What happened with HMOs?

Back in the 1970s, I remember occasionally reading a newspaper or magazine article about this mysterious thing called an HMO—a “health maintenance organization.”

The idea was that the medical system as we knew it (you go to the doctor when you’re sick and pay some money, or you go to the hospital if you’re in really bad shape and pay some money) had a problem because it gave doctors and hospitals a motivation for people to be sick: as it’s sometimes said today, “sick care,” not “health care.” The idea is not that health care providers would want people to be sick, but that they’d have no economic incentive to increase the general health in the population. This seemed in contradiction to Deming’s principles of quality control, in which the goal should be to improve the system rather than to react to local problems.

In contract, the way HMOs work is that you pay them a constant fee every month, whether or not you go to the doctor. So they are motivated to keep you healthy, not sick. Sounds like a great idea.

But something happened between 1978 and today. Now we all have HMOs, but there’s even more concerned about screwed-up economic motivations in the health care system. This time the concern is not that they want us to go to the doctor too much, it’s that they want to perform too many tests on us and overcharge us for ambulance rides, hospital stays, aspirins they give us while we’re in the ambulance or the hospital, etc. I guess this arises from the fact that much of the profit for HMOs is coming not from our monthly fees but from those extra charges.

What’s my point in writing about this? I’m not an expert in health care research, so I don’t have much to add in that direction. Rather, I’m coming at this as an outsider.

The simplest message here is: “Ha! Unexpected consequences!” Or, to get more granular, you could say that as long as there’s loose money floating around, there will be operators figuring out how to grab it.

Still, it’s interesting to me how HMOs solved a problem of counterproductive incentives but then this led to a new problem of counterproductive incentives. And I don’t think it’s inevitable, as there are lots of other countries that don’t have this particular set of problems with their health care systems.

71 thoughts on “What happened with HMOs?

  1. It’s a widely held view that doctors perform too many unnecessary tests as a result of economic incentives, but I don’t think this is well substantiated by empirical evidence. It’s just that we observe tests that turned out to be unnecessary and usually don’t observe tests that would have been necessary and weren’t done. That seems to be really common too: http://www.nber.org/papers/w26168

    So I think the better model of the world isn’t that doctors are trying to take advantage of reimbursement, but that they try and guess who needs tasting and treatment in a very noisy environment and based on an inaccurate model built largely on anecdotal evidence.

    • If a patient remains healthy it is impossible to prove that a medical treatment was necessary to prevent an illness. There is no evidence except professional opinions, and they may differ.

      The optimal economic strategy based on a typical medical tariff is to postpone preventive actions and to wait for a serious illness that would permit more expensive actions and medications.

      • Not impossible, but it requires randomized controlled trials. You need to randomize people to do preventive care, and not do preventive care and then look at rates of illness in the two groups. It’s generally not done really.

        • Unfortunately, there is no such thing as random people, there are only uncontrolled variables. And in most cases the professionals who collect the data can manipulate them in their favor.

          Even the double-blind randomized controlled trials make this only difficult, but not impossible because placebo usually does not produce side effects.

        • When you’re treating a specific illness with a drug that has side effects it’s more complicated. When you’re doing a comparison of preventative care to no care all you need is to follow up with the control group long enough to get their outcome measures, you don’t need to give them a placebo. They don’t even need to know they’re in a study really, just select them off the rolls of your health insurance plan as controls.

        • Unfortunately, there is no such thing as an uncontrolled control group.

          The disaster with all predictive models in the COVID-19 pandemic has clearly demonstrated that it is not enough to believe that some variables are random or not connected. You must prove this on base of knowledge, not on base of ignorance.

          The medicine, the human behavior and even the food are changing over time. The preventive care is also based not on a random selection, but on conscious actions of patients and their doctors. You cannot claim that the variables you ignore are fixed or not important (if you try to get real knowledge and are not simply playing with numbers).

        • It largely depends on the situation. If you want to know the difference between “doing x” and “doing nothing” over a period of 2 years in a specific patient population then going to the list of those patients, selecting 2000 of them, randomizing them to 2 groups, doing x to 1000 of them and doing nothing to the other 1000 and then following up with everyone in 2 years is a valid study design. The “do nothing” group need not even know they are in the study. This is a valid study design precisely because you defined their group as “doing nothing”

          If instead you want to know what happens when that group gets a placebo treatment… Then you can’t do this design.

        • It seems you mistake unknown dependencies for randomness. Your method will only prove that the hospitals are dangerous because most patients there are ill and frequently die.

