About 8 years ago I broke my leg and eventually developed a methicillin-resistant infection where screws had been inserted. Fighting this type of infection in the bone is difficult. I spent 11 months in a hospital bed plus some time in a SNF. A total of 7 surgeries in the first 18 months and another 2 after that, the most recent 3 years ago.
I can second the experience of the author. All in I had contact with over 40 different providers. I was lucky in that I had to leave my job and could concentrate on the administrative work required full time. I eventually learned I needed to keep a detailed written narrative up to date with a tl;dr at the top. Eventually I added appendixes that summarized lab tests and surgery reports. This was the only way I could make sure each provider had the details they needed. I would always send it advance, most of the time the doctor hadn't read it so I brought paper copies and sat there while they did.
The billing and who covered what was hopeless. I had to fight with medical insurance, the medical disability company and Medicare when I maxed both of those out. I went through every bill line by line to identify mistakes, there were many. Then I would make sure each had received a copy of each bill and start figuring out who would cover what, sometimes line-by-line. This all had to be done over phone and fax.
It's broken and I am sure it's killing people. I also don't see a technology fix. Anything that requires more than two or three providers is an edge case, this space is 90% edge cases.
I grew up in England. Same deal. In and out, no bill.
The Americans who decry "socialist" medicine have never used it. There has to be a way to divorce health care and profit. English, Aussie, and Kiwi doctors all make about the same pay as American doctors, but they work in a non-profit system. Go figure...
Americans are largely opposed to a system where there is no profit. The Americans are the Ferengi of medicine, this much is certain.
Is this the average doctor or some specialist? The fact that some specialists can hugely profit from the system the same way the hospitals, pharma companies and insurance do, is likely port of the point of the previous comment. The important takeway is the average doctor does likely also not see much of that overhead money that goes to the pockets of a couple individuals and already rich companies.
My father developed Parkinson's a few years back. Got referred to a specialist by his GP - it turned out to be the most senior specialist in the country. Waited a few days for the appointment, never saw a bill. In New Zealand.
I broke my hand when I was a kid. The fragment of a bone was near a tendon and private doctors didn't have absolute consensus on surgery or not surgery for my case.
A friend of my mothers worked in the ministry of public health. She got me an appointment to one of the most important hand doctors in the country. I went there and skipped a line of 100 people wanting to see him. He took a glance at my X-Ray and said there should be surgery with general anesthesia to prevent any damage to the tendon.
I worry that this is path dependent. Recently, I went to a talk by a guy from New Zealand with an expensively manageable disability. I asked him what it would take to get the NZ accident compensation scheme to happen in Australia. The answer was, "Start funding it 30 years ago. It's great, but there is no way that NZ could afford it today."
It's a bit scary how much Australians owe to Neal Blewett.
More and more I am becoming convinced "killing people" is an intended "feature" rather than a bug. I'm sure it's not an explicit goal of any but a tiny fraction of participants in the "system", but, cynically, I am becoming convinced it is somebody's goal.
I don't think it's on purpose. It's decomposing a monolith down to microservices, without any verification. Since each player is only responsible for their little corner of the world, no one actually has any sort of responsibility to ensure the overall system still works.
> It's broken and I am sure it's killing people. I also don't see a technology fix. Anything that requires more than two or three providers is an edge case, this space is 90% edge cases.
Vertical integration is the biggest hope. With vertical integration, there is no billing.
i guess Kaiser Permanente is the closest to the vertical integration we're ever going to get here.
I cannot wrap my head around how that would even happen in North East region with fragmented hospital systems. They would need to join together to form a single hospital system, and/or buy out primary care practices, then merge with a large insurance company and PBM.
There are plenty of incentives to help care and improve: the better healthcare you provide the less they cost you long term. Vertical integration puts preventative care in the scale.
It sounds like the answer would be to standardize everything so that it wasn't 90% edge cases but there is no incentive for many of the players to do so
Standardize what? With a complex medical condition like that every patient is different so it's tough to apply evidence-based medicine practices.
The technology for sharing patient records is gradually being standardized. But that won't help if the doctors don't actually take time for a detailed review of the patient's records.
Personally, from my observations as a software engineer married to a doctor and friendly with lots of doctors, and as an occasional participant in the American healthcare system, the general inadequacy of electronic medical systems is one of the most maddening aspects of our system. Epic is a monstrosity and none of the other systems are much better. The tech is outdated, the interfaces are awful, they're incredibly difficult to get to communicate with each other, and it sometimes feels like every single provider is using a different system that won't integrate with any of the other systems. It makes me angry as person whose doctors are using those systems (and it kinda scares me), and it makes me angry as a professional, because whoever the members of our profession are who are building those systems are doing a crap job.
> whoever the members of our profession are who are building those systems are doing a crap job.
They're doing an excellent job, probably producing a level of functionality comparable to Amazon web developers or Oracle database writers. They're doing an excellent job at navigating the unholy mess of archaic regulations, mismatching institutional requirements, and hostile corporate interests, without getting sued or convicted. User experience, or even user usability, is a secondary concern, since being difficult to use (even if this leads to multiple deaths per day) is in no way illegal.
Medical informatics is definitely a field where smart and motivated people can make a huge difference to the world, and perhaps even get filthy rich while doing it. But it will take much more than a hotshot UX designer to work out.
Our situation is almost identical. I refuse to even go to the doctor unless I have something I suspect is going to be life threatening. My wife thinks I'm nuts, but she understands. I grew up in Europe under the "socialist model" and I miss it dearly.
If I need to go because I have an infection, I go to the indigent clinic, and pay the $25 for anything they need to do. I then go around the corner to the indigent pharmacy and get my $4 RX.
Yes, we have insurance. But it's still so freaking expensive to use it I never go. Insurance premiums, co-pays, RX costs. Why even go unless you HAVE to go. My wife takes the children to see the doctor when they need it. I refuse to go. I've not had a physical since the early 90s and I don't plan on going. I refuse to enrich the system. Now that the mandate has been undone, I may drop myself and cover my family alone. I can always go to the indigent clinic. Anything more serious and I just cannot afford to pay. I do not want to leave my family in medical bankruptcy or massive debt. It really sucks that in America, one has to first consider whether one can afford to visit the doctor in the first place. And I cannot convince my wife to consider living in Europe or Australia, both places we could easily move to and adapt with our relative skill sets.
While I admire your principles, it seems that by not getting physicals, you appear to be trading off your health for your principles. It is a choice for you to make but might I suggest that if the insurance/healthcare that you get is too expensive, it might be worth making an annual trip to a suitable country to get the physical done. Alternatively, consider paying a doctor with cash for a pre-negotiated price.
These are unsolicited suggestions on my part but my concern is that by not getting these physicals, which arguably have a significant impact in early detection of preventable diseases such as high cholesterol, you are endangering your life. Just my opinion.
I honestly have no clue how my eye doctor fills their stuff out. It looks like someone discovered Visual Basic's visual design tools, went nuts, then never evaluated whether or not it was a good idea. No alignment on the inputs, they're just placed willy nilly with seemingly no rhyme or reason beyond maaaaybe being contained inside a labeled box. Maybe.
I'm convinced that whoever designed it thought that inputs in the middle of sentences was a super clever idea. Well, "designed."
Maxander is correct. As they say, "Don't judge a person till you've walk a mile in his shoes." As a someone who has been writing healthcare software (not EPIC but close enough) for nearly 10 years I can tell you it's not the software engineers.
The regulations (often vague and open to interpretation by the customer) often play a part in creating the monstrosities that power our healthcare systems. Because of the subject to interpretation aspect customers often say, "No. This is how it has to work because our processes say this is what we do to meet the regulation." Inevitably it's implemented to be configurable because that's what's required.
Another culprit is the institutions and lack of standards surrounding process. There's a reason EPIC software is customized for every institution it is installed in. It's because every institution wants to do things differently. Even in the space which I work, it's the same. Every institution wants "some specific change" that they can't live without and won't go live until it's available. I'm saying this is neither a good nor a bad thing. It's just a reality.
And the ever present legacy, take EPIC as the example, it was founded in 1979. I'm not saying that their code is all from 1979 but there's definitely a fingerprint of what was in their modern day applications. There are layers upon layers of data from mergers and acquisitions translated into various codes and mapped to various databases for any number of uses. Any day of the week your state code may be two letters, three letters, full name, a custom internal legacy code, you name it you'll see it.
Spend a year working for a company with a regulated legacy healthcare product and significant user base. You'll have to become proficient at security, regulations, data standards (HL7, FHIR, etc), legacy data migration, and any other number of skills. If you're lucky enough to have all of those in place then you're still going to spend time coming up to speed within the specific healthcare domain you're working in and where it touches other healthcare (and non-healthcare eg financials) domains. Oh, and often you won't be allowed access to production instances to troubleshoot issues and a copy of the production instance isn't available because HIPPA and the customer is uncomfortable giving access to engineers. You get really good recreating problems purely via error logs and staring at the code where the issue "might" have occurred.
I've worked as a healthcare professional provider in a major medical center in a major metro area. My parents are both physicians and my wife is also a professional provider. I've used EPIC during an initial rollout, and my wife has used it during two rollouts. I've also used other EHRs in smaller clinics since then, and have used the VA system.
