
The rise (and rise) of the healthcare administrator - SQL2219
https://www.athenahealth.com/insight/expert-forum-rise-and-rise-healthcare-administrator
======
mikhailfranco
Parasites always expand as far as possible without actually killing the host.

 _I 'm an administrator and I'm here to help._

There is actually a symbiosis between the government administrators creating
more and more regulations, and the healthcare administrators who implement
them. There are also self-reinforcing effects in licensing professions, which
demand more qualifications, feeding the vocational training industry. Same in
finance, with Dodd-Frank, AML and KYC (all justified by fake 'wars on terror'
and 'war on drugs').

It is an infestation of the western world. Social democracy is a self-
reinforcing doom loop of bureaucrats and welfare recipients voting for more
bureaucracy and handouts. Overheads and taxes expand to crush productivity,
but not quite enough to kill it. Whatever happened to small government and
small bureaucracies?

Time to invent some antiadminotics, but then they will eventually develop
resistance.

~~~
craftyguy
> Whatever happened to small government and small bureaucracies?

It doesn't protect citizens against wrong-doing by for-profit companies, hence
the regulation. There was a time when the medical field was largely
unregulated[0], and it was a dangerous/misleading time. Snake oil, anyone?

0\. [https://www.webmd.com/a-to-z-guides/features/look-back-
old-t...](https://www.webmd.com/a-to-z-guides/features/look-back-old-time-
medicines)

~~~
erentz
The strongly libertarian/anti-regulation folks really don’t seem to have an
answer for this. And it’s where thier whole philosophy falls down because it
so fundamentally ignores human behavior so it’ll never work.

Sure, imagine you could just pull a trigger and one day remove all
regulations. Then see what happens. Buildings will collapse, people will
organize to require building standards. Quacks will kill patients. People will
organize to require testing of drugs. It’ll all just build up again. Rules
(however you want to define and manage them) exist everywhere, they’re an
unavoidable consequence of society.

I think the strongly libertarians/anti-regulation folks need to come up with
solutions to over regulation, bad regulation, regulatory capture, etc that
work within a realistic understanding that humans are humans. Then they might
get somewhere, propose some changes that help everyone in the process. (Though
I sometimes think there’s a contradiction there that if you do understand
other humans you don’t tend to end up so far down the libertarian scale in the
first place)

~~~
da_chicken
> The strongly libertarian/anti-regulation folks really don’t seem to have an
> answer for this. And it’s where there whole philosophy falls down because it
> so fundamentally ignores human behavior so it’ll never work.

Sure they do. "The invisible hand of the market"! Which requires customers to
have perfect knowledge of the market to work. Somehow they can't fathom that
someone who is willing to harm others in order to make a profit might also be
willing to act dishonestly and commit fraud in order to make even more profit.

The other argument is, "Well, it would happen anyways with regulation!" Which
is true, but, just like the "bad regulation" and "regulatory capture"
arguments, effectvely boils down to saying, "I don't need to go to the doctor
because I'm going to die anyways."

~~~
antidesitter
_Which requires customers to have perfect knowledge of the market to work._

How so?

It’s precisely _because_ no one has perfect knowledge that markets beat
central planning, as Hayek articulated in _The Use of Knowledge in Society_.

~~~
jtmcmc
when you have strong information asymmetry between purchaser and seller the
market can become unsafe. These information asymmetries occur in highly
specialized areas like...medicine where it is extremely difficult if not
impossible for the consumer to be able to judge what is best. Which is why
regulation is good and useful. It recognizes that we can not all be expert in
all areas.

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montalbano
Anti-administrator sentiment doesn't seem limited to healthcare, here's an
interesting article focused on the same theme in academia:

[https://www.theguardian.com/higher-education-
network/2018/ju...](https://www.theguardian.com/higher-education-
network/2018/jul/20/im-an-academic-and-i-feel-underpaid-and-over-monitored)

Also, the comments on that article provide some insight into the
administrator's point of view.

~~~
L_Rahman
A key reason that these are the two industries we highlight is that they are
beset by cost disease. Some charts to explain the point.