          First of all, you have no permission for “doing x” to humans. There are the basic rules you must follow to avoid jail. You need at least a confirmation form with a personal signature from each participant, and already this introduces hidden dependencies into the data.

          It is also impossible to prove that the patients in two groups are the same unless you make the same measurements and the same professional diagnostics in both groups. Even if the precise data is stored somewhere, you are not permitted to use it without personal permission from test subjects.

          There is only one valid design in medical studies: fix all the variables that can affect the results, except the variables you are researching. Otherwise, the results would be as useless as the results in the nutrition and food studies, where basic concepts get periodically proven completely wrong.

        • I’m not exactly disagreeing with you. I mean, the best studies involve careful measurement and control of things. But I am saying that you can determine how much of an effect “trying to do x” has on people (on average) using the design I mention (obviously you’re right you can’t just “do x” unless “do x” means “offering some treatment”). That’s not a very strong form of measurement, but it’s not observational nutrition either. Remember, here we have a direct treatment: supplying X to a particular group, whose only commonality is that it was randomized together by an RNG. You don’t have any of that in observational nutrition.

          If you use tiny sample sizes you’ll have more serious problems. But if you’re randomizing a large group (thousands), balance between the two is virtually guaranteed to within reasonable epsilons by the RNG.

        • Taken to its logical conclusion your claim is that if a group goes to a region in west africa, and randomizes different people in villages to receive either nothing or a vaccine against some mosquito born infection, and then follows up with that entire list of people in one year to determine whether they experienced the symptoms of the mosquito born infection at any time during the last year… that they might as well have just thrown their money and drugs in the trash, it offers no information about the effectiveness of that vaccine.

          I strongly disagree.

        • The medical experiments usually do not find something new, but only prove already existing observations. In many cases they simply fool the experimenters who are blinded with hope to prove the things they believe in.

          You are not permitted to simply give any vaccine to any random people in the USA or in the wildest parts of West Africa. You must prove to authorities that your experiments are ethically correct even before you give something to experimental mouses. And you cannot let people die by simply placing them them into a “control group” which will be not provided with some medication or vaccination that promises to save their lives.

          There is a simple dilemma: clean medical experiments are not ethical, and ethical medical experiments are not really clean.

          The problem is hidden behind the term V&V. It is not enough to prove that your results are statistically significant. (Verification) It is critically important to prove that they are not meaningless. (Validation)

          There are 2 main problems:

          1. You can extract some information from big samples, but you cannot control important variables. A human is a complex self-organized system with unpredictable reactions to the simplest signals. Even the same amount of the same food can be healthy for one person and cause a life-threatening allergic reaction by another. You could not find the difference unless you have data from very specific allergy-tests. However, if you ignore such reactions you could measure not the effect of your medication but the effect of a some random component in the cover of your pill.

          Most findings in such studies are produced by ignorance of unknown dependencies.

          In your sample with West African villages you could measure not the effect of vaccines but the effect of sizes of villages or the distances from a village till the nearest swamp. The size of your group do not solve this problem. You cannot be sure that your randomization is really random enough unless you carefully analyze all such things.

          The main problem with the current pandemic is that the critically important data is simply not collected. (The bureaucrats are again saving money in the wrong places. Some of them even claim that the doctors do to many “unnecessary” vitamin-D3-measurements, however the level of this vitamin is the factor of survival by COVID-19.)

          2. You can make tests, observations, inspections, and gather all important data from each test subject, but this is not for free. Let’s say, a complete sets of measurements costs $100 per mouse and the analogous set of measurements of a human patient costs $1’000. You have a budget that could not exceed $20’000, and you must prove your theory on the mouse model and on humans. How many patients could you recruit for your research?

          You could rise mouses from one genetic line and claim that they are nearly the same, but all your patients are entirely different. (Experiments which include siblings are much more expensive.) This means, the reaction of your test subjects to the same medical intervention will surely to be different, and you can only hope that these differences would be small enough to let your results remain somewhat statistically significant.

      • Vit R –

        > The optimal economic strategy based on a typical medical tariff is to postpone preventive actions and to wait for a serious illness that would permit more expensive actions and medications.

        Would that be the optimal economic strategy if you consider the “opportunity cost” of identifying illnesses at an early stage?

        • A right process design aligns the personal goals of people who participate in this process with the main goal of the whole process. Such optimization is very difficult in this area.