My sense is that EHR mandates were colossal screwup. They should have never happened. No matter how good they seem in the ideal, mandating them should have never been the case.
The reason why is because each hospital had a very well-tuned staff with a system that was designed for that hospital, in-house, over years. Implementation of EHRs should have been done the same way, ground-up, on a site-by-site basis, in a way that allowed for more gradual, flexible adoption with complete autonomy by each site. If they wanted to buy into something like EPIC, great. If they wanted to develop something in-house, great. If they wanted to contribute to an open source project, great. That sort of system would have been much better in the long run.
As it happened, EHRs were just sort of slapped on, top down, with the providers being forced to adapt to them rather than vice versa. It was horrible, and a perfect example of government regulations fucking things up. I'm very pro-public sector, nonprofit, etc. but also think that regulations (in terms of restrictive licensing laws, FDA nonsense, things like EHR mandates, etc.) are the unrecognized disease in American healthcare systems.
EHR mandates at each hospital system I or my spouse worked at to resulted in cost overruns of billions of dollars. Those are just two systems in the US, and believe me, neither of those hospital systems--which were very successful, well-run enterprises, without EHRs--would have never implemented them when they did without the mandates.
The most egregiously stupid thing about the mandate is that EHRs would have been implemented in both these hospitals relatively soon anyway, but it would have happened on a much better timeline, in a much more sane way.
The EHR mandates were very loose and had long deadlines. Hospitals had plenty of time to buy or build whatever they wanted. But it would be ridiculous for almost any hospital to develop something in house; they don't have the engineering resources or a core competency in software development, and it would be a huge duplication in efforts. Some hospital administrators like to think their institutions are unique and special snowflakes, but the reality is that most of them are the same and would operate more efficiently with standardized tools and processes instead of something customized.
While a single hospital might be able to operate reasonably well without an EHR that's just no longer sustainable in the broader healthcare ecosystem. Hospitals can't be islands. They have to be able to share data with payers, public health agencies, other hospitals, outpatient clinics, researchers, etc. Doing that requires an EHR now.
Agreed. Just standards in general. I'm all for continuing efficiency improvement through pilot programs but 80% of the function and business process of healthcare should be standardized. However, is it going to happen? No, probably not. I see it similar to the metric system. The US decided not to adopt what is a (better and universal) standard because "That's not how we do things here."
The EMR usability problem is tough and expensive to solve. Medicine is extremely complex and every specialty has a different workflow. Build a system that pediatricians love and oncologists will hate it, or vice versa. Instead of just complaining that Epic developers are doing a crap job, what specifically should they change?
The communications and integration problem is gradually improving. In order to comply with government mandates, most EMRs now include HL7 interfaces that comply reasonably well with current standards and no longer charge extra for that feature. But every system still has a different internal data model so something is always lost in translation.
Everyone is saying "don't blame the engineers", so I felt the need to post this.
I am a software developer at Epic. I've been here long enough to have gone on sabbatical.
This place has some of the most outdated software engineering practices I've ever seen. There are nearly no automated tests; a team of ~1000 people manually tests everything, including things like scaled pub-sub systems. The company actively maintains about 25 million lines of code. 1000 people couldn't possibly manually cover all of that each year. The majority of known bugs get released.
Internal builds are broken more often than not; there is no CI system exposing this fact. The code is mostly giant, unmaintainable monoliths. I saw a single class that was 50,000 lines long. Imagine trying to modify that monster with no automated tests to support you.
Nearly all of the developers that Epic hires are fresh out of college. Life-critical systems are regularly designed, built, and manually tested entirely by developers with <3 years of experience.
I've seen more than one bug get released that could have killed someone. It wouldn't surprise me if one has.
There is no incentive to change. We make so much money that the execs do not care. It makes me depressed.
ICD 10 is a medical classification system by the World Health Organization. It contains thousands of extremely detailed codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. It is used by all parties in the healthcare system.
Everyone in the industry is well aware of ICD-10 and we've been using it extensively for years. It's only one small piece of the puzzle and not nearly sufficient on its own. Just within the terminology / ontology space most clinical systems will have to support a wide range of others that are mostly orthogonal to ICD-10 such as CPT, RxNorm, LOINC, SNOMED-CT, etc. And that's not even getting into issues with message and document formats.
It's amazing that someone can go through this and come to the conclusion, at the end, that the solution is that this is a business opportunity that would make a lot of money if someone could just make it more efficient. Trying to make money off of healthcare is exactly how we have gotten the absolute mess that is the American medical system. All the incredibly complex rules exist so that health insurance companies can elect _not_ to pay for things that were deemed necessary by a medical professional. If insurance companies would be willing to pay for the services that were needed, there would be no 1600 page rule books. Of course, a system that actually paid for the care that people needed wouldn't be so obscenely profitable for them, and so they lobby massively against it.
Theoretically, then, there should be a niche for an insurer who covers more, who treats you less shitty, but costs more.
Consider the example the OP gives is a patient who they're paying thousands of dollars a day for, rather than hundreds. They're paying several people to work for days just to figure out how the rules work. It's only marginally working for them.
And let's not forget that they are also fighting profiteering on the other side; is it inherently wrong that your insurance might not pay for a new brand-name medicine that costs 100x as much as a generic with only the barest minimum difference they could sneak past the FDA and get a patent for?
I have Kaiser. Kaiser is a special beast, but one thing it does do pretty well is talk to itself. Combining providers and insurance under one roof provides a lot of upside in knowing what will be covered (though it has the downside that you really don't have options if Kaiser isn't getting the job done).
I recently had the experience of setting up a procedure done by an entirely private (accepts no insurance) practice, because Kaiser wasn't coming through for me. I was shocked how easy it was.
In one phone call, I was able to set up a consult, and even a tentative date, for a fairly complicated (day-long) surgery. Craziest of all? I got a price estimate. (It was 5 figures, but I expected that)
That was something I thought just wasn't possible in the medical world. There's so many variables, they haven't seen my X-Rays, etc, etc, etc. But still they did that. Entirely for profit, though.
I'm not saying for profit is the answer to everything or anything - someone less fortunate than me wouldn't even be able to consider going outside of Kaiser. Just that there aren't any easy solutions. I'm surprised by the system almost every time I interact with it.
Let's not forget that most people get insurance through their employers, which really limits the choices.
Paying up front for medical services - especially in today's "Chargemaster" world where nobody has a clue what anything really costs - requires you to be REALLY rich. A straightforward appendectomy for me required an overnight hospital stay which was billed at a $17K (the surgery, etc, was more).
Funny thing about that link. It has a chart of "The average number of days to get a non-emergency doctor’s appointment". Los Angeles is pretty flat around 23 days. Guess what time limits the state of California places on that legally? (hint, it's less: http://www.dmhc.ca.gov/HealthCareinCalifornia/YourHealthCare...)
The American medical establishment is the ONLY one I am aware of that should you want a service, you go into the arrangement rarely, if ever, knowing how much you might pay on the other side.
I refuse to p(l)ay. My wife is medical and we have insurance, but I go to the indigent clinic for any infections I may get and buy a $4 prescription. This same experience with a doctor in a nice area would be lots more, even with insurance. Sure, you can tell these bastards you want no tests, etc., but some won't treat you without them, and most are not needed. Think I have strep? That's one test that's cheap. That and flu a/b. Any others are ridiculously pricey.
I spoke to one of the indigent doctors and asked him how he stays in business making $25, $25 there. He says he's not in it for the money. I believe him. He told me that in everyday doctors' offices, the doctors are convinced by the pharmaceutical sales reps to push product. They can win cruises, cars, etc., based on much drugs they push out the door in RX, so the desire to make money trumps being minimalistic in care. Give me only what's needed for the time being. I don't want long-term drugs and refuse to take them. I will only take antibiotics if I need them and only antibiotics. I will never take meds for high blood pressure, cholesterol, etc. Look at the numbers. The threshholds for these numbers have been lowered in the last decade or two to push RXs.
Like I mentioned in another post, the Americans doctors are the Ferengi of medicine. I refuse to pay more than $25 to see the doctor. I've even had stitches for $25. Try getting that price going to a non-indigent clinic. And, the Mexican and Indian doctors at the clinic have been doctors for over 20 years each. I've never been misdiagnosed.
To those who are sick of paying out the nose, look for the cheaper clinics that serve immigrants. They prefer cash, don't need insurance, and actually treat you like a human being.
I can get a flight to/from Taiwan from (say) SFO for ~USD$450. I can get a fairly complicated dental procedure done for (uninsured, out-of-pocket), USD$400. (The same thing can be done w/ Panama, fwiw, but I understand Han culture and communication better than Latinx)
Is that wrong?
Q2: Why should people be denied treatment that they can (and are willing to) pay for? Because not 100% of the people are able to? If so - where does that reasoning go? Rich people shouldn't buy a Tesla because poor people can't afford a Tesla? Rich people buying Teslas ultimately drive the price down, right? Then more and more people can buy them, right? If immortality cost $1M/year (not much money, actually) - more and more people would get it and sooner-or-later it would be $10K/year (this happened with fax machines in the 80s). Then $5K/year -- or whatever. I believe that rich people subsidize R&D (for selfish reasons) that benefit us all in the future.
Profit seeking destroys markets with large externalities or where utility isn't readily discernable at low relative cost, and where for either or both of those reasons the rational choice model doesn't reasonably approximate actual behavior in the market.
