4 ms·

A more optimistic formulation would be that that represents millions of people who could be doing something a bit more generally useful than mastering the intri

A more optimistic formulation would be that that represents millions of people who could be doing something a bit more generally useful than mastering the intricacies of the layers and layers of bureaucracy built up around medical billing. And probably wouldn't mind having a slightly less mind-numbing job themselves. Too bad the US is also epically bad at supporting people in career transitions.

ethbro 8y ago
The magnitude of the data systems migration is usually discounted as well. Insurance companies generally have atrocious IT (it's not their core competency) and consequently inflexible IT stacks. Elimination the layers and layers of bureaucracy also means change / rewritting all the places that's embedded in code. ... and the real kicker? Those changes have to happen on both sides of any party / counterparty transaction. While supporting a normal volume of work. Small example? ICD-10 code support https://www.cms.gov/Medicare/Coding/ICD10/index.html https://www.cms.gov/Medicare/Coding/ICD10/index.html
- darawk 8y ago
  That's a capital cost though, not a marginal cost. Amortize it over the essentially infinite savings on a long enough time horizon and it's basically free.
  - ethbro 8y ago
    Assuming success. Which has a pretty atrocious probability from what I saw (see above reply).
- bunderbunder 8y ago
  I think, though, that they would find a way to clean this all up toute de suite, if only they were given a proper incentive to do so. For example, if there were real competition in the marketplace (say, by moving to a system where most consumers go to actually shop around and choose their own health insurance company), I expect you'd find insurance companies start to streamline their own processes, both internal and external, more-or-less immediately.
  - ethbro 8y ago
    I think the issue there is risk. Specifically, what is the likelihood of success if I attempt to migrate / change / remove X system? I can't understate the complexity and intricacies. Imagine legally defining all possible medical transactions, then writing software thats compatible with those legal agreements, then running it, changing the agreements, and adding features over 50 years. While the systems being interacted with also mutate. And all of this being done haphazardly and uniquely because there's no one in control of the entire process (Medic-are/aid aside). I'm hard pressed to think of a messier computing system in aggregate. I'd guess even the financial system is more rigidly defined, has fewer players, and doesn't have to map with as high fidelity to real life. ACA provided a fair number of incentives and penalties, re: actual vs industry standard overhead. And it caused change, but there were a lot of failures.
  - mmt 8y ago
    Indeed, imagine a system where some providers are cash-only. They wouldn't even care about that ICD-10 stuff, let alone pay even the cost of entry for the proprietary coding system. Of course, I realize, that were an insured patient to use such a provider, that would shift the insurance claims burden onto the patient (much as is often the case PPO out-of-network claims today), but this could be a point of competition for would-be insurers under your proposed system.
    - ethbro 8y ago
      If a patient is cash-only, how would their electronic records be stored, if not ICD-* compatible?
      - mmt 8y ago
        Using any technology that predates ICD-*, including paper. Current regulations may preclude using anything but a compatible EMR, but this implementatino detail is hardly fundamental to the practice of medicine.
        ethbro 8y ago
- LyndsySimon 8y ago
  > Insurance companies generally have atrocious IT (it's not their core competency) and consequently inflexible IT stacks. I've been working at startups in the healthcare industry for a few years now, and agree. It's not just insurance companies, either - hospitals are just as bad if not worse. It's even worse for hospitals that are affiliated with a University.
- dragonwriter 8y ago
  > Insurance companies generally have atrocious IT And mandatory IT standards (e.g., those adopted under HIPAA) in the healthcare field are written almost entirely by insurance industry IT.
  - ethbro 8y ago
    Everyone gripes about HIPAA, but from where I sat, it was a pretty sane standard. Admittedly I wasn't in implementation. But it read a lot like an IETF RFC. "Covered entities shall implement network protection." "Covered entities shall not disclose PHI." Outcome-specified, implementation-agnostic. And then set penalties based on whether the breach was accidental / willful / limited / or ongoing.
    - dragonwriter 8y ago
      > Everyone gripes about HIPAA I am not griping about HIPAA. The quality of stone of the specific transaction standards developed by industry groups and adopted as mandatory in regulations implementing HIPAA, OTOH, are another story.
jonhendry18 8y ago
"A more optimistic formulation would be that that represents millions of people who could be doing something a bit more generally useful than mastering the intricacies of the layers and layers of bureaucracy built up around medical billing. And probably wouldn't mind having a slightly less mind-numbing job themselves." The same could be said of coal miners. And miners probably didn't take on school loans to learn their profession. It's easy to handwave retraining millions of workers, but it's not that simple, and the jobs have to exist.