1\. Cost of healthcare vs life expectancy for first world countries:

[http://slatestarcodex.com/blog_images/cost_countries.png](http://slatestarcodex.com/blog_images/cost_countries.png)

2\. Cost of K-12 education per student versus test scores in the United States
over time:

[http://slatestarcodex.com/blog_images/primary_scost.gif](http://slatestarcodex.com/blog_images/primary_scost.gif)

3\. Salaries for K-12 teachers over time:

[http://slatestarcodex.com/blog_images/cost_teachersalary.png](http://slatestarcodex.com/blog_images/cost_teachersalary.png)
[http://slatestarcodex.com/blog_images/cost_teachersalary2.pn...](http://slatestarcodex.com/blog_images/cost_teachersalary2.png)

~~~
rootusrootus
Looking at those teacher salary numbers, I am struck by how much of a calling
teaching must be to lure people to do it for such mediocre compensation.

Why can you not be more specific than total costs versus test scores? AFAIK
school budgets are public, so surely there are more detailed analyses that
have been done?

~~~
Noumenon72
Being at 1.0 on the average income ratio is well above average. The median US
worker comes in at .7 on that chart.

You can work a lot harder to make even more mediocre compensation -- I worked
12-hour days in manufacturing for ten years to make less, and it was pretty
difficult on my body. If teaching weren't such a horrible job with little
possibility of self-improvement, I would definitely envy them their
compensation.

~~~
rootusrootus
To be fair, the comparison should be with the median worker _with a bachelor
's degree_, because (AFAIK) that is a requirement to be a K-12 teacher. As a
practical matter, a master's in education is a realistic requirement in many
places as well.

I certainly wouldn't do it for 60K.

------
maxxxxx
I think this is a trend in most big organizations. In my company we also have
a host of business analysts, project managers, architects and line managers.
Then you have some random people who pop up with big titles where you don't
even know what they are doing. They spend endless hours reporting to each
other, evaluating options and making sure that the few people who do something
stay under control.

A lot of projects have more management than people who actually implement
something.

~~~
rootusrootus
I have thought for a long time that big corporations are really just a sort of
welfare system for the middle class. So many jobs that exist only to support
other jobs which only exist to support... and so on.

I was talking to a Facebook recruiter a couple weeks back and he told me that
something like five floors of people (or ten? I cannot recall exactly) in
Seattle were dedicated to the Messenger app. Seriously? That is absurd. What
are all those people actually doing?

------
motohagiography
Spent a lot of time in Heath tech. Main driver for administration is costs
imposed by insurance schemes, even (especially) in public systems.

Insurance causes hyperinflation in drug prices and services. It's just a giant
pool of money that nobody owns and everyone wrestles for, except instead of
competing on price and service quality, they use lawfare and bureaucracy to
impose costs and disincentives on each other.

Administration bloat has a few causes, some as a result of the effect above,
and some from political factors.

The solution? Automation. If you want to get rid of the administrative
bureaucratic layer, develop technologies, products, and platforms that
decimate it.

------
User23
It’s an iron law of bureaucracy that the nominal purpose of the organization
is always secondary to the unstated primary purpose of persisting and growing
itself. a particular amusing example is that the British Colonial Office was
at its largest size after Britain had lost her colonies.

This story is another particular case.

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nwhatt
It's a shame the data stops in 2010 - I bet we're seeing an even larger boom
due to HITECH. Technology has not solved many problems in healthcare. Medical
coders for example, are still a thing, even though everything is tracked
electronically, there is still a game to putting codes on claims for higher
chance of reimbursement.

~~~
digi_owl
Gets me thinking of an episode of the original Connections, where the host
muses about how computers will make corporate management mostly obsolete.

He envisioned them doing little more than sitting idly around waiting for the
computer in the basement to churn out the game plan for the next business
period.

------
RickJWagner
Unsaid: the continually rising cost goes hand-in-hand with the extra drag.

This probably should be studied, though we'll also have to study improvements
in health care along with the extra headcount.

------
jernfrost
Reading the denials of these people about the problem reminds me of the
emperors new clothes. They don’t see what is plain to see for anyone with half
an open mind.

This insane growth of bureaucrats is particular to the US health care system.
While it grows in socialized medicine as well it does not do so at the same
insane rate.

This is what the free market fundamentalists wont accept: that their precious
private enterprise is often terribly bloated and inefficient.

I live in a country with socialized medicine and I’ve lived in others with
universal health care. The most free market oriented I’ve experienced was the
American one and it was by far the most bureaucratic.

In software development terminology I think it is easy to describe the issue.
You got several components you want to talk to each other. In software
engineering that means some central group of people create common interfaces
for the components to speak to each other.

That is essentially the function of government. It is what creates the common
interfaces. Except in the US this doesn’t happen because somebody is going to
scream “socialism” from the top of his lunges.

Instead every component speak to every other one in a clunky manner. Through
faxes, paper forms, which are never standarized.

That is what I notice most about the US. There are so often no standards for
anything. People just wait for the magic of the market to create one, except
that never happens and you end up with half a dozen competing and incompatible
standards.

The bureaucracy is the equivalent to all the insane amount of glue code you
got to write when nobody has agreed upon standard interfaces.