Lots of real goods don't face that problem, but healthcare definitely does.
Whats the externality of providing healthcare, and in regards to the diffuseness of utility, food has the same problem and its a relatively very efficient market.
> in regards to the diffuseness of utility, food has the same problem and its a relatively very efficient market.
Food is a frequently repeated purchase with significant immediately-apparent utility and disutility, and so discovery of utilities is quick and the market reasonably efficient in terms of immediate utilities. (There are long-term utilities and disutilities that are less immediately experienced with consumption, and the food market is hardly efficient in terms of those.)
Healthcare products are infrequently purchased, and the relative utilities of different options are far from apparent. It's not at all similar to the aspects of the food market that can reasonably be described as relatively efficient.
I would argue that food escapes its measure of utility because otherwise, we would all be eating only the cheapest and healthiest option all the time, but our constant hunger also makes us purchase things against our long term interest. If so, you would expect the market to be really inefficient, but at least in terms of satisfying demand, its very hard to make money producing food.
Its true healthcare has less frequency so you cant be a sophisticated consumer: but its more frequent than a car, which is also a necessity in many cases, and the lack of sophistry does not make it an inefficient market.
Im not even sure healthcare is a special market, certainly not for infrequency, or because you must pay with your life (i.e. that you make a decision of life and death for resources). Not for restrictive application of labor (lawyers have that), not for the high costs of technology in its application (consumer tech? space exploration?).
I think at this point what makes the healthcare market unique is the common belief of the people that it is unique. It forces the consumer to consciously think of the cost of life, a question we are somehow bred all our lives to hate to ask, but that we answer every day unconsciously.
> I would argue that food escapes its measure of utility because otherwise, we would all be eating only the cheapest and healthiest option all the time
Economic utility is subjective; while it includes health effects, to be sure, it also includes things like the taste and other enjoyment factors. It absolutely is not the case that, were food a perfect example of rational choice, we would only be buying options that cost-effectively optimized healthiness.
> Its true healthcare has less frequency so you cant be a sophisticated consumer: but its more frequent than a car
“Healthcare” is a broad class of different products and services, many of which are far less frequently purchased than autos (if you buy open heart surgery more often than you buy a car, you are way out in a tail of frequency-of-purchase distribution of at least one of those items.)
OTOH, cars are also a market in which purchasers take a number of steps to counteract the low frequency. No one is test driving a variety of different surgerical interventions before choosing one.
> Economic utility is subjective; while it includes health effects, to be sure, it also includes things like the taste and other enjoyment factors. It absolutely is not the case that, were food a perfect example of rational choice, we would only be buying options that cost-effectively optimized healthiness.
Sure, I agree completely, but at least nominally the argument that healthcare is unique because its a necessity and it has irrational behaving actors is not qualitatively different than the food market.
> “Healthcare” is a broad class of different products and services, many of which are far less frequently purchased than autos (if you buy open heart surgery more often than you buy a car, you are way out in a tail of frequency-of-purchase distribution of at least one of those items.)
Thats as practical a segregation as saying that the people that buy the same model of a car the same year and with the same gas price tends to be 1 at most, hence almost no car purchases are ever repeated!
> OTOH, cars are also a market in which purchasers take a number of steps to counteract the low frequency. No one is test driving a variety of different surgerical interventions before choosing one.
Not really qualitative differences, just quantitative. Many car purchases are done without test drives (argentina doesnt do test drives often for example).
But again, even if you find some truly unique property of healthcare, which in this debate i don't recognize yet, i dont know how it will show that it should be private but public.
> Sure, I agree completely, but at least nominally the argument that healthcare is unique because its a necessity and it has irrational behaving actors is not qualitatively different than the food market.
“Necessity” wasn't part of the argument, and the argument wasn't really of a qualitative difference so much as them being different degrees of the same issues (food is considerably regulated—even by the same agency involved in much healthcare regulation in the US—for many of the same reasons, though the degree of deviation from ideal market conditions is lesser than for healthcare.)
You know those regulations are there for a reason right? Would you like to go back to the days where people are kicked off insurance for extremely dubious pre-existing conditions?
>If profit-seeking destroyed markets for profit, we would all be starving.
It depends on what you mean by 'destroy markets.' The market is functioning well in the sense that healthcare stocks keep going up. It's functioning poorly in the sense that it's the ill who have to die or go bankrupt to support it.
>You know those regulations are there for a reason right?
The road to hell is paved with good intentions.
> It depends on what you mean by 'destroy markets.' The market is functioning well in the sense that healthcare stocks keep going up. It's functioning poorly in the sense that it's the ill who have to die or go bankrupt to support it.
The measure of the health of a market is not the profits of the industry in it. A better rule of thumb would be how many people get serviced and at what relative cost. In that sense, the american healthcare market is very unhealthy.
Oh come on, this platitude applies to people saying 'less regulation' just as much as it does me.
>The measure of the health of a market is not the profits of the industry in it. A better rule of thumb would be how many people get serviced and at what relative cost. In that sense, the american healthcare market is very unhealthy.
Sure, but in that sense we can look around and see that healthcare markets are generally less healthy when they are (1) more private and (2) less regulated.
> Oh come on, this platitude applies to people saying 'less regulation' just as much as it does me
I didn't argue that regulations are good because there was a purpose to them nor its opposite. So it doesnt really apply to my stance so far.
> Sure, but in that sense we can look around and see that healthcare markets are generally less healthy when they are (1) more private and (2) less regulated.
I disagree with that statement, and I am sure that you will find examples of private markets that are more efficient than public markets, of the which you only need 1 to disprove the idea that public > private on health.
>I didn't argue that regulations are good because there was a purpose to them nor its opposite. So it doesnt really apply to my stance so far.
I mean 'the road to hell is paved' is just an argument against trying to do anything good, it's not exactly relevant.
>I disagree with that statement, and I am sure that you will find examples of private markets that are more efficient than public markets, of the which you only need 1 to disprove the idea that public > private on health.
Well no, because I'm speaking in general. But I'd love to know your example.
>Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable).
And what is 'efficient'? I think a major component of a well functioning healthcare system is that it's equitable. Our problem with healthcare is driven by the generalized problem of 'economization.' A rich person doesn't have some intrinsic quality that makes them more deserving of quality healthcare.
A healthcare system which is extremely efficient at treating the rich and letting the poor die isn't really what I'm looking for. Efficiency and equality must be balanced. What I'd say is that the US is pretty terrible at both and that's sad.
>Instead of wasting time with examples that don't go for the core of your stance, can you share what would change your mind in the general?
Some evidence that shows that mostly private healthcare systems generally function better than mostly public ones or some evidence that healthcare regulation in the US has led to worse outcomes and not better ones would at least give me a jumping point. But I'd also ask you to answer your own question here.
> What I'd say is that the US is pretty terrible at both and that's sad.
Right, inefficiency tends to harm both equitability and value/cost(loose efficiency definition), but the US market is not what it is because it is efficient or because it is equitable, which is a classic dichotomy of microeconomics.
> Some evidence that shows that mostly private healthcare systems generally function better than mostly public ones or some evidence that healthcare regulation in the US has led to worse outcomes and not better ones would at least give me a jumping point.
I see. So the challenge here is that we can only compare apples to oranges over and over again: we could try to see east germand and west germany, but for other reasons the economics were different. We can compare same country public and private like Germany and Argentina, and get to different conclusions (in germany, private is for the rich, in argentina, public is for the poor). We can compare England to the US, but how do you adjust for cultural and income differences?
For example, healthcare in the US was relatively very cheap 50 years ago, where it was still private. What happened in the middle?
Instead of looking so broadly at private vs public, its better i think to focus on why its expensive. And I can assure you that the top 5 reasons why healthcare in the us is expensive is due to government irresponsibilities. If the government cant even fix its own mistakes, how is it going to handle a much larger responsibility?
> But I'd also ask you to answer your own question here.
>Right, inefficiency tends to harm both equitability and value/cost(loose efficiency definition)
Well no... Inefficiency is totally independent of equitability.
>For example, healthcare in the US was relatively very cheap 50 years ago, where it was still private.
This increase in healthcare expenditure across time has happened in all western countries has it not?
>Instead of looking so broadly at private vs public, its better i think to focus on why its expensive.
Broadly looking at private vs public is a very good way to guide our focus to what makes our healthcare in the US so expensive.
>And I can assure you that the top 5 reasons why healthcare in the us is expensive is due to government irresponsibilities.
You mean how the government has failed to regulate more? How the government has failed to de-privatize certain portions of the American healthcare system? How the government has hamstringed public options (like Medicare) to prevent the american public from realizing how much cheaper the government can provide care than can a private system? Totally agreed!
>If the government cant even fix its own mistakes, how is it going to handle a much larger responsibility?
What are you talking about? Private healthcare companies make mistakes all the damn time. The reason we trust government is because we get a voice in it. If your point is that american government needs to be more democratic and responsive to the wishes of individuals and cut the crap when it comes to sponsorship by large insurance conglomerates then I'm all with you.
>I did.
Did I miss it? Maybe you could post it again here. I'm just looking for what could change your mind.
> Well no... Inefficiency is totally independent of equitability.