          For instance, a qualified decision about a therapy strategy must consider opinions of two professionals from different fields. The first is an internist who gets money for curing a pancreas and who awaits many future sessions with the same patient. The second is a surgeon who gets money for cutting the same pancreas off and who makes this operation one time.

          Even worse, two doctors in the same field could objectively need quite different budgets for tests because one of them has less experience and needs more data to make the same right decisions. But the same economic description could mean that one of them is more experienced and objectively needs additional data to make more precise decisions and to recognize exotic cases.

          Except for some criminal cases, the private healthcare makes the health better and the expenditures smaller. It is based on expensive professional services, extensive tests, carefully selected interventions and limited medications.

          The fools who control the health care business produce conflicts of personal goals and turn the behavior they “try” to prevent into the optimal economic strategy.

          The tariff systems produced by bureaucrats force limited professional services, carefully selected tests, extensive interventions and expensive medications. I know some German doctors who were forced to pay the insurance companies from their own budgets because they did not let the patients get ill and “caused not allowed expenditures”.

          If a hospital receives the biggest profits from terminally ill patients — and this is usually the consequence from the rules — an optimal strategy would be not to stop the illness and produce expensive meaningless manipulations that cannot cure and cannot harm the patient. Any spending would be proven because this strategy would produce the best bureaucratic proof: a surely dead patient.

  2. The “loose money” is grabbed first (and overwhelmingly) by insurers, second by pharma/med device, third by hospital systems, fourth by physicians. Follow the incentives of the highest moneyed players in the system and you will find the rules of the game. Briefly, HMOs as evolved in the event, are instruments of player number 1, with concessions to players 2 and 3. Player 4 deals with the faît accompli of the first 3 either by doing crooked things (small percentage), following incentives to prefer remunerative options over similarly helpful less-remunerative options (larger percentage), or letting the system play them and figuring they will make pretty good money if they just do their jobs (most).

    Other developed countries avoid the problem by having a robust public insurance option (which has its own problems) but keeps costs way down. In this country, the dominant insurance player is Medicare (needless to say, public), but due to inordinate influence from player 1 (and the complicity of the other players), it is largely a toothless competitor with the private segment. As an example, only private insurers can negotiate with pharma for retail drug prices for their enrollees. Medicare cannot. You can imagine how drug prices might change if that negotiation were permitted. This is only one such example.

    As a practical matter, as long as the lobbies of the above players—in particular, the first 3–remain unchecked, you can forget about a robust public option. The most likely scenario toward improving that incentive structure would be a gradual drop in the qualifying age for Medicare, starting with 60. If it ever gets as low as 50, that’s the tipping point. I don’t see the overall game changing without that dynamic.

      • I might be misunderstanding what you’re saying. To me it makes perfect sense to point out that some drug is barely useful, and then “enthusiastically” advocate for it being cheaper. If a drug is better than nothing, but not by a lot, then I might think it’s not worth $100/dose but if they can get it down to $1/dose then yeah, absolutely, that’d be great!

    • When universal healthcare was being proposed in the Truman administration, it’s worth remembering that the AMA (i.e., doctors) were one of the main obstacles to reform. This was a time when the other players you mention were much less strong in influence. I think your comment lets doctors off the hook as a group of individuals with substantial influence. They have a lot to lose from a more robust system of public insurance.

    • > Medicare (needless to say, public), but due to inordinate influence from player 1 (and the complicity of the other players), it is largely a toothless competitor with the private segment. As an example, only private insurers can negotiate with pharma for retail drug prices for their enrollees.

      Someone could understand from that description that Medicare pays whatever drug companies want to charge but it’s more complex than that. For example, drug reimbursement in Medicare Part B (which covers physician-administered drugs in an outpatient setting, mostly oncology treatments) is linked to the average price paid by non-federal buyers (plus 6% intended to cover for overheads).

      Anyway, drugs are only a part of Medicare spending and that example may not be representative of the full picture. Private insurers pay more than Medicare for hospital and physician services: https://www.kff.org/medicare/issue-brief/how-much-more-than-medicare-do-private-insurers-pay-a-review-of-the-literature/

  3. One of my favorite subjects. For starters, I recommend highly, Marty Makary’s The Price We Pay. It delves into the business of medicine which is not well understood by consumers of medicine. I claim that people can’t evaluate the value of physician’s medical diagnosis and prognosis without also an understanding of the hospitals’ business model and more specifically its billing system. This is especially necessary to contest surprise billing.

