The difficulty of fixing and improving these systems is frankly overrated. It has more to do with penny pinching and profiteering that they haven't modernized. I don't mean a rewrite in JavaScript either, I mean sensible engineering, which many people are ready to do but not paid to do, because it weakens the upwards money vacuum the finance cabal wants to maintain. Progress isn't profitable enough according to the Excel spreadsheet.
The irony of attributing the free market healthcare disaster we have here to regulation. Things are plenty regulated in Australia and other socialized countries and they have none of the crazy billing / coverage issues we have. It's frankly, bullshit.
It's not the same regulation.
Yeah. A lot of flamewars have happened: "regulation bad!" vs "no, regulation good!".
But in reality, good regulation is good, and bad regulation is bad.
It sounds silly written out because it's a tautology, but if more people internalized it we could have much more productive conversations. Instead of going back and forth on whether regulation is good or bad, we should try to figure out which regulations are good and which are bad, and then try to get rid of the bad ones and pass more of the good ones.
It sounds silly because it is silly. Interested parties prioritize various policies with varying degrees of priority.
I’d argue that the underlying system that makes the regulation in US is broken. So you aren’t going to end up with many good regulations without changing the system. Which looks nigh impossible until some black swan event.
>But in reality, good regulation is good, and bad regulation is bad.
No one brick in the road to hell is bad. But you can definitely pave a road to hell with the accumulation of "positive" changes. People tend to define positive over too short a timeline or too narrowly.
No one square meter of nature is bad. But you can definitely doom people to horribly die because there is a natural swamp between them and the hospital. People tend to define 'natural' too narrowly, forgetting that 'things that are natural' includes cocaine, tapeworms, rape, birth defects, the Plague and cancer
Effective regulation is somewhat of an organisational skill.
Perhaps its just low pay attracting low talent
There can be bad actors in free markets or socialist institutions. The issue isn't the system itself, but instead the people overseeing it.
It seems more regulated healthcare systems are also significantly less capable of developing innovative treatments (although this could be a misunderstanding of mine)
I think it is a misunderstanding. The two places in the world where everyone agrees it is easiest to get medtech devices developed are Australia and Mexico.
(Source: was doing medtech development for a while in the early 2010s).
You are wrong on this point. Some years ago, I’ve undergo some pretty innovative surgery procedure (I was one of the first hundreds people in the entire world).
I don’t know how it works in the US but at least in France, most hospitals are part of universities so they are also doing a lot of research.
A common thing many tend to misunderstand, is that there's a difference between a free market, and a competitive market.
The most competitive/efficient markets generally need the optimal amount of regulation to keep/get them that way. Those regulations would ensure that these conditions continue to be met in order for it to be a competitive market: https://en.wikipedia.org/wiki/Perfect_competition#Idealizing_conditions_of_perfect_competition https://en.wikipedia.org/wiki/Perfect_competition#Idealizing...
Free markets that are completely unregulated will tend to veer towards collusion and monopolies, in which case they're no longer competitive and the customers suffer. Free markets that are overly regulated will also suffer, but more-so due to things like the regulatory burden/barriers for new entrants.
What we have in the US healthcare system is a demented hybrid where some parts are free market but under-regulated, while other parts are free market but over-regulated. It's the worst of free market and state-run combined.
> Progress isn't profitable enough according to the Excel spreadsheet.
It's precisely the opposite. Its a racket but its not for profit. If you made a health care service that didn't have any of this cruft and just provided great care, it would not be used, because it would not be compliant with insurance, and employees would not get the tax benefit of using it.
If it were for profit, it would work better.
Yes, the fact that literally all health care goes through insurance is a big part of the problem. As my dad says, if you had to get all car maintenance done through your car insurance, changing your oil would cost $5,000.
It is not like that at all in countries like Germany and France, where really literally all health care (for a lot of people) is covered (mostly) by general medical insurance. The pricing explosion is exclusively an US problem.
(Germany has private insurance and France as well in parallel, but the main system is "sozialised")
I wish more Americans knew this.
The healthcare systems in Canada, the UK, France, Germany and Switzerland are all distinctive (they’re main commonality I suppose is that they somehow deliver quality healthcare at a fraction of the US cost.). But to hear Americans say we should “do it the way it’s done in Europe” is to understand that the person likely don’t know how the healthcare systems operate in different countries.