The reason why inefficiency is tied to equitability in the real world is because equitability is enforced, which means you spend resources to achieve it, and that is the successful case of enforcement. i.e. forcing everyone to take insurance to give coverage to the sickest can increase sickness because there is no economical consequence to unhealthiness.
> This increase in healthcare expenditure across time has happened in all western countries has it not?
No..if it had, we wouldnt be talking about a problem of healthcare in the US. Its grown disproportionately here. But the whole point is that 50-60 years ago, healthcare was cheap and it was private.
> You mean how the government has failed to regulate more? How the government has failed to de-privatize certain portions of the American healthcare system? How the government has hamstringed public options (like Medicare) to prevent the american public from realizing how much cheaper the government can provide care than can a private system? Totally agreed!
I will be more practical then. What do you think are the top 3 issues that make healthcare expensive? Concretely, not abstractly. What are the 3 things that if didn't happen, healthcare would be much cheaper, and I challenge that all 3 of them are the result of regulation. That is, the government made it expensive.
> Did I miss it? Maybe you could post it again here. I'm just looking for what could change your mind.
->
> what would change your mind in the general?
> Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable).
>The reason why inefficiency is tied to equitability in the real world is because equitability is enforced, which means you spend resources to achieve it
Now you're switching around your causality. Earlier you said: "inefficiency tends to harm both equitability and value/cost"
So you don't believe that inefficiency causes equitability, just that equitability causes inefficiency?
>No..if it had, we wouldnt be talking about a problem of healthcare in the US. Its grown disproportionately here. But the whole point is that 50-60 years ago, healthcare was cheap and it was private.
So, in response to demographic changes across the western world (like an aging population) a bunch of countries made their systems more public and were able to keep costs down and the US has kept theirs more private and costs have ballooned. Maybe the answer is self-evident.
>I will be more practical then. What do you think are the top 3 issues that make healthcare expensive?
I think there is basically one cause: the existence of for-profit insurance companies. In a public system where government provided healthcare there would be a large monolithic body which could assert it's power to keep prices down. In a market with multiple insurance companies, they'll never have enough individual power to keep prices low. That's how the market is supposed to work by keeping power divided, it's just that healthcare is a terrible place for markets.
>Mine is that lightly regulated free healthcare markets will be efficient (though might not be equitable).
So to get you to change your mind that public systems are better than private equitability never comes into play? What is the point of efficiency if not to help people? If the point of efficiency is to help people then how is equitability not important?
> So, in response to demographic changes across the western world (like an aging population) a bunch of countries made their systems more public and were able to keep costs down and the US has kept theirs more private and costs have ballooned. Maybe the answer is self-evident.
I've had private insurance my entire life in a western country with free public healthcare. I have practical experience of the trade-offs of public vs private as a consumer and a tax-payer. The demographics changes hit my home country just like any other, but it didnt make public more efficient than private, nor more effective.
> I think there is basically one cause: the existence of for-profit insurance companies.
I have mentioned 2 counter examples: my home country (argentina) and historical US. You can also see Germany also has public/private mix systems.
Health insurance companies actually have very low profit margins. Lower than the general market, lower than insurance companies, etc etc. They are not raking it in. The ones that are raking it in are providers.
> In a public system where government provided healthcare there would be a large monolithic body which could assert it's power to keep prices down. In a market with multiple insurance companies, they'll never have enough individual power to keep prices low. That's how the market is supposed to work by keeping power divided, it's just that healthcare is a terrible place for markets.
There is some contradiction in the previous statement (for profit) vs this one. You are arguing insurance companies cant negotiate prices down because they are not a monopoly, not because they are for profit. If there were only 1 insurer, they could definitely keep prices down, particularly the price of providers. But its hard to think a monopoly is the solution to a market problem.
Moreover, you say the state would have the power to drive prices down. This contradicts reality today, where Medicare by law cant negotiate prices. The government is eager to put itself a restriction on negotiating, and is politically unable to remove it. If it cant change medicare when its a fraction of the market, do you think it will change more when its 10 times its size?
The state can, in 24 hours, reduce healthcare prices by just removing economic consented bad regulation. Read what the healthcare economists say: allow free trade for drugs and doctor immigration and you solve such a massive part of the cost immediately. The government has full power today to solve those problems and it cant. Doesn't that make you lose any faith in the government's capacity to solve healthcare?
Do you remember the Obamacare website debacle? Do you think medicare will make a kickass insurance website?
>I've had private insurance my entire life in a western country with free public healthcare. I have practical experience of the trade-offs of public vs private as a consumer and a tax-payer. The demographics changes hit my home country just like any other, but it didnt make public more efficient than private, nor more effective.
...wait wait wait. How much experience do you have with the American system?
Libertarian arguments only hold for free markets. Even eliminating all regulations and restrictions imposed by the government, healthcare does not become a free market for two reasons:
1) Information is not symmetric, contractual obligations are made before pricing information can be discovered (thereby compared and moving into market dynamics)
2) Services are requested under the duress of health problems without the ability to end the agreement.
I think we can agree that there are degrees of freedom in a market, and that the us healthcare market is far from a the freest possible version of healthcare.
Im not sure about the information asymmetry argument: insurance companies also lack lots of information. And some of that the patient knows and the insurance doesn't. (pre-existing conditions for example). Also, there's plenty of markets with information asymmetry that dont show the backwardness of US Health care.
> Services are requested under the duress of health problems without the ability to end the agreement.
That is the nature of any insurance market. You cant bargain with your fire insurance when your house is burning down. Well, not effectively, if you look at the richest man in old rome.
Definitely agree that there are degrees of freedom, I'm just not confident that a removal of regulations in the healthcare market would lead to a positive outcome (higher quality/less expensive healthcare).
>> Services are requested under the duress of health problems without the ability to end the agreement.
>That is the nature of any insurance market.
I was actually thinking about when medical treatment is being received. Once you're under a hospitals care you're largely subject to their pricing for services (e.g. I can't choose to use the cheaper MRI machine down the street). There's a bundling of services at a healthcare provider that seems to contradict free market arguments as well, but I was mainly trying to get at the (effectively) binding agreement to use a particular facility once you are checked into it.
Edit: To be a little more concise, you agree to a particular payment structure for services without knowing what the cost of the services are or which services you'll be receiving when checking into a hospital, this opacity in hospital pricing also means that different parties are paying different rates for the same service at the discretion of the billing department.
> Definitely agree that there are degrees of freedom, I'm just not confident that a removal of regulations in the healthcare market would lead to a positive outcome (higher quality/less expensive healthcare).
Economists have a high degree of confidence that some of the rules that are restrictive of a free market account for sizable chunks of the cost: not being able to import pharma and immigrant restriction on doctors being quintessential.
Not being able to import pharma is denounced both by Bernie Sanders and Rand Paul (whereas the first wants to socialize medicine, and the latter remove regulations).
Doctor's immigration restrictions are large but also very hard to politically fight. Also the high cost and restrictions of medical licensing. Friedman was very unsuccessful in turning the public against them.
> I was actually thinking about when medical treatment is being received. Once you're under a hospitals care you're largely subject to their pricing for services (e.g. I can't choose to use the cheaper MRI machine down the street).
This applies only to emergency care: if you have cancer, for example, you have plenty of time to choose going to the cheaper chemo. And even a smaller fraction of emergency care: breaking a leg is painful but it does not incapacitate you to choose one hospital or the other: in fact, we do that all the time by picking which one is closest (choice that must indubitable be made in comparison to another option).
And after that, you have an insurable market, which means that you have all the time in the world to choose between options.
> you agree to a particular payment structure for services without knowing what the cost of the services are or which services you'll be receiving when checking into a hospital, this opacity in hospital pricing also means that different parties are paying different rates for the same service at the discretion of the billing department.
Same as car insurance, or mal practice insurance, or house fire insurance, or renters insurance. Not knowing what you will get is at the core of the insurance service models.
I see a struggle to find what makes heealthcare unique to falter in two regards: first, that finding that quality that makes healthcare a unique market does not show anything other than identity: it might be the quality found points to private healthcare instead of public. But also, the extreme difficulty to find a qualitative difference between health and other markets is due to the fact that it might actually not be qualitatively different at all.
No, it is profit-seeking that created this cluster-fuck. It only seems to be a problem in third-world nations like the US; the rest of the world seems to be blissfully free of broken profit-seeking institutions that cannot talk to other profit-seeking institutions so that they can collectively figure out the least amount of healthcare they can provide to the patient (so that both can maintain their profit.)
I am from a partially socialist country that has free healthcare. I have had private healthcare, along with most of my socio-economic class, my entire life.
Making it socialized does not mean it will be better. Coldly, see it as a different system with different consequences. Bringing it to the US: look at how much medicare costs today: 3.6% of gdp, servicing 56 million americans. If you extended medicare to the entire population at the same per capita, it would be 26% of GDP.
Actually, the first world nations that have socialized healthcare systems experience better outcomes than the United States with less per capita spending.[1] Medicare as it is currently formulated is specifically targeted towards at-risk populations that have higher incidences of medical usage than the general population; you can't just apply the exact same per capita spending across the American population. 80 year-olds use more health care than 25 year-olds.
> Actually, the first world nations that have socialized healthcare systems experience better outcomes than the United States with less per capita spending
It is beyond question that the healthcare market in the US is terrible, because its expensive and ineffective. That is out of discussion for any reasonable debate.