    More importantly, a prelude to this subject, it is helpful to appreciate the twins: overdiagnosis and overtreatment. Gilbert Welch’s Overdiagnosed is worth a read. Paul Offit’s Overkill, and Shannon Brownlee’s Overtreated.

    In reading these books [countless others as well], I don’t see much effort in the statistics expertise that can address these issues without also risking career.

  4. To add, my former husband was Director of Compensation and Benefits for the Harvard Community Health Paln as well as Boston’s Children Hospital back in the early 80s and as a partner at KPMG, he had hospital clients.

    Since the, I managed to keep abreast of the Evidence Based Medicine movement.

  5. The nut of the problem right here: “seemed in contradiction to Deming’s principles of quality control, in which the goal should be to improve the system rather than to react to local problems.”
    Healthcare misinterprets Deming’s philosophy as “quality control” when he considered attempting to “control” a system as “tampering,” and the enemy of “continuous quality improvement” of systems.

  6. “this mysterious thing called an HMO” originated from Congressmen with the 1973 HMO Act.

    It’s a non-actuarial “insurance” scheme for medical care, where providers limit their costs by limiting services.
    The government heavily regulates/controls everything.

    ‘Medical/Health Care’ is a vague open-ended concept which does not mesh with objective standards of normal insurance programs.
    One does not insure against routine events that will likely occur; one does not buy insurance to pay for oil changes & replacement tires on an automobile — insurers would have to charge premiums higher than the normal costs of these services and/or severely limit how much service they will pay for. Same thing happens in medical care, except the government mandates many services and heavily subsidizes medical care via taxes and debt.

    Massive economic distortions are introduced into what should be a relatively straightforward buyer/seller relationship– everyone is thus confused and costs rise greatly and constantly.

  7. See Deming’s 14 points for management: https://deming.org/explore/fourteen-points/

    For example, instead of eliminating these “controls”, healthcare has gone all in:
    11b. Eliminate management by objective. Eliminate management by numbers, numerical goals. Substitute leadership.
    10. Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.
    12b. Remove barriers that rob people in management and in engineering of their right to pride of workmanship. This means, inter alia, abolishment of the annual or merit rating and of management by objective.

  8. The model followed by medicine in the previous era was predicated on professionalism. Professionalism is an ethic that the doctor will place your interests above his own. The overwhelming majority of physicians acted largely in accordance with this idea. Medicine was a lot less technical then, only plain X-rays, minimal chemotherapy, very few cardiac surgeries, etc. As better imaging, chemotherapy, cardiac surgeries, joint replacement surgeries, etc came along costs to consumers rose. A cost to the consumer is revenue to health care systems. When these revenues got really big, the delivery system changed. I remember sitting in lots of hospital staff meetings where some healthcare MBA would say “You doctors have to learn to think like businessmen.” We never did, and they bought us up. Vertical integration followed, and big business has acted the way it always does.
    The problem with a business based approach is that it requires a free market to work in order to provide effiency and low cost. A free market requires symmetry of information and freedom to walk away from the deal for both buyers and sellers. If you’re having chest pain, you are not in a good position to walk away from the deal. You need a countervailing influence. In most nations this is the government. Our government has made ten thousand rules, laws, and regulations for healthcare, but regulatory capture is part of healthcare. Thus a unit of blood ready to be transfused costs $900 in the US, $150 in Germany, and $100 in the UK with very little difference in quality.

    • Underlying the quality of health care systems is the question of the value of many major medical diagnoses and treatments: evaluate cancer and heart disease treatments.

      Granted hospital emergency room procedures have saved lives. But in so far as other functions of hospital and physician care, a patient has to be exceptionally savvy about the treatments offered. Only a subset will inform patients of the downsides of some treatments and their longer term effects.

      Unfortunately patient advocacy has been compromised considerably by virtue of it being sponsored by special interests. So far only a handful of non-profits have been able to maintain a larger degree of independence. Lown Institute as one. The Arnold Foundation is one grant sponsoring entity that also presents forward thinking on healthcare.

      Thankfully, As pioneers of the Evidence Based movement, David Sackett, Doug Altman and others brought the state of medical education to the attention of the physicians themselves for subsets of them have authored some exceptional work.

