couldn't find one after my old one sacked me. The private dentists probably have the same problems as described here. But I luckily found a small, nice, ethical one who was recommended by people in town I trust. Literal word-of-mouth still beats any algorithm I know for this kind of question.

Honestly, I think it can happen anywhere - I've had several fillings for very marginal cavities from an NHS dentist that probably weren't necessary.

Part of the reason is that fashions change... that dentist was trained at a time when minor cavities were always treated as soon as they were noticed, but the more recent recommendation is to monitor and treat only if it gets worse.

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