What is also out of debate are many reasons why is it so expensive today: restrictive immigration of doctors, importation restrictions on drugs, self imposed gov restrictions on bargaining, hospital building regulations, malpractice legal costs.
Government taking full control of the system fixes NONE of the problems listed above, which are by and large some of the biggest price drivers. It might make them worse, because all of the ones above are exclusively decisions of the government.
> you can't just apply the exact same per capita spending...
I agree, tho at the same time you cant expect the government to be more efficient as it increases its scope of scare. Economies of scale dont work for the government. 10x service might cost 50x. It should be clear however that its a reasonable order of magnitude: more than barely double digits. A 20% gdp cost on healthcare will come with cuts in service, I guarantee that.
The link I posted does suggest that economies of scale do, in fact, work for other governments, and that despite covering 100% of their population, they see significantly better efficiencies than our system does. If you're going to claim that economies of scale don't apply here, you're going to have to provide some evidence that contradicts the lower per capita spending/better outcomes we see in other systems.
You still haven't actually laid out a metric showing that Medicare is inefficient; you just keep asserting it is not efficient in the face of evidence that single-payer systems are in fact pretty efficient. To add more evidence to the "you are incorrect and single-payer systems are in fact pretty efficient" pile, here's another potential efficiency metric we could compare: Medicare spends significantly less (approximate 1.4%) on overhead costs, compared to private insurers that average around 12.4%.[1]
So, again: the US as a whole, using a primarily market-based healthcare system, spends more money per capita for worse results than most other developed nations, most of which are using single-payer systems. Within the American healthcare system, there is a limited single-payer system that only covers a particularly high-risk patient population, and yet despite that patient population, runs more efficiently as an organization than the market alternatives. What evidence are you offering to make the argument that that limited single-payer system is actually more inefficient than the private alternatives?
> You still haven't actually laid out a metric showing that Medicare is inefficient; you just keep asserting it is not efficient in the face of evidence that single-payer systems are in fact pretty efficient
Medicare is an example of a government run healthcare service in the US. Its way more relevant to compare to Medicare than to compare with foreign countries health results. Its also revelant because single payer proposals in the US are basically expanding Medicare. So even if every single single-payer system in the world were efficient, if Medicare isnt, it wouldn't matter.
> Medicare spends significantly less (approximate 1.4%) on overhead costs, compared to private insurers that average around 12.4%.[1]
Sure, thats because it doesn't do price-fighting like private providers have to with insurance companies. It has the basic incentive to cede at every corner as an institution. But lets look at other reasons why healthcare is spending and how medicare solves them. How about pharma costs, doctor salary costs and legal costs. Is medicare cheaper on these other predominant reasons why healthcare is expensive?
You will find that Bernie sanders understands well that pharma is expensive because government restricts its importation. So if as an organization the government is strained to even bring drugs from abroad, a problem it has unique power and responsibility to solve today and no-one else can do except for 'retail smuggling', and we are supposed to put our entire faith into the same hands that cant solve that?
If you just eliminated restriction of drug importation, you would drop healthcare costs enormously in 24 hours. The only thing you have to do as a government, is to stop doing a thing. How simpler can it be.
The core idea here is that the debate of public vs private is a red herring. Healthcare is not expensive in the us because of private vs public. Its expensive for its own particular policies, which economists have consensus on and are hard to take on due to lobbying, or lack of public interest, or mere gubernamental complexity. The topic is presented as two black bentos, where you can only see the results in the faces of people eating them. But they really aren't. You can see what each has and why.
I live in a "first world nation" and 10 years ago (before the global financial crisis even) public vs private healthcare meant the difference between leg amputation and implantation. The public system is only good for routine diagnosis and minor surgery. For everything else, care quality goes down the toilet. Not to mention on the effectively complete lack of dental care.
I'm not sure where you live and you're not providing any links or statistics to back this claim up, so it's difficult for me to respond to what you're trying to claim here. If you read the link I provided, you would see that they use cancer, heart disease, and diabetes mortality as a shorthand for patient outcomes in significant health events, and that while the US healthcare system ranks reasonably well in cancer treatment, it is significantly behind other developed nations in treating heart disease and diabetes. They also provide statistics regarding mortality rates in various populations, and the US lags other developed nations in basically all of those populations.
Your point about dentistry is interesting, although also mostly unsupported, and I'm having a difficult time finding good statistics about dental care, spending, and outcomes. Anecdotally, dental care in the United States is sharply linked to money; people with money have good/great teeth and excellent dental care, people without it frequently have major issues with their teeth. I don't know how that compares to other countries.
We can complain about capitalism all we want, but at the end of the day, in America, we still live in a capitalistic society. Good deeds that cannot happen profitably will not happen here en masse without subsidies, period.
Given that our government has proven incapable of subsidizing healthcare in a way that promotes a combination of efficiency and effectiveness, it makes total sense that people would try to make a profitable business that meets the needs of our citizens. That's just how capitalism works.
Edit: To those downvoting me, can you please explain? What flaw do I have in my logic?
The problem is that you have a marked tendency to turn HN threads into generic ideological tangents, as you've done here, and this takes them in a direction of lower quality. If there's any generalization about HN threads that holds up, it's that one, so would you please take this in and stop doing this here?
This isn't an observation for or against capitalism. It's an observation about ideological arguments on the internet. The specific ideological flavor doesn't matter; it works the same dismal way regardless.
I was responding to a comment that starts "It's amazing that someone can go through this and come to the conclusion, at the end, that the solution is that this is a business opportunity that would make a lot of money if someone could just make it more efficient." It's a pretty direct critique of the use of capitalism in the healthcare industry. How did I make it any more of a generic ideological argument than my parent comment?
edit: Upon review of my recent comments, I'll admit that their quality is poor. I'll try to avoid ideological squabble in the future. If you could still answer my question on this particular post, though, I'd appreciate it.
These things are relative. You're right that the parent comment was turning toward an ideological tangent, but at least it was still moored to the original topic. Yours became unmoored and went fully generic. In both cases it would be better not to do this and to stay more substantive, but we only tend to post moderation comments in the second case, it being the more egregious.
I greatly appreciate your intention to avoid ideological squabble in the future. If only everyone would do the same our happiness would be complete! On that scale at least.
> Edit: To those downvoting me, can you please explain? What flaw do I have in my logic?
The idea that we're in a "capitalistic society". Every country in the world lives somewhere on the spectrum between capitalism and socialism. The US is further towards the capitalistic side than Europe, but we've plenty of non-capitalist aspects of our society.
We already accept a wide array of socialist policies in the form of Medicare, Social Security, etc. We've also plenty of evidence from the rest of the developed world that the socialist approach to healthcare provides similar outcomes at greatly reduced cost. "We're capitalists, deal with it" is a fundamentally silly reason to avoid healthcare reforms.
I'm not saying that we shouldn't continue pushing for reform. I'm just saying that our government has proven incapable of reformation, and we should be pushing towards non-governmental approaches until they can get their act together. If we can improve the way things are through capitalism, that's still better than just yelling at politicians that don't do anything.
Can you explain your logic about pushing for non-government reform if "government has proven incapable of reformation"? There is no healthcare fix without government reform. If you provide healthcare, you must adhere to government regulation. You must accept Medicare/Medicaid reimbursement rates. If you provide insurance, you are at the whim of the government and what each new year brings [+].
> If we can improve the way things are through capitalism, that's still better than just yelling at politicians that don't do anything.
You cannot improve this with capitalism. You can only improve this by replacing politicians who are married to a broken system through vested interests.
Scale is supposed to make things more efficient, not less. That's the whole idea behind "economies of scale".
Sure, if you want to pretend the EU doesn't exist, and that the US doesn't already manage Medicaid on a state-by-state level, there's a significant population difference... but Germany has nearly 100M people. We have strong evidence single-payer healthcare already works with large numbers of people.
Didn't downvote you, but I do want to point out that health care providers earn a good living in places like Italy, where I lived for some time. My wife's family friend is a local doctor. He's got a nice house, a place in the mountains, a boat... he's doing well.
What's different is all the insurance BS we have in the US is missing.
I don't feel comfortable laying the abysmal and depressing tar pit of money and productivity that is the US healthcare system at the feet of "capitalism". In my opinion, the clumsy and inefficient interplay between health care providers, insurance companies, employers, the state and (lastly) individual people strikes me as one of the least capitalist-like situations we see today. It's almost a thought experiment: what would the US look like if people could afford to choose an affordable insurance company, peruse the various healthcare providers and choose among them and, lastly, be able to predict (with some amount of reliability) their healthcare costs over time?
Personally, I can't imagine it. All I know is that it wouldn't look like what we have now. Likewise, this argument that any criticism of the US healthcare system is somehow a criticism of capitalism strikes me as particularly unhelpful.
Medicare doesn't cover "everything" though -- nor could it. No health "insurance" whether it is single-payer, private, public, can just open the checkbook for every patient.
In the software world, we would fork or rewrite, and deprecate the old version. I think we should do the same for healthcare. The existing system is unmaintainable spaghetti code that needs to be deleted.
Create a new single payer healthcare system that is completely separate from anything existing now. Don't attempt to incorporate any existing insurance, regulations, medical records, etc. Allow the new system to ignore any existing drug patents. Get a few brand-new hospitals, a few hundred doctors fresh out of med school/residency, and tens of thousands of people using it - probably do this in a single city, a la Google Fiber. Spend a couple years working out the kinks.