    • This is a pretty good analysis. The logical conclusion is that we should embrace a free market approach when the issues are relatively less urgent, such as say knee or hip replacement, cataract surgery, and everyday treatment for sprains or blood pressure management or whatever, and put the govt in charge of handling “emergency” situations where there is little chance for competition. The answer is what I’ve advocated to my friends who want UK style health:

      1) Have the govt create a universal billing clearing house, similar to the checking clearing house. Everyone bills the govt clearing house using your SSN or whatever.
      2) The government covers 100% of amounts above some threshold (ie. GDP/capita/5, currently about $12k)
      3) UBI paid by the government to all citizens and residents can be used as cash for whatever, should be in the same range GDP/capita/5 or so.
      4) Individuals are responsible for their bill up to the threshold by paying the single clearinghouse.

        • Pre-Negotiating prices for emergency care procedures would be part of the whole stop-loss coverage thing, just as it’s part of Medicare reimbursement currently, yes. It wouldn’t really require adding in much new, just applying the existing mechanism more generally.

    • This is on the right track. Our health care system(s) if full of warped incentives, but in my view the biggest issue with HMOs is a statistical one. If the distribution of physician talents was degenerate, then most of the stated arguments would suffice for analysis. However, physicians vary considerably in their abilities. In general (with all the caveats that go along with generalizing), I’ve had the impression that the “best” providers do not want to be employed by HMOs – the productivity targets (see a patient every 10 minutes, for example) conflict with what they consider good medical practice. So, the quality of care you get from an HMO is worse than through other insurance schemes (although PPOs have some similar characteristics). I think it has at least as much to do with the quality of the providers as with the incentives for quantity of care.

  9. Andrew, the answer is that the HMO model you’re thinking of doesn’t exist anymore except outside some niches. They were driven away by a backlash in the 90s that was worried about something different—paying a capitated rate gives providers the incentive to undertreat. The consequence of the backlash was an increase in spending/health share of GDP (http://economics.mit.edu/files/8448), meaning those fears were probably overblown. With ACOs it looks like there’s some appetite to get back to that, although not that much of an appetite. People are probably sick of large paradigm changes in US health care at this point…

    It is pretty clear to me that the unbundling of health care since that time has been surprisingly bad, despite what we usually worry about when potential competitors coordinate. https://www.nber.org/system/files/working_papers/w23623/w23623.pdf is a good example of when unbundling in the hospital raises prices for patients severely.

  10. Just a few points: First, HMOs sort of came into popularity in the 1980s and especially 1990s. This is what the temporary slowdown in healthcare costs in the 1990s is sometimes attributed to (no idea if it’s actually the case). However, my understanding is that “consumers” hated them — i.e., the goal of the HMO was to provide care while controlling costs, and this meant going through your primary care doctor for referrals to anything, and they would not undertake unnecessary (or in some cases, what seemed like necessary to the patients) care, supposedly. There are still some popular HMO systems — see Kaiser Permanente in California or Georgia. Second, the way our insurance system reimburses care is important. That is, largely fee for service, generally, although with the ACA there has been some shift to try and make this less the case — others with more expertise can comment on the current status of things. This has certain incentives. See for example, the phenomenon of “upcoding”: https://twitter.com/asacarny/status/1427285494317010954

    I find some of the above comments about blaming insurers, pharma, and hospitals first before blaming doctors to be quite interesting. The way to reform the system is to have a robust public insurance system (we don’t need private for-profit insurance companies) that negotiates prices with pharma, and to take antitrust action against hospitals and physician groups creating large conglomerates. What’s interesting to me is the lack of mention of the American Medical Association (AMA), essentially a cartel of physicians that has (1) opposed public insurance expansion throughout our modern history, because it would mean lower salaries on average to them (still high when comparing to any other country); (2) restricts the supply of doctors. Look at the doctor to population ratio in the U.S. vs a lot of other countries, and also look at their salaries. They are not a blameless group, and indeed, they are often one of the major obstacles to change in our system. Having more doctors might have helped in the last year or two.

  11. “Items like drugs, medical equipment, and computer software, which would all be relatively cheap in a free market, instead cost us huge amounts of money because of these monopolies. In the case of prescription drugs alone, patent monopolies and related protections may add more than $400 billion a year (roughly $3,000 per family) to our annual bill. In total, the cost from these protections can easily exceed $1 trillion a year (almost $8,000 per family).”

    https://www.cepr.net/the-26-an-hour-minimum-wage/

    “Similarly, the push for free trade has been very one-sided. While our trade negotiators worked hard to eliminate barriers to trade in manufactured goods, thereby pushing down the wages of workers in the manufacturing sector and workers without college degrees more generally, they did almost nothing to eliminate the protectionist barriers that allow our doctors and dentists to earn roughly twice as much as their counterparts in other wealthy countries. This transfers roughly $100 billion annually, or $700 per family, from the rest of us to doctors earning an average of $300k a year and dentists earning an average of more than $200k.”

    https://www.cepr.net/can-we-cut-the-crap-on-unconstrained-globalized-capitalism/

  12. You cannot make anything better by inserting bureaucracy into the process. Even if you call it “science”. The intentions are irrelevant. Any kind of bureaucracy always produces unintended consequences.

