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I want a world where doctors are incentivized to keep all people as healthy as possible with the budget society is willing to spend on healthcare. It should also be a world where people would like to work in healthcare and which ensures a proper standard of living for those who choose to. Let's assume that there is the political will to create whatever system is necessary to achieve that goal.

  • If the medical care system of my world is a free market, then doctors will only take care of those who can afford it while poor people will suffer from curable diseases.

  • If doctors in my world receive fixed payments per procedure, they are incentivized to provide quantity over quality. They would rather treat symptoms instead of curing or preventing diseases, because that means more long-term income for them.

  • If all doctors are fixed salary employees, then there needs to be some incentive for them to do more work than strictly necessary to avoid getting fired.

  • If their salary is performance-dependent, then my world would need some system to measure their performance. But how could one measure their success in a way which is objective, fair and not vulnerable to attempts to game the system?

  • If the government would regulate medicine so strongly that doctors have no choice regarding what treatment to provide to whom, then they become too restricted in their decision making and might have to provide suboptimal health care because the rules don't allow them to do what they actually should be doing. Or is there a way to make it plausible that such a centralized decision making system makes only good decisions?

Do you have any idea how one of these strategies could be executed to make it successful? Or any ideas for alternative strategies?

Tech level: Near future.

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    $\begingroup$ "a world where doctors are incentivized to keep all people as healthy as possible with the budget society is willing to spend on healthcare" is exactly the reason of the shortcomings you list. $\endgroup$ – L.Dutch - Reinstate Monica Oct 23 '19 at 12:01
  • $\begingroup$ If there was a "best" answer to this question, it would have been implemented already somewhere on Earth. Voting to close as primarily opinion-based. $\endgroup$ – Frostfyre Oct 23 '19 at 14:31
  • $\begingroup$ Why not have your government incentivize people to be healthier? Like, some kind of bonus for exercising regularly, not over-eating, not smoking, not drinking, not doing drugs, etc. $\endgroup$ – CrossRoads Oct 23 '19 at 16:47
  • $\begingroup$ @Frostfyre The best answer to this question exists, everyone knows it is an option, but it is also so unethical its not used in the real world. Since the OP specifes "Let's assume that there is the political will to create whatever system is necessary to achieve that goal.", the ethical restrictions can be lifted for sake of this answer. $\endgroup$ – Nosajimiki Oct 23 '19 at 19:47
  • $\begingroup$ The problem here is that we actually have a close approximation to such a system: there's a vast amount of information on how to stay healthy, vaccines and other prevention measures are relatively cheap, a lot is spent on public health, &c. The problem is that most people just don't bother, then want a miracle cure when they get sick. (E.g. my neighbor, who has smoked for decades, drinks a lot, never exercises... and is scheduled for open-heart surgery next week.) $\endgroup$ – jamesqf Oct 24 '19 at 18:03
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It's almost all cultural

Healthiness must not just be needed if you're sick, but if it must be the most desired state everyone wants to achieve, they need to have healthy lifestyles.

The issue with free health care and salaried doctors is that it is still just the same as the NHS in the UK, or Medicare in Australia. Free health care may be a necessity, but does not make healthy life more desirable nor make people more healthy - it just gives them the option of health care when they become sick. Drug use, obesity and preventable disease are commonplace if cultural factors are ignored.

To truly have "people as healthy as possible" you need a system where all citizens want to be healthy. For that to occur we need:

  • A culture where it is desirable for people to have healthy lifestyles. That means eat healthy foods, exercise regularly, and regularly take care of themselves.
  • A culture where it is not desirable for people to be unhealthy. This means it needs to be 'uncool' to take drugs, alcohol or smoke. It means it should be undesirable to eat too much, and to eat unhealthily.
  • If they do succumb to illness or disease, then yes a health-industry care focus is important, however this extends not just to doctors and hospitals, but aged care, preventative medicine and research, palliative care, cancer research, education, advertising, anti-smoking advertisements, anti-alcohol strategies and so much more.

As you can see, a lot of factors go into what makes your citizens healthy, not just doctors who are often at the 'end' of the process of being healthy. It is far more easier to promote healthy lifestyles than to fix someone when they become ill from preventable disease.

If you can achieve the above, then some of your scenarios may not even need to apply, because you would simply not need to primarily focus on doctors. In which case they can be simply salaried, with free health care as they are actually a last resort measure (a literal 'safety net'), not a primary focus.

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The problem with all these answers we've come up with so far is that we keep trying to find a system to address Health, Affordability, and Morality. With that many parameters, every answer becomes opinion based because everyone has a different idea of what balance of those things are optimal, but the question does not ask that. All it asks for is the best way to keep people healthy while remaining affordable. This makes the solution much easier.

