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Two interesting problems. One is that a free market might result in "better" purchaser decisions, but a free market requires a meeting of the minds and some pa

by VLM 11y ago

Two interesting problems. One is that a free market might result in "better" purchaser decisions, but a free market requires a meeting of the minds and some patients won't have minds, temporarily or permanently, and those that do have a staggering power imbalance of one uneducated untrained individual vs a thousand person highly trained organization. We're not talking about two commodity traders exchanging with each other. This is before we get into "state of mind" and panic, someone having a heart attack can't focus on contractual negotiations quite like the guy across the table not currently having a heart attack. And then there's the timeliness issue, and geography... The second, is medical care cannot be treated as a commodity. I was horrified at the "taylorism gone wild" in the article where one surgeon used twice the bandages as the other, and therefore is bad. In the real world that will be implemented as "well, yes I know your tumor was a completely different size and shape than his tumor, and bandages cost almost nothing compared to a human life, but we have beans to count and quotas to stay under so you'll just have to bleed to death because it would take too many bandages to save your life" or "well yes half his patients are permanently crippled and none of hers do, but she uses twice as many band aids, so we'll have to downsize her and keep him, to stay under our bandage budget". Without a commodity of interchangeable identical product, you can't have a free market or at least not the gains of a free market. Its interesting that the medical system admits as such... there are specializations of patient disease clusters, but despite the best efforts of centuries of work we still can't specialize beyond a very shallow level, we have cardiologist specialists not specialists in 25% arterial blockages of the left ventricle, even though its "obvious" that if it were implementable, specialization to that level would be very helpful. This is before we get to the issue that you get what you count, so if you count meaningless metrics you'll get excellent meaningless metrics, not health care. A better model for the economics of health care would be fine art. Or maybe education. Notice how the money spent correlates strongly with how much money is available, and has little correlation with results, at any level beyond bare requirements. Or how attempts at taylorism style management provide laughable comedy results. Health care does seem to "fit" better with fine art or education, than with accounting or a manual factory assembly line.

zeveb 11y ago
> I was horrified at the "taylorism gone wild" in the article where one surgeon used twice the bandages as the other, and therefore is bad. It didn't say that it was bad; it just noted it as a fact. Perhaps Dr. Jones's patients need more bandages because of the types of patient he sees (which might indicate that he's really good at what he does); perhaps his incisions are larger (which would be bad); perhaps he just wastes bandages (which is also bad). All measurements can do is demonstrate a difference: good management is required to discern the reason for the disparity, and determine if it's a positive or negative indicator.
- VLM 11y ago
  Its possible the reason is unknowable at this time. As an example one theoretical reason you didn't mention is changing bandages twice as often reduces post-op infections by 75%, although no one has discovered or proven that yet, its sounds possible, and post-op infections are expensive and painful compared to cheap bandage replacement. Minimization of cost of any random individual component almost always doesn't result in minimization of total system cost. Its important to build robust fault tolerant fail safe systems. By definition, half of all management will be below median. A system designed to give the bad ones maximally overpowered weapons to wreck havoc is not a good system design. Numerology as a weapon can be destructive. It seems reasonable that as a system it might enable the top half of managers to take three steps forward, while enabling the bottom half of managers to take five steps back, not forgetting the fixed cost due to documentation and processing labor (bean counting) and micromanagement somewhere around a fixed two to four steps back just to gather and process the data, regardless if its used or not. That's a badly designed system. This is before design criticism along the lines of never implement a system more complicated than its minimal need. Simplicate and add lightness. The substantial money spent counting, processing, and graphing every band aid could have been spent more simply, probably more productively, by spending $X extra on surgeon hiring salary to get a slightly measurably higher class of surgeon... or manager... Or the mental effort spinning around inside a surgeon's brain while cutting could be spent on improving patient outcomes by perfecting incisions or sutures or during surgery judgement calls ... or those brain cycles can be spent on minimization of band aids to meet band aid quota.

by VLM 11y ago

zeveb 11y ago

> I was horrified at the "taylorism gone wild" in the article where one surgeon used twice the bandages as the other, and therefore is bad. It didn't say that it was bad; it just noted it as a fact. Perhaps Dr. Jones's patients need more bandages because of the types of patient he sees (which might indicate that he's really good at what he does); perhaps his incisions are larger (which would be bad); perhaps he just wastes bandages (which is also bad). All measurements can do is demonstrate a difference: good management is required to discern the reason for the disparity, and determine if it's a positive or negative indicator.

VLM 11y ago
Its possible the reason is unknowable at this time. As an example one theoretical reason you didn't mention is changing bandages twice as often reduces post-op infections by 75%, although no one has discovered or proven that yet, its sounds possible, and post-op infections are expensive and painful compared to cheap bandage replacement. Minimization of cost of any random individual component almost always doesn't result in minimization of total system cost. Its important to build robust fault tolerant fail safe systems. By definition, half of all management will be below median. A system designed to give the bad ones maximally overpowered weapons to wreck havoc is not a good system design. Numerology as a weapon can be destructive. It seems reasonable that as a system it might enable the top half of managers to take three steps forward, while enabling the bottom half of managers to take five steps back, not forgetting the fixed cost due to documentation and processing labor (bean counting) and micromanagement somewhere around a fixed two to four steps back just to gather and process the data, regardless if its used or not. That's a badly designed system. This is before design criticism along the lines of never implement a system more complicated than its minimal need. Simplicate and add lightness. The substantial money spent counting, processing, and graphing every band aid could have been spent more simply, probably more productively, by spending $X extra on surgeon hiring salary to get a slightly measurably higher class of surgeon... or manager... Or the mental effort spinning around inside a surgeon's brain while cutting could be spent on improving patient outcomes by perfecting incisions or sutures or during surgery judgement calls ... or those brain cycles can be spent on minimization of band aids to meet band aid quota.