    An insurance company is not a “health maintenance organization”. It pays the doctors not for the health, but for reports. This is a typical socialistic enterprise where the consumer quality is irrelevant for all people who do and manage the job.

    Consequently, the doctors are motivated to produce illnesses and make them chronic. This allows them to sell medication and to report additional work load to the insurance companies.

    Fortunately, the insurance companies can waste any amount of money on this reports’ production processes because they do not have any responsibilities and always can blame the evil doctors for their greed.

    PS: As a rule, the “expensive” private medicine is cheaper in most cases and is sometimes a factor of survival.

      • Yes, add lots of carbohydrates to it. That makes you crave more food. Why do you think you get rice, fries, bread with every meal at a restaurant?

        It only takes a 3-7 day self-experiment to prove this to yourself. If you have never tried it, you have no idea that what you call hunger is actually an addictive craving. Anyone can do it while saving money.

        • Anoneuoid –

          > Why do you think you get rice, fries, bread with every meal at a restaurant?

          Be use they taste good and are satisfying in the short term. And so that’s what customers seek out. Are you suggesting a kind of conspiracy?

          Seems to me that people eating a lot of carbs was happening for a long time in a lot of places that were pretty much untouched by any involvement of chefs. No?

        • Well,in this case anoneu is not alone. For example, physician-lawyer David Kessler (former FDA commissioner, former dean Yale Med School, etc) wrote a well-reviewed book titled The End of Overeating which expresses similar views. For a reasonably balanced review of it see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2752095/.

          It’s not a conspiracy—it’s just a consequence of incentives. People who eat like tasty food. People who sell food provide what people want to buy, not what is best for people.

          Bob76

        • Bob –

          >Well,in this case anoneu is not alone… It’s not a conspiracy—it’s just a consequence of incentives. People who eat like tasty food. People who sell food provide what people want to buy,

          So the answer to this question…

          > Why do you think you get rice, fries, bread with every meal at a restaurant?

          …is obvious.

          Meaning you agree that yes, chefs “cause hunger?”

        • My comment does not express a position on the proposition that “chefs cause hunger.” Rather, I pointed out that Kessler seems to take that position.

          I did take the position that many chefs try to cook food that tastes good.

          I have found that even when there is no chef within miles, if I have not eaten in several hours I get hungry.

          Bob76

        • Bob –

          I note that in the article you linked, Kessler’s view is that the culprit is other than “rice, fried, bread at every meal” (at least the proximal cause isn’t).

          The point just being that Kessler’s argument and Anoneuoid’a argument are not the same.

        • There’s a lot to unpack here. The claim is something like “chefs ’cause hunger’ by adding ‘rice, fries, and bread at every restaurant’ and/or by adding ‘lots of carbs to the meal.'”

          Are rice/fries/bread added at every restaurant?
          Are lots of (other) carbs added to (every meal)?
          Do rice/fries/bread cause hunger?
          Are chefs responsible for adding rice/fries/bread (or lots of other carbs) at every restaurant?
          What does “cause hunger” even mean?

          etc

          I think the above claim needs to be better-framed before one could seriously evaluate it.

          I don’t think chefs are shoveling french fries down consumers’ throats. They are certainly a popular option at restaurants, but that’s part of the point: they are a menu option. Per Joshua’s point, overeating is complicated. Some people have atypical feedback systems that alert the body it is satiated. Sometimes medication can interfere with this system–talk to anyone that’s been on an oral dose of prednisone for a month!!!

        • Yes. Chefs prepare the food that people will buy the most. If you add carbs to every meal then people will eat larger meals and more often. That is what people want, just like drug addicts want their drug.

          Eat all you want but keep your carb intake under ~50 g/day (even 100 g/day may work) for a week and you will see your appetite plummet.

          You will only feel like eating to resolve real hunger, not those “pangs of hunger” which are instead a carbohydrate withdrawal symptom.