Eugenics

When you eliminate the moral concerns of human rights and preservation of life, this shows many advantages over other systems because the number 1 reason for a person to be unhealthy is because their body is not designed to be healthy. Instead of trying to save everyone, you should genetically test children before they are born for any sort of genetic disorders, weaknesses, allergies etc. If they are not fit enough you have them aborted. For best results you should terminate the living unfit as well to eliminate things like STDs and weaknesses that are not yet identified in the genetic screenings.

While this will not "save lives" in the short term, it will guide the evolution of a nation's population to become more resistant to the genetic and environmental factors that affect most people's health.

After a few generations, the only things doctors will need to regularly treat would be the occasional broken bone or common cold. No, this will not save lives, but it will make for a much healthier population. Not to mention, it's much cheaper to end an unhealthy life than to keep it going.

Side Note: For optimal long term healthiness, one should not select for what are perceived as positive traits, only against the negative traits. If a Eugenics program requires that you have a specific gene, you risk creating health problems if that gene latter becomes associated with a genetic vulnerability.

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    $\begingroup$ This.... is a bad plan. Sure, you might wipe out current afflictions, but you're simultaneously narrowing the gene pool, which makes the entire species susceptible to a sudden outbreak of a lethal disease that wipes out the entire species. $\endgroup$ – Frostfyre Oct 23 '19 at 20:13
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    $\begingroup$ Not at all. This is not much different than herds of deer that are kept healthy by wolves killing off the sick and weak. Bottle necking is only a problem when you reduce a population into the 4 digits or less, but even if you enact a really extreme form of Eugenics that kills off 90% of the world's human population, you are still looking at a 9 digit population. That is still going to allow way more than enough diversity for the population to resist new diseases. $\endgroup$ – Nosajimiki Oct 23 '19 at 20:50
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A brief summary first, then the details. Doctors get paid for healthy patient days:

Bob is my patient. He was not in treatment for 10 days!!! Yay! I get paid 10 units!! I want MORE patients please, so I can make more money!

Their incentive is to have more patients out of treatment for more days. It's a health system that measures its unit of work by healthy days.

Now for the details. As a physician you get paid based on the following criteria:

  1. Your base pay is based on your patients’ healthy days (you earn x dollars / day / patient when your patients are NOT in treatment). Every hour your patient is in treatment, you are working for free, sorry.

  2. You have permanent patients assigned randomly. You CAN NOT advertise your service or pick your patients - there is universal pre-existing condition exemption.

  3. A patient's health record is protected personal property. Just like employment or any other contract, it is illegal to ask a new patient any health questions.

  4. You get a penalty when a patient leaves you or dies

  5. You get a bonus for preventative health visits

  6. National average salary is reduced as the number of occupied hospital beds increase.

  7. Patients have a right to be reassigned by the government (they can’t choose a doctor - the Government regulates your service to distribute "unhealthy" people fairly)

Obviously this leaves room for corruption and violates many rights, if you’re OK with that. Many citizens will NOT be OK with this, so get ready. Giving the State this much control will cause very horrific political corruption in a capitalist society.

Also note “health” is a relative term. You can keep a human being physically alive in a box for 200 years but quality of life will cause them to psychologically deteriorate and many poor conditions will arise. Their immune system may collapse without any physical explanation. Will to live is a part of health.

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    $\begingroup$ "National average salary is reduced as the number of occupied hospital beds increase." - This encourages early dismissal and non-admittance which is bad for health. You are probably better off using this system only for primary health providers and a seperate metric for ER and specialist doctors. $\endgroup$ – Nosajimiki Oct 23 '19 at 15:31
  • $\begingroup$ But it is counterbalanced by the “healthy days” pay method. The system rewards doctors with “healthy patient days” as the unit of production. If a hospital early-releases a patient then they fall ill, the doctor is going to have words with that hospital. The doctor will have grounds to sue the hospital (the hospital took healthy patient days away from him, costing him income). $\endgroup$ – Vogon Poet Oct 23 '19 at 15:33
  • $\begingroup$ Then you are looking at another problem. Medical costs will skyrocket when primary physicians start suing hospitals over every bad outcome and hospitals will begin determining stays based on what best ballences the cost of lawsuits with the salary penalties instead of actual outcome performances. $\endgroup$ – Nosajimiki Oct 23 '19 at 16:31
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    $\begingroup$ Random assignment of patients will dramatically impair outcomes. Doctors aren't all equal, and you're completely sacrificing from your organizational system all the information accumulated by patients and doctors about what makes their relationships work. It would be like randomly sending contractors orders of random construction supplies and then assigning them random building projects. In addition, the best way I see in this system to increase my total number of healthy days is to kill my sickest patients before I invest any resources in treating them. $\endgroup$ – tbrookside Oct 23 '19 at 17:24
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    $\begingroup$ @tbrookside while the penalty for letting a patient die may become less trouble than the benefit of letting them live... this still results in a healthier population by culling those who are too sick to be worth saving. $\endgroup$ – Nosajimiki Oct 23 '19 at 17:45
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So for the performance part, we already do something like this for US Medicare. Generally, we have various best practices for certain things (get a flu shot) or targets (blood pressure under 140/90). We also have an extensive claims procedure by doctors for reimbursement. So you can comb through the claims, come up with a list of patients treated, randomize them, and tell doctors to go through the lists and report whether they performed what they should do for everybody. Then you pay a bonus to them for following best practices (not sure this has actually happened yet, last I checked, clinics just got the bonus for reporting) and randomly audit them to make sure they aren't lying.