The other frustration in talking about this is the tendency to “It’s just” the problems. If this were a simple problem with an obvious solution it likely would have been solved. We are where we are because of a century of organic, and often idiosyncratic, growth. Well intentioned policies of decades ago have come back to bite us with unintended consequences as likely are our best ideas today.
I don’t say we should throw up our hands and give up, but when anyone says there is an easy solution - we just need the political will to let them do what they want - I do see snake oil.
> The difficulty of fixing and improving these systems is frankly overrated. It has more to do with penny pinching and profiteering that they haven't modernized.
Eh, I'd rather listen to duffpkg, with his extensive, real world experience in health tech, than a random comment.
FWIW, a former coworker of mine spent a few years at a health technology company (also worked with MUMPS), and legal compliance was the number one hurdle to modernizing. It was expensive, and created a huge drag.
Exactly. IT, software, systems, etc… are viewed as a cost center. Hospitals aren’t in the business of selling software. How do you increase profits (or get yourself promoted, a bigger bonus)? One way is contain or reduce cost centers. The incentives are stacked against overhauling antiquated systems and modernizing, at least until the issue is forced by major business disruptions or regulations.
Right, and the fact that they are in this mess of tech debt in the first place is because they've cut corners and pinched pennies over many many decades. We shouldn't just nod our heads and be all like, "ah yeah, that's annoying, no way it could be helped". I'm so tired of companies continuing to be short-sighted about technical debt. Clearly it's been that way for more than 50 years, and we continue to validate this sort of behavior with understanding and extending deadlines.
Fine these people out of existence and let someone competent (if such a person exists) pick up the pieces and start anew.
On other hand looking at experiences here the projects to change these systems seem not to go well... So there is also not promise that things will get better...
I was in the physical therapy space for over 15 years. The penny pinching that comes from healthcare giants towards their software vendors are dreadful. It prevents any serious software engineering from happening. One customer billed over a billion dollars in a year to Medicare through our software and paid us $1M that year. I'm still not certain that we didn't take a loss to take that client.
Passing around financial data on SFTP drops is something that irked me. Having the total not add up from the line items is also pretty ridiculous. The systems in place are all about edge cases that have formed over decades.
Software engineers are not invited to the discussions in a lot of these companies. The area is gate kept by healthcare people, which tend to be people who don't know how to do technical writing or planning.
Our company wasn't a huge one. But the huge ones looked to me as run by accountants. If you can't establish an income stream for them, they won't even talk to you.
> Passing around financial data on SFTP drops is something that irked me.
I see this a moderate amount in fintech, or perhaps at least older fintech?
Had a colleague tell me about a new financial info provider he was supposed to connect with for data. "Oh this one will be easy" he was told. "They use oauth". OK... well... you oauth in, then you hit an endpoint that triggers a data build which then puts your data file in to an FTP account of your configuration. But you can't even configure it via hitting the endpoint behind the oauth. You have to log in to a web app to configure the FTP account for your account.
You hit the API endpoint and get 'OK'. But... that's it. You might get a file in your FTP account 5 minutes later. Or an hour later. It's just whenever it gets processed on their end. And... if it doesn't show up - you have no indication whether something broke, or perhaps the data service "just doesn't have any data for you today - you can't expect data every single day".
It's insanely crazy how across-the-board poor so many of these mid-level data vendors are. Colleague is currently supporting 8 different integration ingests like this - some deliver FTP daily, some you have to pull down, etc.
One delivers data which is only ever a delta. You have to continually request previous daily info from them to get to the 'first record' for that account, which can sometimes go back years, but... you don't know that up front. So you have to loop and request "day before", pull down data, parse it, then check the day before, until you don't get anything for that customer, then presume the previous was "initial balance". But you also can't just do that once, because... there may not have been any data the day before because... holiday? system down? So in practice you need to go back 3-4 days at least to verify. Oh... and don't keep looping and requesting too fast... you'll exceed the low rate limit ("we don't want people abusing our API").
I can only barely imagine how systems evolve like this, because they don't really seem to serve anyone's interest fully.
All you need for progress is a sensible regulatory environment.
"Some of you may not be in compliance. We start you off at a fine of $1. For every month this continues, the fine doubles."
All you need for a sensible regulatory environment is a complete overhaul of how your society works, starting with a campaign finance & congressional staffing system that isn't built on implicit corruption.