        • Andrew, I don’t care if you eat bread. But you are going to feel hungrier later than if you had instead eaten some meat and vegetables (and kept this up for a few days).

          It isn’t subtle, it is a really drastic reduction in appetite.

        • Andrew –

          > I just baked a loaf of bread and ate it.

          The whole loaf?!?!

          Anoneuoid –

          While I get the whole carbs thingy, it’s pretty obvious that the dynamics of overeating (not to mention overweight/obesity) is a complex mix of the physiological factors and psychological/emotional and social factors.
          For example, people overeat for more reasons than just “pangs of hunger” or that they feel a craving for food. In fact, I’d be willing to bet that one common dynamic is that after people abstain from carbs for a few days they follow it up with a binge on ice cream or something like that.

        • Joshua:

          OK, if you want to get technical I baked 3 loaves using 1 kg of flour and ate most of one of the three loaves. I guess I’ll finish it soon. Whatever we don’t eat today I’ll put in the freezer. But it’s better fresh.

          Anon:

          There’s individual variation. All my life I’ve loved bread, and it was a real revelation when I grew up and discovered bread that was more delicious than wonder bread or pita bread from the supermarket. I’m one of those people described in the above-linked review of the Kessler book for whom “eating serves a hedonic role to satisfy our liking and wanting of food.” It works for me! I mean, yeah, I know I’m incredibly fortunate to be able to eat yummy food every day, in the same way that I can read any book I want and am not restricted in entertainment to whatever’s on the 3 TV channels, etc.

        • It seems everyone wants to talk about something besides the original topic.

          Can chef’s cause hunger?

          Yes, they can and do by adding lots of carbs to the meal. Nicotine is addictive in the same way, it spikes your blood sugar.

        • Anoneuoid –

          > It seems everyone wants to talk about something besides the original topic

          I don’t know who “everyone” is or why it seems that way to you.

          > Yes, they can and do [cause hunger] by adding lots of carbs to the meal.

          Your logic seems similar to saying gasoline companies “cause” deaths in automobile accidents.

          We could argue the semantics but it seems rather silly to do so. Someone comes to a restaurant hungry. They eat some food because they’re hungry. Maybe if they eat a lot of carbs they’ll eat again soon thereafter. Maybe if they don’t eat many carbs they’ll eat again soon thereafter but less soon thereafter. If they decide not to eat anything and drink water instead, maybe they’ll eat again soon thereafter. It’s obviously multifactorial. It depends on the in social, on their psychology, their emotional state, their physiology, and many sociological and economic or even demographic factors.

          Personally, I think the logic of your causal statement is so simplistic as to be rather absurd.

          If you want to say instead that the amount of simple carbs that are readily available and eaten in large quantities by Americans (in particular), including including in restaurants, contributes to the problems of overweight/obesity – that seems to me to be entirely reasonable.

        • Just even looking at something as simple as the amount of rice served in Asia makes it clear why your simplistic causality is pretty meaningless, imo.

          Do Asian “chefs cause hunger” by feeding their customers significant quantities of rice with every meal? How about Asian mothers that have been serving large quantities of rice to their families with every meal they serve for centuries?

        • Andrew -.

          As for your bread baking/eating. I certainly understand. The smell of fresh bread out of the oven, with butter melting into the still warm slices. I blame God for all of that – because it makes me hungry.

          I’ll stop with Anoneuoid now.

        • As I said originally, you can do a simple, safe, and cheap self-experiment to find out what I mean. Or not. I.e., anyone can use science if they care to find out. If not, that is your loss for resisting an opportunity to better understand your own body and health.

          The number of paragraphs this has generated is ridiculous.

        • This one more.

          Anoneuoid –

          > Or not…

          I’ve followed the keto diet for fairly long stretches more than once, and I do multi-day fasts from time to time.

        • I had the opportunity to try Anoneroid’s experiment over two weeks ago, actually, when I went on vacation with another family (they like to eat!). We went to restaurants for breakfast, lunch, and dinner, and we ate a lot of carbs (e.g. breakfast consisted of doughnuts or pancakes every morning, dinner was pasta or fried food, etc). I could only handle this pattern for a couple of days–I found myself not being hungry at meals any more and started dreading going out to eat! It seems the short-term impact of eating a lot of carbs at meals decreased my appetite. The exact opposite outcome from Anoneroid’s claim.