~~~
sfRattan
> This is what the free market fundamentalists wont accept: that their
> precious private enterprise is often terribly bloated and inefficient.

> The most free market oriented I’ve experienced was the American one and it
> was by far the most bureaucratic.

Private enterprise? Free market? You seem to either misunderstand these terms
or make incorrect assumptions about the workings of healthcare in the United
States.

A necessary component of any free market is open price signals which
communicate information to all parties of a transaction, _before the
transaction takes place_ (e.g. a forest fire reduces the supply of trees;
lumber companies charge paper companies more; the price of paper goes up in
turn; I buy less paper because it is more expensive, and no regulatory czar
needed to adjust his schemes and standards in light of the forest fire for me
to know to buy less paper... I didn't even need to know about the fire to have
actionable information about its consequences). Prices communicate more
information with greater efficiency than is possible with central planning
because they communicate information without an administrative overhead.

But the US 'market' for healthcare deliberately obscures price signals for the
actual goods and services involved in each transaction. How many Americans
know, upon receiving a prescription, what the listed medicine will cost? How
many know the costs of each medical test recommended by a doctor? This
opaqueness is a result of rent seeking by some parties to the transactions.
(How many know about the kickbacks their doctors receive from pharmaceutical
companies for recommending medicines and tests?) Yes, these rent seeking
parties are usually corporations of one kind or other, _but their business is
so intertwined with and dependent upon the state, its powers, and its whims
that these corporations cannot reasonably be called 'private enterprises'
anymore, if they ever could have been._

The US market for healthcare is not a free market.

It is a highly regulated (as in controlled) and opaque market with no downward
pressure on price from consumers because no price is visible until after the
transaction is complete. That state of affairs is plainly absurd (and not at
all apparent) to anyone not from the US. But it's also not a free market,
either as casually or formally understood.

> That is essentially the function of government. It is what creates the
> common interfaces.

Disagree strongly here. People create common interfaces because they are
useful, then the government codifies and calcifies those interfaces and
standards (which does have some utility on a case-by-case basis). PDF is not a
government-created standard. Though international and governmental bodies have
standardized it after the fact, it was created by a private company and even
before the format's standardization you could view a PDF on just about any
computer. Linux was not created by the conscious effort of any state, but it
runs on myriad hardware and is used by the majority of web servers. Even POSIX
and other engineering and scientific standards are usually agreed upon by
private (as in non-governmental) professional associations before the state
becomes actively involved, if it does so at all.

 _The function of government is to institutionalize the use of force in
society_ , recognizing that force of some kind will always exist and it should
be limited in some way (unless you disagree with the latter two propositions,
in which case you might be a philosophical anarchist).

> That is what I notice most about the US. There are so often no standards for
> anything. People just wait for the magic of the market to create one, except
> that never happens and you end up with half a dozen competing and
> incompatible standards.

 __Can you give examples? __

I grew up in America, have lived elsewhere, and 'no standards for anything'
isn't part of my experience, either as an American or in comparison to other
places I have lived. I would argue that maybe Americans don't wait for the
magic of the state to create standards, and set about the business of creating
standards and doing work for themselves. Sure, you sometimes have competing
standards, but I don't see how that's a problem. A better, more robust, more
useful standard is likelier emerge from that competition in-the-field than it
is to emerge from the diktats and musings of bureaucrats in-their-towers.

~~~
jernfrost
I said MOST free market. I never claimed it operated under ideal conditions.
The fact is still though that most other health care systems in the west are
considerably LESS market oriented than the US.

A more free market oriented approach than today would just make the US system
even worse. Health care is not a natural market. There is too much information
asymetry, and wrong incentives at play.

As for standards, you seem to have a rather naive idea of how government makes
standards. Usually it will heavily involve industry. It is not like government
just dreams up arbitrary shit.

As for example of lack of standards. I remember when living in the US having
to deal with 4 different incompatible cell phone standards. I remeber arguing
with an American on how it was better to standarize on GSM. He made your point
that the market would eventually produce a much better standard than GSM.
Except by the time the US market got anywhere we were already moving over to
3G. Sorting stuff out in the market is often simply way too time consuming
when technology moves at the current pace.

Anything with banking and finance in the US seems to sorely lacking standards.
But I am sure things must have improved since I lived there 15 years ago. Then
there was no standard for electronic bills, sending payment to other bank
accounts electronically, simple stuff like the formatting/layout of a paper
bill.