Once that is done, migrate everyone to the new system over the course of a decade or so. Any existing hospitals, doctors, and patients are free to stick with the existing system, but I suspect they'll learn to regret that decision.
There are no technical or medical roadblocks to this that I can see. The only obstacles are political and legal, which can be overcome in one or two election cycles.
> Create a new single payer healthcare system that is completely separate from anything existing now.
We don't have to create some new system from scratch. Medicare already exists, and it's extremely efficient[0]. Medicare-for-everyone is arguably the best path forward to a national healthcare system.
> According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of operating expenditures. Defenders of the insurance industry estimate administrative costs as 17 percent of revenue.
There is some old "baggage" that you'll necessarily need: written procedures; the experience of, uh, experienced medical staff; and patients' histories. If you can bring those along without polluting the new system, you might be onto something.
It's arrogant to assume that a new system will be better than the old one merely because it was re-written from scratch. Many companies died because someone said "let's rewrite this bit of software" and the project ended up failing because people vastly underestimated the difficulty of the re-write. Even though they were smart professionals who knew how to write software well.
Considering that software companies frequently fail to succeed at re-writes with something as inconsequential as software, what makes you think society can do it with something as consequential as healthcare? Especially considering that healthcare is in many ways much harder and more poorly understood than software?
This is like saying that Netscape can re-write Navigator because they can copy Internet Explorer. It ignores that Netscape and Microsoft had totally different reasons for the choices they made, and that changing those choices in a re-write was very non-trivial for Netscape, to the point where it ceased to be a company.
You will likely find similar problems with this in attempting to replicate other health care systems. Indeed, you could complain that the mess we are in now is the result of doing a poor job replicating Switzerland's health insurance laws.
> In the software world, we would fork or rewrite, and deprecate the old version.
Yes and no. Can you name even one specific example of this being done with software on a scale within even an order of magnitude of "healthcare"?
Certainly people fork and rewrite software all the time. But almost all of those projects fail to replace the 'old version'.
And even large software projects that are rewritten are often (heroically) written so as to be (maximally) compatible with the ecosystem of users.
> The only obstacles are political and legal, which can be overcome in one or two election cycles.
This is both wildly optimistic and pessimistic. Vermont voters passed a single-payer referendum (but the government decided to cancel the plans because of the estimated cost). I'm not sure that there's much of anything stopping a single city from doing so (besides things like free-healthcare tourism).
I've been through similar experiences with my mother.
The best thing you can do, before your parent gets too old, is to consult with an elderlaw firm to get health care directives, wills and power of attorney written up. Most importantly, be sure to fully talk through the possible scenarios for what happens financially in the event of putting your parent in an SNF (skilled nursing facility).
Private pay for SNF in the USA is about $10000/month. That's a steep rate for middle class and even upper middle class folks. That's what your family will pay until medicaid "kicks in" when the savings of the parent are depleted. If your parent made the mistake of giving away part of their wealth to family within 5 years of entering SNF, that money still counts and they have to pay it to the SNF. The medicaid provider for your state will demand 5 years of bank statements for all accounts as well as query ALL financial transactions. You might have to hire a lawyer just to untangle the mess. Dealing with this stuff is a nightmare in paperwork at the worst possible time you can imagine.
I have found that face-to-face communication with the bureaucrats helps a lot. The HHS staff people who process medicaid long term care enrollments in SNF's have massive, soul-crushing workloads. Of course they're going to just skim the hundreds (not exaggerating) of pages of documents you send them. The article is right. You have to watch out for your family. No one else will do it.
Eldercare consultants cost several thousand dollars. We decided not to engage one because the SNF provided a lot of support and we had previously worked with an elderlaw firm, but it probably would have saved us some stress when dealing with medicaid/HHS as I was on the hook for $100K+ until a property sale from 4 years ago was sorted out. There are families that end up going bankrupt needlessly just because a parent wanted to "leave something" to their children and didn't know about the 5-year-lookback trap (Thank George W Bush for that fuck-up, see Deficit Reduction Act of 2005). We were fully aware of the basics and still narrowly averted a financial disaster.
"There is, in fact, no system. There are systems, but mostly they don’t talk to each other. I have to do that."
That's something I have noticed too. My girlfriend had to visit several doctors for a problem. One was confused about the notes of the other doctor so I proposed to call and figure it out together. The doctor seemed really perplexed about this suggestion and instead ordered the same series of tests again.
Because ordering a redundant set of tests generates revenue. Just consulting another doctor wastes both of their time better spent ordering up redundant tests and quickly moving on to the next victim that can have tests ordered.
Yap that's what I realized as well. It is a complicated beast in that some things happen because there is a profit attached to it, some happen because there is regulation requiring it.
Unnecessary tests are not even the worst, unnecessary face and nose surgery as suggested by one of the doctors for a family members was really terrifying. Good thing we decided to spend more money an time to get second opinions.
Doctors have learned through experience to mistrust data from other sources because it's so often incorrect or incomplete. So they often think that the fastest and safest course of action is to start over from scratch with the patient history, lab tests, etc. One partial solution is the growth of large integrated delivery networks which combine a bunch of medical specialties in a single organization sharing patient records. That way there's more trust and lower barriers to communication.
I don't know. It should but something wasn't clear. The point is that for some reason they didn't make a quick call to clarify and seemed genuinely confused about this suggestion. Instead they ran the tests again.
I have a hypotheses. My experience with doctors (that is, general practitioners) is that they think very highly of themselves but usually aren't actually that good at their job. Consequently, they believe they know everything and other doctors know nothing.
It's possible I've just had a lot of bad doctors though.
I love this article. I feel like it gets down to the real root of the problems with the complexity of Western culture. I feel like this perspective applies to a lot more than healthcare. It matches my own thoughts that technological complexity is getting so high that eventually it will be beyond our own understanding, both individually or in a group of any size. We as a species simply won't be able to make use of our own tools and systems because they are so complex.
I'm as guilty as some people of just citing "excessive regulations" as a problem without mentioning the mechanics that make that a problem, since so many people see "regulation" as a good thing by just thinking of it as "regulating away the bad outcomes". But this article gets to one of the mechanisms I think of when I cite regulation as a problem; regulation casts in concrete a particular way of doing business, and makes it literally illegal to do it any other way. Can't even try something new as a one-off; it's illegal to do anything else. Doesn't matter how brilliant your idea is; it's illegal. Doesn't matter if you've got a startup with the software all ready to go; it's illegal. Are two regulations either interacting poorly, or outright contradictory? Not only is it illegal to not conform to both of them, now we've introduced an adhoc meta-regulatory regime with regard to how to address the overlaps, with the de facto force of law behind this unwritten metaregulation, and/or impedance mismatches between two bits of the industry resolving them in different ways.
Even if we stipulate that The Hypothetical Medical Regulation Act of 1983 was somehow the miraculous embodiment of perfect medical regulation for 1983, it would be causing major problems for the medical system today. Mere time would be enough to cause problems with medical regulations, and alas, they aren't perfect to start with, and they seem to be ever-growing in size, and there's no way the complexity growth is merely O(n). We've almost certainly passed the point where regulations are appearing for the sole purpose (if one did a full cause analysis) of dealing with the fact that regulations are blocking the system up.
(My biggest objection to "national healthcare" is that unless you find me some different authors to write it than our current Congress and current regulatory state, I have approximately 0.001% confidence that "nationalizing healthcare" will fix this. Advocates of nationalizing healthcare would have a much easier time convincing me if Obamacare had simplified health care, instead of massively adding to the pile of regulations and massively empowering more regulations going forward.)
Obamacare complicated health care because it was designed to preserve the existing system of insurance companies, employer-provided insurance, and patchwork regulations. So, of course, it introduced more patchwork regulations, along with subsidies to the existing players.
A single-payer system (Canadian style) would greatly simplify the health care system, largely by cutting out the insurance-company layer for most people. A British NHS-style system would arguably be even simpler, but is even more of a political non-starter in the US.
I think you sort of misunderstood my point. My point was that you'd have an easier time of selling me on it if Obamacare had actually simplified things. Which was one of the promises it made, after all. Explaining why it failed to do so does not contradict my point, it reinforces it.
In terms of Obamacare not simplifying things, my engineering answer is "Then why did we implement it?" If a goal is impossible for some reason, then the correct solution is not to try to obtain it, not to just cruft up the system harder anyhow. How many people can tell the same story of failure in their engineering jobs? Since this is the same set of people who want to bring us nationalized healthcare and want to write all the regulations for it, it does not encourage me to think well of their judgment in doing so.
I am abundantly confident that our current ruling class would find some way to muck it up. Even if we handed them The Pristine National Healthcare System Act of 2018, they'd have regulated it to death in just a handful of years. Our current ruling class doesn't seem to be able to sneeze in anything less than 50 pages of legislation and several hundred pages of accompanying regulations.
That's not how politics works. Everyone has a different opinion and priorities. Obamacare made the overall system better by providing more people with affordable access to healthcare, at the cost of increased complexity in some areas. It was a good trade-off. If everyone had insisted on perfection then nothing would have been changed at all.