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  • $\begingroup$ The RL answer is Value-based care, e.g. ACO program run by Medicare. In the sense, Doctor also acts as an insurance company: he gets fixed payment for each patient assigned to them, and then pays for all the care the patient receives, either at their office, or the hospital. If doctor is not taking good care of the patient, patient will end going to Emergency Room and/or stay in the hospital for a while, which is really expensive for the doctor, so doctor wants to avoid it. $\endgroup$ – Bald Bear Oct 23 '19 at 15:43
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Medicine is "free" for all the people, doctors who are employed by state (with possibility of opening private practices if they so desire) are paid great fixed salaries, with bonuses for working overtime and for time spent in service. Medicine/drugs is paid a certain price by the state, according to best practice rules, but doctors have quite a wide leeway to decide among the list of medicaments and treatments. How to measure efficiency of healthcare can be read here.

This is all financed with progressive taxes, with tax rate decided mostly by your income but adjusted with risky behavior (obesity, bad eating habits, lack of exercise, smoking, drug abuse etc). For example, if you are below poverty line, you are not paying any taxes to state anyway, but are instead getting help from state. If you are rich, your revenue is high, you pay higher taxes. If you are rich and obese, you get added +0,1% on your taxes. If you are rich and smoking and obese, you get added +2% on your taxes etc.

State is constantly advocating healthy lifestyles via ads. State periodically controls doctors efficacy... Doctors can be fired by state, of course. When doctor is prescribing medicine, he/she has to input patient data for the receipt to be processed. And bare minimum effort means bare minimum salary for a doctor, of course. That salary is still slightly higher than average salary in society, but truly great and hard working doctors can earn up to 5 that much from the state.

But doctor's salary also depends on location and specialization. Number of patients served, number of prescriptions fulfilled, medical issues solved... There are multiple parameters for efficacy of medical care. And if it is really barely settled location, with low population density in the middle of wilderness, than you may get the situation that doctor is getting paid better for less work than his colleague in the big city, just because you want to HAVE doctor in that location AT ALL.

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  • $\begingroup$ How would this system deal with lazy doctors who put in the bare minimum effort? $\endgroup$ – Philipp Oct 23 '19 at 13:40
  • $\begingroup$ Control. Doctors can be fired by state, of course. When doctor is prescribing medicine, he/she has to input patient data for the receipt to be processed. And bare minimum effort means bare minimum salary for a doctor, of course. That salary is still slightly higher than average salary in society, but truly great and hard working doctors can earn up to 5 that much from the state. $\endgroup$ – jo1storm Oct 23 '19 at 13:47
  • $\begingroup$ How would this control system measure how much effort each doctor puts in? $\endgroup$ – Philipp Oct 23 '19 at 13:50
  • $\begingroup$ Depends on the location and specialization. Number of patients served, number of prescriptions fulfilled, medical issues solved... There are multiple parameters for efficacy of medical care. And if it is really barely settled location, with low population density in the middle of wilderness, than you may get the situation that doctor is getting paid better for less work than his colleague in the big city, just because you want to HAVE doctor in that location AT ALL. $\endgroup$ – jo1storm Oct 23 '19 at 13:54
  • $\begingroup$ If I get paid based on number of patients I see, then I will see as many as I can and spend as little time as possible treating them. If it's based on how much treatment I dispense, I can offer tons of unnecessary or even harmful treatments just to maximize my payout on each visit. If you use a combination, then I will always suggest the treatment that takes the least of my time regardless of efficacy. What you're really doing here is gamefing medicine. $\endgroup$ – Nosajimiki Oct 23 '19 at 15:27

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