11 ms·

Post-apocalyptic life in American health care

164 points by primodemus 9y ago

dredmorbius 9y ago
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.
toomuchtodo 9y ago
> 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.
- arielweisberg 9y ago
  Sounds like you need patient advocate insurance. I wish I were trolling.
  - a3n 9y ago
    Because medical insurance itself has worked so well for us.
- gt_ 9y ago
  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.
  - pc86 9y ago
    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.
    - lukeschlather 9y ago
      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.
  - ceejayoz 9y ago
    The patient advocates employed by insurers are primarily there to try and reduce your medical needs, so they can save money. They're not going to reconcile differing diagnoses, they're going to ask if you've gotten your flu shot yet.
maxxxxx 9y ago
"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.
- yborg 9y ago
  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.
  - rdtsc 9y ago
    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.
- u801e 9y ago
  Shouldn't the results of the previous tests be part of the medical record? If so, then the other doctor should have been able to view the results.
  - maxxxxx 9y ago
    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.
    - AnIdiotOnTheNet 9y ago
healthcare-mess 9y ago
For-profit healthcare is a crime against humanity.
- arielweisberg 9y ago
  Wow you needed a throw away to post that? Is there a story behind that?
dbpatterson 9y ago
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.
- conanbatt 9y ago
  It isn't profit-seeking what makes healthcare what it is. Its the incredibly burdensome regulation and restrictions. If profit-seeking destroyed markets for profit, we would all be starving.
  - evgen 9y ago
    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.)
    - conanbatt 9y ago
      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.
nathanaldensr 9y ago
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. Ah, the hubris of humanity...
- jerf 9y ago
  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.)
jbob2000 9y ago
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.
- trowawee 9y ago
  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.
- crispyambulance 9y ago
  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.
frgtpsswrdlame 9y ago
I really can't agree with this paragraph: 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.
- conanbatt 9y ago
  No matter how much money in lobbying anthem might have spent, the ultimate responsiblity for the law as written is of government. Government should fix the current problems it has before asking for more responsibility.
  - frgtpsswrdlame 9y ago
    I don't understand how your comment relates to mine. Care to elucidate?
    - conanbatt 9y ago
      "Anthem should do their best to explain the complex rules set forth by government"
poppingtonic 9y ago
https://equilibriabook.com/molochs-toolbox/ https://equilibriabook.com/molochs-toolbox/
- tvanantwerp 9y ago
  I read this a few weeks ago when it was linked from comments on a different HN discussion. Definitely describes well the problems facing health care.
draw_down 9y ago
The important thing is to refrain from assigning blame for any of the problems in our healthcare system. Politics are bad, and we shouldn't try to figure out how things got this way because we don't want to get into any politics.
shrike 9y ago
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.
- lovich 9y ago
  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
  - nradov 9y ago
    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.
    - trowawee 9y ago
crispyambulance 9y ago
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.
testplzignore 9y ago
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.
- delinka 9y ago
  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.
- ForHackernews 9y ago
  > 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. [0] https://www.healthaffairs.org/do/10.1377/hblog20110920.013390/full/ https://www.healthaffairs.org/do/10.1377/hblog20110920.01339... > 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.
- thehardsphere 9y ago
  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?
Florin_Andrei 9y ago
> the biggest failing of the American health care system is its fragmentation This flaw will be extremely difficult to fix for as long as its nature is perceived as "freedom" or "choice".
- SN76477 9y ago
  I am always looking for the most fundamental answer, I think this is it.
jf 9y ago
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.
carapace 9y ago
> 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.
mattchew 9y ago
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.
- aeorgnoieang 9y ago
  > weird terminology 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'.
EliRivers 9y ago
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.
- ashark 9y ago
  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).
- jpk 9y ago
  > 73% of the labor cost Key qualifier: "of the labor cost". Presumably, there are additional, non-labor costs that may not be reduced by more efficient communication.
- tinymollusk 9y ago
  "The number 73% is my dazed estimate based on informal observation and analysis conducted in doctors’ examination rooms." from the footnote
justinhj 9y ago
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?
- liveoneggs 9y ago
  a very old fashioned retirement/pension scheme probably provided for this; these are all gone
- InitialLastName 9y ago
  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.
bawana 9y ago
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.
- bogomipz 9y ago
  >"Healthcare is becoming increasingly corporatized." Hasn't healthcare been corporatized since the dawn of HMOs almost 50 years ago though?
  - bawana 9y ago
    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.
JimboOmega 9y ago
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.
communalnotes1 9y ago
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.
maxander 9y ago
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.
hectorr1 9y ago
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.
yodsanklai 9y ago
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?
- mnm1 9y ago
  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.
  - bradknowles 9y ago
    But if you have a bad job, or maybe just one that is less than perfect, it can be almost impossible to get good insurance.
- pjdemers 9y ago
  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.
deleted 9y ago
[deleted]