The ACA originally was going to have a public health option (but it was removed because a senator at the time threatened to filibuster). Had that been included, I believe it could have led to something very similar to a single-payer system.
I really hope we are both wrong, but I agree with you. I worked in healthcare and health insurance, and I have a unique perspective on the mass of regulations from across the US. I see the same patterns in many areas, government, finance, manufacturing and more.
I think that as things have evolved more and more quickly (rate of technological change, complexity of systems, increasing amounts of information/data, amount of knowledge and requisite volume and velocity of learning required to keep up), it has surpassed our ability to absorb/reason effectively and it continues to get worse.
I think the reason humanity is struggling to try to get AI (to help us carry the load) is related.
I think that there is a trend here, at least in Western culture, we can see manifested by the size of industries. If you look at the biggest industries contribution to GDP, they are also some of the most complex industries[1]. It seems that, among other things, when you have many individual players and groups with competing agendas, money and complex systems, you have these issues.
Perhaps it is literally survival manifesting itself in the modern age.
Anecdotally, I also see people looking to the past for simpler techniques and "core" knowledge, trying to find more general, longer-term survival/coping skills that cut across time and technological change.
Most Western societies are able to operate healthcare systems that don't have this problem - and this "solution" is often advocated as a panacea for the coordination issues they face due to centralization.
I switched to Kaiser after my own dealings with the kafkaesque world of healthcare that this article describes.
Kaiser is amazing in comparison.
With Kaiser, I no longer have to stare into the abyss of the "post-systematic atomized era" of healthcare. I don't have to use CPT codes to compare prices on bills with Medi-Cal rates, study legal agreements to find discrepancies, or repeat myself to every different medical provider I visit. Instead, I can go about my life and focus on the things I care about. Kaiser isn't perfect by any means, but it's astonishingly better than the alternative.
I'm living this situation right now. In my own life.
I'm transgender, and transgender care is a VERY complicated beast. I'm a Kaiser member, and Kaiser NorCal (though not SoCal, so I hear...) is about as good as you can get for Transgender care.
Do you know how hard it was to find someone who had some idea what Kaiser (or any insurance) did actually did cover? And even when I did find that out, it was (of course) changing. It took me talking to multiple member services reps and people at both of the regional transgender facilities before I found someone who could refer me to the person who knew.
What resonates most about the article - the "communal" aspect of it all - was around a specific surgery I need - facial feminization. Kaiser has one provider, basically. Great guy. Horribly backlogged - 2 year wait they told me.
Through lots of redditing I found the one person who knows exactly how to work this system. How to file the right grievances with the right language to put everything in order. Things like - you need an appointment with another provider so they can't merely claim there isn't a provider who can't do it. This person has basically walked me through the entire process.
A fun and related fact is that California has a board that handles disputes and does "Independent Medical Review". For facial feminization surgery, this amounts to them deciding if given traits of a face fall within feminine norms (which would make the surgery aesthetic, and not covered) or not (which would make the surgery reconstructive, and covered). I've read a bunch of them that go both ways. A really weird experience (the decisions are publicly available!)
The ability to "work the system" is entirely too necessary - never mind the cost, hassle, and everything else about it. You need "bureaucratic perseverance". You absolutely need to be ready to call, mail, file papers, whatever it takes to kick up a fuss. And if you have somebody who knows how it works on your side it's SO much easier.
Corporations increase complexity as they grow - each department needs to maximize its revenue - thus complexification is justification for increased budgetary needs. Healthcare is becoming increasingly corporatized. All the talk about outcomes is just that. TALK. It has been so difficult to actually understand how to improve efficiency because there is no good measure for it. Everyone is arguing about outcomes and what actually is a meaningful measure. The net result is laughable - everyone is looking at Press-Ganey scores (basically a popularity contest as to how their 'customers' feel). Real outcomes take decades to measure and for-profit healthcare systems are run by CEOs who want to maximize their quarterly bonus(BTW the CEO of AETNA got a $500million bonus for retiring-that came from premiums) It is criminal to profit from the unintended misery of the unfortunate. The practitioners should be paid. But everyone else who is pushing paper, massaging electrons or jawboning about the share price is just dead weight on the system.
Ironically, the author found peace by hiring a consultant - back to square one - a one on one transaction between two humans without a middleman.
HMOs were a minor player 50 years ago. They are a euphemism for the corporate cancer that maximizes profits at the expense of the sick. Even when I started working in Mass 25 years ago, it was one of the few states with HMOs. They have continued to morph and are now ripe for purchase by the more profitable corporations (pharma) CVS buying Aetna is the first shot. Although Aetna is an insurance company, they offered many stripped down 'products' = HMO like plans.
> In 2017, software is conspicuously not eating the cost-disease economic sectors: health care, education, housing, government. They are being eaten—by communal mode tribalism.
Software can't fix political problems...
Bucky Fuller predicted that we would describe our problems to the computer and it would calculate the optimal deployment of resources to solve them. He estimated that we would have the technology to supply everyone on Earth with a decent standard of living by sometime in the 1970's, provided that we used our resource and technology efficiently. In other words, if you accept Bucky's point, all of our problems now are psychological rather than technological. (We have all the technology we need.)
Standard of living problems have mathematical solutions, psychological problems don't.[1]
> hire an independent health care administration consultant
"Add another layer of abstraction."
But now the consultant has a clear disincentive ($150/hour!) to fix the problem.
The U.S. health system is pathetically broken, and I have no idea how to fix it. This seems like a poor solution, even though I can understand why the author would do it.
I really feel for the author. My mother has dementia and is slipping away fast. Thankfully my sister has the time and energy to move back in with our mother and care for her. She's also with Kaiser-Permanente which seems to let us avoid the worst of the systemic problems. So, in a way, we're really lucky.
[1] "psychological problems don't [have mathematical solutions]" Although... There is something called Neuro-Linguistic Programming (the other NLP) that is a kind of model of psychology that does admit of algorithm-like protocols for therapy. E.g. the "Five-Minute Phobia Cure" which is an algorithm that cures phobias.
The need to hire a 'consultant' is extremely depressing. That is what doctors (primary care managers in particular) are supposed to do.
But their pay is terrible compared to specialists, especially when you consider medical school debt and that they don't start earning until years later than most. They have diminishing power in the hospital organizations unless they go into management. There are exceptions, but most medical students with options don't choose Primary Care.
For specialists, the model is just as broken. If you do procedures, you are incentivized to do procedures. Sometimes this is the best option for the patient, sometimes it's not, but you are going to get paid one way and not the other. And there is a good chance that unless you are at a top-tier academic hospital, there will not be anyone around to second guess you unless you realllllly screw up.
There is also tremendous pressure to produce, which is why doctors triple book fifteen minute appointments, and you end up in freezing the waiting room with no LTE for two hours. A good doctor would love to spend more time with you directly, and a lot more time managing your care, but that's not what the system incentivizes. And tying compensation to quality ratings is hugely problematic when the job is to often tell people they are fat alcoholics who need to quit doing opiates.
My wife is a doc, and it breaks my heart when she says she wouldn't recommend it for our kids.
> For complex health care problems, I recommend hiring a consultant to provide administrative (not medical!) guidance.
This is called a patient advocate. Think of them as your healthcare guardian.
Sometimes you hire one, sometimes one will be assigned to you in more progressive healthcare systems. If you are fighting a chronic or potentially lethal disease, I highly recommend one.
Edit: Your patient advocate is usually covered by insurance if they work for the hospital or the insurance company, but not if you hire them directly. Take that for what you will.
Does American insurance cover this? I have inquired about something like this before when I was getting conflicting diagnoses and treatment plans. Everyone I asked (at my insurance company) acted like they didn’t know what I was talking about. I did not size the phrase “patient advocate” but if one were available, I think my need for them would have been clear.
If insurance denies claims for life-saving medical procedures because they happened out of network, I have a hard time believing they'd pay for someone to give you advice.
The article gives a good example of why it's in the insurance companies' interest to pay people to give you advice. It was obvious to everyone on the ground that the insurer would save money if they just sent the author's mother to an out-of-network physical therapist rather than keeping her in the hospital. But the insurer didn't have anyone who could quickly make that cost-saving judgment call.
Really, the biggest problem in a lot of cases is not that insurers deny claims for life-saving procedures, it's that they prioritize expensive and ineffective treatments over inexpensive and effective treatments.
Best article I've read this year. (Haha, but it's very good, if a little burdened with weird terminology.)
I have been through some similar experiences myself. Not as bad, but enough to find OP's story not-really-remarkable.
This is what we've got for healthcare in the USA. I wish it was fixable, but I do not believe it is. Powerful interests will resist or subvert any substantive change. (I do expect new "reforms" that will promise fixes and then pump even more money into the broken system, though.)
If you get sick, hope that it is something utterly routine that your applicable system will process without a hiccup. Failing that, expect this kind of craziness and prepare for it. Defensive record keeping and navigating bureaucracies will be necessary skills in 21st century USA.
That's due to several factors but one of them is that some of the terms are specific 'concepts' described elsewhere on the same site, which is itself a 'book'.
The author concludes that communal or relational modes of interaction will become more common as systems fail. It would have added a lot to the article if he gave some tips on talking to the various providers and bureaucrats in the system (the only advice is working in a medical office and "having charm").