ethbro 8y ago

The magnitude of the data systems migration is usually discounted as well. Insurance companies generally have atrocious IT (it's not their core competency) and consequently inflexible IT stacks. Elimination the layers and layers of bureaucracy also means change / rewritting all the places that's embedded in code. ... and the real kicker? Those changes have to happen on both sides of any party / counterparty transaction. While supporting a normal volume of work. Small example? ICD-10 code support https://www.cms.gov/Medicare/Coding/ICD10/index.html https://www.cms.gov/Medicare/Coding/ICD10/index.html

darawk 8y ago
That's a capital cost though, not a marginal cost. Amortize it over the essentially infinite savings on a long enough time horizon and it's basically free.
- ethbro 8y ago
  Assuming success. Which has a pretty atrocious probability from what I saw (see above reply).
bunderbunder 8y ago
I think, though, that they would find a way to clean this all up toute de suite, if only they were given a proper incentive to do so. For example, if there were real competition in the marketplace (say, by moving to a system where most consumers go to actually shop around and choose their own health insurance company), I expect you'd find insurance companies start to streamline their own processes, both internal and external, more-or-less immediately.
- ethbro 8y ago
  I think the issue there is risk. Specifically, what is the likelihood of success if I attempt to migrate / change / remove X system? I can't understate the complexity and intricacies. Imagine legally defining all possible medical transactions, then writing software thats compatible with those legal agreements, then running it, changing the agreements, and adding features over 50 years. While the systems being interacted with also mutate. And all of this being done haphazardly and uniquely because there's no one in control of the entire process (Medic-are/aid aside). I'm hard pressed to think of a messier computing system in aggregate. I'd guess even the financial system is more rigidly defined, has fewer players, and doesn't have to map with as high fidelity to real life. ACA provided a fair number of incentives and penalties, re: actual vs industry standard overhead. And it caused change, but there were a lot of failures.
- mmt 8y ago
  Indeed, imagine a system where some providers are cash-only. They wouldn't even care about that ICD-10 stuff, let alone pay even the cost of entry for the proprietary coding system. Of course, I realize, that were an insured patient to use such a provider, that would shift the insurance claims burden onto the patient (much as is often the case PPO out-of-network claims today), but this could be a point of competition for would-be insurers under your proposed system.
  - ethbro 8y ago
    If a patient is cash-only, how would their electronic records be stored, if not ICD-* compatible?
    - mmt 8y ago
      Using any technology that predates ICD-*, including paper. Current regulations may preclude using anything but a compatible EMR, but this implementatino detail is hardly fundamental to the practice of medicine.
      - ethbro 8y ago
LyndsySimon 8y ago
> Insurance companies generally have atrocious IT (it's not their core competency) and consequently inflexible IT stacks. I've been working at startups in the healthcare industry for a few years now, and agree. It's not just insurance companies, either - hospitals are just as bad if not worse. It's even worse for hospitals that are affiliated with a University.
dragonwriter 8y ago
> Insurance companies generally have atrocious IT And mandatory IT standards (e.g., those adopted under HIPAA) in the healthcare field are written almost entirely by insurance industry IT.
- ethbro 8y ago
  Everyone gripes about HIPAA, but from where I sat, it was a pretty sane standard. Admittedly I wasn't in implementation. But it read a lot like an IETF RFC. "Covered entities shall implement network protection." "Covered entities shall not disclose PHI." Outcome-specified, implementation-agnostic. And then set penalties based on whether the breach was accidental / willful / limited / or ongoing.
  - dragonwriter 8y ago
    > Everyone gripes about HIPAA I am not griping about HIPAA. The quality of stone of the specific transaction standards developed by industry groups and adopted as mandatory in regulations implementing HIPAA, OTOH, are another story.

jonhendry18 8y ago

"A more optimistic formulation would be that that represents millions of people who could be doing something a bit more generally useful than mastering the intricacies of the layers and layers of bureaucracy built up around medical billing. And probably wouldn't mind having a slightly less mind-numbing job themselves." The same could be said of coal miners. And miners probably didn't take on school loans to learn their profession. It's easy to handwave retraining millions of workers, but it's not that simple, and the jobs have to exist.