164 points by primodemus 9y ago

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.

toomuchtodo 9y ago

> 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.

arielweisberg 9y ago
Sounds like you need patient advocate insurance. I wish I were trolling.
- a3n 9y ago
  Because medical insurance itself has worked so well for us.
gt_ 9y ago
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.
- pc86 9y ago
  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.
  - lukeschlather 9y ago
    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.
- ceejayoz 9y ago
  The patient advocates employed by insurers are primarily there to try and reduce your medical needs, so they can save money. They're not going to reconcile differing diagnoses, they're going to ask if you've gotten your flu shot yet.

maxxxxx 9y ago

"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.

yborg 9y ago
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.
- rdtsc 9y ago
  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.
u801e 9y ago
Shouldn't the results of the previous tests be part of the medical record? If so, then the other doctor should have been able to view the results.
- maxxxxx 9y ago
  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.
  - AnIdiotOnTheNet 9y ago

healthcare-mess 9y ago

For-profit healthcare is a crime against humanity.

arielweisberg 9y ago
Wow you needed a throw away to post that? Is there a story behind that?

dbpatterson 9y ago

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.

conanbatt 9y ago
It isn't profit-seeking what makes healthcare what it is. Its the incredibly burdensome regulation and restrictions. If profit-seeking destroyed markets for profit, we would all be starving.
- evgen 9y ago
  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.)
  - conanbatt 9y ago
    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.

nathanaldensr 9y ago

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. Ah, the hubris of humanity...

jerf 9y ago
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.)

jbob2000 9y ago

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.

trowawee 9y ago
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.
crispyambulance 9y ago
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.

frgtpsswrdlame 9y ago

I really can't agree with this paragraph: 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.

conanbatt 9y ago
No matter how much money in lobbying anthem might have spent, the ultimate responsiblity for the law as written is of government. Government should fix the current problems it has before asking for more responsibility.
- frgtpsswrdlame 9y ago
  I don't understand how your comment relates to mine. Care to elucidate?
  - conanbatt 9y ago
    "Anthem should do their best to explain the complex rules set forth by government"

poppingtonic 9y ago

https://equilibriabook.com/molochs-toolbox/ https://equilibriabook.com/molochs-toolbox/

tvanantwerp 9y ago
I read this a few weeks ago when it was linked from comments on a different HN discussion. Definitely describes well the problems facing health care.

draw_down 9y ago

The important thing is to refrain from assigning blame for any of the problems in our healthcare system. Politics are bad, and we shouldn't try to figure out how things got this way because we don't want to get into any politics.

shrike 9y ago

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.

lovich 9y ago
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
- nradov 9y ago
  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.
  - trowawee 9y ago

crispyambulance 9y ago

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.

testplzignore 9y ago

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.

delinka 9y ago
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.
ForHackernews 9y ago
> 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. [0] https://www.healthaffairs.org/do/10.1377/hblog20110920.013390/full/ https://www.healthaffairs.org/do/10.1377/hblog20110920.01339... > 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.
thehardsphere 9y ago
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?

Florin_Andrei 9y ago

> the biggest failing of the American health care system is its fragmentation This flaw will be extremely difficult to fix for as long as its nature is perceived as "freedom" or "choice".

SN76477 9y ago
I am always looking for the most fundamental answer, I think this is it.

jf 9y ago

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.

carapace 9y ago

> 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.

mattchew 9y ago

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.

aeorgnoieang 9y ago
> weird terminology 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'.

EliRivers 9y ago

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.

ashark 9y ago
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).
jpk 9y ago
> 73% of the labor cost Key qualifier: "of the labor cost". Presumably, there are additional, non-labor costs that may not be reduced by more efficient communication.
tinymollusk 9y ago
"The number 73% is my dazed estimate based on informal observation and analysis conducted in doctors’ examination rooms." from the footnote

justinhj 9y ago

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?

liveoneggs 9y ago
a very old fashioned retirement/pension scheme probably provided for this; these are all gone
InitialLastName 9y ago
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.

bawana 9y ago

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.

bogomipz 9y ago
>"Healthcare is becoming increasingly corporatized." Hasn't healthcare been corporatized since the dawn of HMOs almost 50 years ago though?
- bawana 9y ago
  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.

JimboOmega 9y ago

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.

communalnotes1 9y ago

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.

maxander 9y ago

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.

hectorr1 9y ago

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.

yodsanklai 9y ago

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?

mnm1 9y ago
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.
- bradknowles 9y ago
  But if you have a bad job, or maybe just one that is less than perfect, it can be almost impossible to get good insurance.
pjdemers 9y ago
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.

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