Once you've seen it, the communal/relational mode of interaction is immediately easy to spot and is actually a very rewarding way to interact with people. Although it doesn't happen as often in large cities except among large families or tight-knit ethnic groups, I think a well-functioning workplace should have some of it. People helping others out, getting to know each other, and so on. The problem is the conflict between the way the health care system presents itself and is organized (systematic/transactional) and the way it really works.
Tips on seeing the communal mode and maybe practicing a bit: Note how your group of friends relates when they're camping or otherwise on a trip of some kind. Spend some time in a smaller town where you know at least a couple people. Spend time with lower-income people from a similar background to you, who have to rely on each other more versus their bank accounts. Outside large cities, ask people at the stores or wherever how they're doing and actually care about what their response is.
I know this is going to be controversial, but at this point:
> My mother’s mild dementia began accelerating rapidly a year ago. I’ve been picking up pieces of her life as she drops them. That has grown from a part-time job to a full-time job. In the past month, as she’s developed unrelated serious medical issues, it’s become a way-more-than-full-time job.
I would have kept my mother out of the healthcare system and let her pass at home or in a hospice. You can't save someone from dementia and old age, don't even try, you are just prolonging their pain. Let her drop the pieces of her life and leave them there. Lymphedema treatment? She's 84 years old with dementia, she isn't going to get up a run a marathon, why would you treat this?
I say this having never have dealt with a dying parent, so this may be ignorant on my part. I am sure it is difficult standing by while a loved one fades. I think it would be better to spend a few stress-free, happy months in a hospice than years running around between the confusing, painful, stressful mess that is the healthcare system.
I understand what you're getting at but it's not that easy: it is not a clear-cut decision when it happens to your family.
Usually, old folks develop an ever growing list of aliments which add up over time, usually one serious medical crisis every few months to a year until their number is called.
Moreover, many of aliments of old folks aren't "terminal". You can't take your octogenarian mother to the hospice, for instance, because she broke a hip, had a stroke, got sepsis from a UTI, or suffered a venous ulcer that put her in a wheelchair (all those happened to my mother in a span of 2 years).
Also, "dementia" (not to be confused with Alzheimer's) is a side-effect of something else rather than a condition in itself. A simple infection is enough for an elderly person to develop dementia to the point where she does not know where she is. Even a pain-killer regimen requires careful management to keep the patient on a knife-edge between lucidity and la-la-land.
I don't think that's a particularly controversial view. Your last few sentences touch more on the issue - when you're faced with losing someone, it's very easy to say "Pull out all the stops, having [ mom | dad | grandma | grandpa ] here for one more year is worth it." Honestly, the only group of people I've ever been around who have less trouble with that mindset are medical professionals. Most doctors, especially if they're 65+, are DNR/DNI because they've seen what spending significant time in the healthcare system is really like. But I've seen some of those same people fall into the trap of demanding care for their aging parents that they've explicitly rejected for themselves.
I don't think it's controversial at all. Nobody gets out of life alive. If I make it to 65 or so, I feel I've had my share. It's all downhill after that point anyway, why would I want to prolong the misery?
An easy statement to make when you're nowhere near 65. I've spent a lot of time in my life thinking about death, and as a result I've come to certain philosophical conclusions regarding it. But I know that philosophy is something that exists comfortably in mind of someone without a gun to their head.
It appears that 73% of the labor cost of a health care organization is spent on trying to communicate with other health care organizations that have no defined interface.
So if it worked properly, US healthcare would cost one quarter if what it does. Less, once the people engaged in trying to talk to each other are no longer required. That's quite a statement.
Considering that (IIRC) other OECD states typically sit between 40% and 60% of US spending on healthcare per-capita, and they presumably haven't actually eliminated these sorts of inefficiencies (so some percentage even of that 40% is still communication overhead) I'd say 73%'s at least plausible (could still be wrong, of course).
If someone has a reasonably high-level position in a major medical services organization, and wants to help us advance as a species, here's something to push for; get your company to throw out all its fax machines.
Every office in the world can use non-fax communication technologies; they just have policies that prevent them. If they encounter a sufficiently large healthcare entity that simply shrugs at them and says "we don't do faxes," those policies won't matter, for precisely the reasons stated in the article. People will do what needs to be done to get things to happen, policy or no (if they care; if they don't, it won't get done, regardless of the number of fax machines involved.)
One organization making a stand could start the process of getting us past that particular perverse element of the medical system.
Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best. They call the agencies to try to find out what the regulations are supposed to mean, and they spend hours on hold, are transferred from one official to another and back, and eventually get directed to a .gov web site that says “program not implemented yet.” Then they make something up, and hope that when the government sues Anthem, they don’t get blamed for it personally.
Anthem doesn't do their best to help people navigate their insurance and get solid answers. Individuals within the company may do their best but the company itself chooses how to fund those departments, how to run them, etc. Healthcare is confusing because 'healthcare explainers' and 'insurance navigators' are cost centers and so our privatized system places no real emphasis on them.
Besides it's not like these rules emerge from the ether either, they exist as a response to shady tactics by insurance companies. Surely we're not so far removed to have forgotten all the abuses of pre-existing conditions by insurance companies?
I might be able to say this isn't the fault of healthcare and insurance companies only so far as it's the fault of government for not just ending the charade and making the whole thing public.
She retired in 97 and still has health coverage by her employer. Is that typical in the US? Is it very expensive to insure someone in perpetuity like that?
I assume it's tied to some kind of pension (which is tied to the former employer), so the premium would be ongoing and taken out of the pension payout.
Otherwise, I'd imagine yes permanently insuring someone would be extraordinarily expensive.
This is a systems interface essay. The lede is buried very deeply:
It’s like one those post-apocalyptic science fiction novels whose characters hunt wild boars with spears in the ruins of a modern city. Surrounded by machines no one understands any longer, they have reverted to primitive technology.
Except it’s in reverse. Hospitals can still operate modern material technologies (like an MRI) just fine. It’s social technologies that have broken down and reverted to a medieval level.
Systematic social relationships involve formally-defined roles and responsibilities. That is, “professionalism.” But across medical organizations, there are none. Who do you call at Anthem to find out if they’ll cover an out-of-state SNF stay? No one knows.
The author recommends hiring a consultant. I'd like to suggest an alternate approach.
In complex disputes between parties, we have several systems or dispute resolution. One is to engage the services of an alternative administrative system: the courts.
While Anthem may be governed by 1,600-page rule-books, a judge is not. Or rather, a judge has a different set of rule books and considerable autonomy to make decisions independently.
(With provisions for review.)
One way of considering this is as a collapsing of complexity: where a system becomes too complex to function reasonably, a third party is called in.
The U.S. healthcare "system" has become vastly too complex to function with any semblance of sanity. It is in desperate need of a complexity constraint being applied to it. What we might in other political contexts call a revolution. Perhaps a reform.
But it seems vastly beyond the realm of incremental change.
I'm wondering, is the American health care bad for (upper) middle-class too? let say you have a good job in a big corporation, do you have to worry about healthcare? can you go to a decent hospital for any problem you may have and get appropriate care without spending any dime?
Yes, it's horrifically terrible. The hospitals/doctors you can go to are dictated by your insurance. Having a good job does not equal having good insurance. It's hit or miss. Having a good job does not guarantee you have someone to help you out with the paperwork and the stress from that can and will kill you even if you survive the actual hell that is the healthcare itself (topic of the article).
If you get injured on the job, you have to go through the worker's compensation system which can take months to years just to be seen for certain conditions like RSI. And if you change states, you're fucked because there's literally no one who knows how the systems should work together. The more history you have, the worse. Sometimes you have to lie and omit medical history just to get your foot in the door.
I worry about healthcare and whether I will be able to do my job (writing software) next year, let alone ten or thirty years from now because I simply cannot get the care I need for a problem that's 100% caused by work. This is supposed to be covered 100%. Now imagine how bad people without insurance or people who have otherwise not-covered conditions have it. It's a fucking nightmare for everyone who is not part of the upper class and can afford good insurance and the ability to hire assistants to actually make the insurance work for them, so much so that certain companies have contracted out for such services for their employees. It's a perk of employment that very few employers offer. I'm sorry, but horrific doesn't even begin to describe the situation ... I'm actually at a loss for words in describing how bad healthcare is in the US.
If you work for a company that is big enough for a large group plan, and you pay extra for PPO insurance, you can choose any provider you want. But there are significant out of pocket costs and all the paperwork and disfunction mentioned in this article.
I can second the experience of the author. All in I had contact with over 40 different providers. I was lucky in that I had to leave my job and could concentrate on the administrative work required full time. I eventually learned I needed to keep a detailed written narrative up to date with a tl;dr at the top. Eventually I added appendixes that summarized lab tests and surgery reports. This was the only way I could make sure each provider had the details they needed. I would always send it advance, most of the time the doctor hadn't read it so I brought paper copies and sat there while they did.
The billing and who covered what was hopeless. I had to fight with medical insurance, the medical disability company and Medicare when I maxed both of those out. I went through every bill line by line to identify mistakes, there were many. Then I would make sure each had received a copy of each bill and start figuring out who would cover what, sometimes line-by-line. This all had to be done over phone and fax.
It's broken and I am sure it's killing people. I also don't see a technology fix. Anything that requires more than two or three providers is an edge case, this space is 90% edge cases.