          To make myself hungry at meals again, I switched to a low carb diet of bacon, yogurt and coffee in the morning and exercised in the pool. I found my appetite slowly came back. I then decided to eat fish and vegetables at dinner too. Once I did this, then I became hungry for all three meals again and enjoyed going out to eat. Interesting! (And sorry Anoneroid, but your absurd claim is “debunked” by the level of absurd evidence you request: self-reported experiment.)

  13. Seems to me that a for-profit healthcare system is inherently working at cross purposes. You’re necessarily introducing conflicting incentives: providing the best healthcare, and making a profit.

    Exchanging one system of unintended counterproductive incentives for another set of unintended counterproductive incentives is treating the symptom and not the disease.

    You already have one set of inherently conflicting incentives: providing the best care possible, and keeping costs down. Isn’t that enough to deal with?

    But there seems to me to be one obvious way to at least ease into addressing that problem – pay doctors a salary rather than fee for service, and make compensation for doctors more in line with other professions like teachers or firefighters. (Hey, a man can dream, can’t he?)

    • “You’re necessarily introducing conflicting incentives: providing the best healthcare, and making a profit.”

      You missed 50% of the equation: in private health care people can switch providers if they don’t like the outcome, service or price. That’s the check on the profit motive.

      Your idea that there’s some “best” or optimal treatment that only an expert can discern is highly questionable. Given accurate symptoms Google is probably better at diagnosing any given condition than the average doctor and might even be better at recommending treatment. Doctors have a very strong tendency to rely on their personal experience (e.g., bias or prejudice) over general knowledge. So consumers of medical care don’t need to rely on doctors for opinions about treatment. They have plenty of information at hand.

      • A:

        There are many dimensions to a health care system. In France you can go to a hospital or a private doctor and pay, just like how it used to be in the U.S. when I was a kid. The current U.S. system is kinda private in that lots of providers and insurance companies are taking their cut, and kinda public in that everything requires a pile of paperwork.

        Your comment about Google being better than the average doctor is interesting. I guess it depends on how people do their googling. I don’t think googling works better than my doctor, but then again I don’t really know. Also it depends on what the issue is. We’ve had some issues regarding recovery from injuries where I think doctors have been very helpful in a way that Google would not have been for us; on the other hand a bad doctor could’ve made things worse?

        • “I don’t think googling works better than my doctor, but then again I don’t really know. ”

          Maybe not better than *your* doctor – your doctor might be the greatest doctor that ever lived – but better than the average doctor. First it has broader reach and far larger memory than *any* doctor. Second it is weighted to the most recent information. Third, it has direct access to the world’s best health organizations and providers (e.g., Mayo clinic, others).

          “a bad doctor could’ve made things worse?”

          I don’t think “bad doctor” is an appropriate characterization. Doctors can give poor advice for myriad reasons. But yes of course they can make things worse with poor advice. I had issues with recovery from injuries where the doctor’s advice was useless – advice for therapy rejected, injury healed in reasonable time (months) anyway. Recently our family had a significant argument with a doctor over medications for my mother. Finally we won the argument and her condition improved significantly. Doctors have many conflicting incentives and relatively little time to balance them carefully.

  14. I happened to stumble over this amusing video yesterday. https://www.youtube.com/watch?v=Ig_ugJBmO2Y

    I think the first 5 minutes provide a good snapshot of the views of most non-USAans about the perverse US health care “system”.

    I live in Canada (ONT). Two years ago, I spent ~ 2 months in hospital after a very bad accident. A couple (3?)MRIs, attendance by a 2 or 3 neurologists, a specialist rehab physician, a GP, and several physio & occupational therapists resulted in out-of-pocket expenses to me of buying a couple of candy bars and a butter tart. The hospital even paid for a taxi home as they asked me to leave a day early to free up a bed and the person who was to pick me up was out of town.

    Oh, I almost forgot, I also received home visits from a physiotherapist and an occupational therapist for 12 weeks.

    I did get a $45 bill for the ambulance.

    Note: Our health care insurance is very good but no-where as good as some other countries.

      • Hanson’s reference concerns people fleeing the HMOs – this was a result of the poor quality of service many provided. I still think quality is a problem, but the latest incarnation is the Medicare Advantage plans. The operate in the same way – they offer lower costs in exchange for considerable constraints on services provided. I wonder how this will turn out, but it has the benefit of appealing mainly to relatively poorer older people – who may not be able to judge the quality of service they get (of course, can any of us do that? But I speak from the personal experience of my parents who sacrificed quality of care for the cheap prices).

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