~~~
sfRattan
> As for standards, you seem to have a rather naive idea of how government
> makes standards. Usually it will heavily involve industry. It is not like
> government just dreams up arbitrary shit.

I'm not sure how you draw 'naive idea of how government makes standards' from
my post. _I specifically point out that the government mostly does not make
standards..._ Non-governmental industry/professional organizations agree on
standards and then the government (maybe, and sometimes usefully) adopts them.
Often, the (admittedly bureaucratic) teams of professionals establishing
standards by committee within these non-governmental organizations are merely
formalizing and documenting work already done by individuals and companies. My
point is that the state is not a creative (driving) force. It follows after
the people who know what they are doing... if it is working well and if it
needs to participate in a standardization process at all (usually as it
relates to commerce). Maybe that is all naive, _but your quoted sentence above
is not engaging with what I wrote._

GSM/CDMA were competing standards, and their coexistence was largely an
artifact of Sprint & Verizon-forerunners switching to digital systems at a
time when CDMA was a newer and (debatably) better technology. Let me point out
that the standardization process was corporate-led, government-following as I
have described: 3GPP (created GSM) was an old AT&T/Nortel partnership which
European public/private-ish telecoms eventually joined, and which governments
_later_ legislated into force as you describe.

I'll agree that American banks have (and still do) drag their feet about
adopting new digital standards, though what you describe (moving money between
accounts) hasn't been a problem in my adult lifetime.

I'm not sure why government needs to actively legislate the layout or
formatting of a paper bill/invoice. In a common law system, a bill is just
some (among other) evidence of a transaction/contract in the event of a
dispute. Fraudulent bills are already against the law, and what constitutes
fraud (including deceptive/hostile formatting) is extensively defined by
common and case law (precedent). Bills over a certain amount (I think $500 or
$600) require standardized accompanying IRS forms (further evidence of the
contract/transaction). The standards are there, but maybe not recognizable to
someone coming from a civil/Napoleonic law system, which is most of the not-
formerly-British world, and where such things would need to be _legislated_ in
extensive detail.

------
woodandsteel
How does this compare with the situation in other developed countries?

~~~
jakewins
So the US averages a ratio of 10:1 administrative employees[0] per doctor. As
a random comparison, Sweden maintains roughly a 1:1 ratio [1].

Ironically, the link below is a Swedish article about how the Swedish admin-
to-doctor ratio is bloated and problematic.

[0] [https://hbr.org/2013/09/the-downside-of-health-care-job-
grow...](https://hbr.org/2013/09/the-downside-of-health-care-job-growth)

[1] (in Swedish, Doctors vs. Admin)
[http://www.lakartidningen.se/Aktuellt/Nyheter/2018/05/Admini...](http://www.lakartidningen.se/Aktuellt/Nyheter/2018/05/Administrativ-
personal-har-gatt-om-lakarna/Grafik-Administratorer-i-varden/)

------
AzzieElbab
This is killing Canadian health care too. I can understand why every nurse
wants to become an administrator though

------
DanielGee
Isn't this the same thing with colleges? Most of the rise in tuition costs
goes to administration rather then education.

~~~
xvedejas
I can't speak for all colleges, but most of the top colleges in the US do not
need to charge tuition at all to make ends meet, regardless of the rising
administrative costs. They mostly charge tuition because 1. most other sources
of money are earmarked for other purposes, and 2. it's good for rankings and
admission purposes to charge very high tuition and also offer large financial
aid packages to some subset of entering students.

~~~
YinglingLight
He's probably referring to the other 90% of colleges.

------
aurizon
How to squeeze Americans to death and make more $$$

~~~
dang
Please don't post unsubstantive comments here.

