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The profit-obsessed monster destroying American emergency rooms
- 29athrowaway 2y agoMBAs will turn everyone into The Joker.
- api 2y agoMBAs and similar types are the Western capitalist equivalent of the Soviet apparatchik: https://en.wikipedia.org/wiki/Apparatchik https://en.wikipedia.org/wiki/Apparatchik Entities like PE or conglomerates are a lot like Soviet bureaus: giant bastions of bureaucrats appointed to run things they have no direct expertise in running. The underlying issue here is what I call the "big dumb money problem." You get entities with more resources to deploy than intelligence or expertise to deploy them efficiently. A major argument for things like anti-trust and some degree of progressive taxation is to avoid what I call "Soviet Kapitalism" -- which the top of the economy ends up dominated by big dumb money and bureaucratic monopolies. When this happens a market economy starts looking indistinguishable from the USSR. In a way you could say a totalitarian state like the USSR is just an extreme version of this with the state acting like one giant monopoly mega-corp. Money needs to be redistributed so the ratio of dollars to brain cells is more balanced.
- robertlagrant 2y ago> Money needs to be redistributed so the ratio of dollars to brain cells is more balanced. It will likely do that naturally unless something gets in the way in the name of progress.
- alan-hn 2y agoMoney and greed naturally get in the way. Is that not obvious? People are finding any way to game the system just to get more money You're thinking of using money as a measure but everyone else is using it as a target...
- jerrycabbage 2y agoThe answer is a wealth tax. The inequality grows leading into a need for investments like these. If all other assets weren't so inflated then we could at least wish PE wouldn't need to do things like this but this is what will happen. Excess capital keeps buying up assets lower classes need due to lack of options otherwise.
- pessimizer 2y agoI'm still an advocate of the old-school top income tax bracket of 85-100% i.e. a maximum income. A general wealth tax always seems like double-dipping; today I take $1 out of your $10, and a year from now I take 90¢ from your remaining $9. It's more of a motivation for one to continue accumulating (a floor, even) just to tread water. Property taxes are different, because more services get provided to people with more property. Income taxes are fine because we take it as a given that the state has the ability to regulate every aspect of domestic financial transactions and financial lives, at least in our currency (even if we don't or shouldn't, we of course can.) A yearly individual income cap means at the least people would have to put money in more hands. Being corrupt on a large scale would hopefully require a larger conspiracy. I'm fine with arbitrary wealth taxes and taxes on capital, with arbitrary justifications, so I'm probably not saying much here; but I'm not in support of a revolving wealth tax.
- robertlagrant 2y agoNo, greed (or wanting money) is one of the reasons some people with brains get paid better. if they can think of things or ways of doing things that save money or create value, or both, then they will get paid lots. They could still agree with their employer that they get paid the equivalent of a postgrad stipend, but they probably don't. You don't need to game a system for that to happen.
- alan-hn 2y agoSo why does a PhD university professor make less than a wall st trader frat bro
- bloopernova 2y agoI wonder what would happen if private equity firms all threw their money into planting trees?
- giardini 2y agoIndeed MBAs helped sell American USA) industrial production out to first Mexico and later to China. Sometimes a little knowledge can be a dangerous thing. In Ricardo's simple economic model of "comparative advantage" an entire generation of CEOs and MBAs found justification to sell out corporate capital (everything except the labor, which was laid off) for billions. A deeper understanding of the economy (not of economic theory necessarily, but of our economy) might have suggested that such a rapid and total sell-off might be very destructive to society. But greed prevailed and now a generation passed before the full scope of the oversight was realized by most. Society took that long to realize a course correction was required. Capitalism is be a formidable mechanism for good but pure unfettered capitalism usually has bad "side" effects. That's why we regulate businesses. Sometimes it works.
- copperx 2y agoHow can I avoid an ER run by private equity?
- morkalork 2y agoVote for politicians who support a single payer health care system
- ALittleLight 2y agoDoes a single payer healthcare system change this? Presumably that would change who pays the healthcare provider - not who owns the healthcare provider, right?
- sowbug 2y agoIt's a collective-action problem. Nobody likes the current healthcare system, but what can we do? Ask the ambulance to shop around while we're bleeding out in the back? But as the single payer, the government would have the incentive and power to address the problem systematically and deliberately.
- classichasclass 2y agoOdds are you probably can't, at least not when you need the care most, which is the exact issue the article decries. Systems like Kaiser Permanente are not, but Kaiser is a vertically integrated HMO and structured very differently (disclosure: worked for Kaiser as a hospital per-diem for a number of years). Your best option is to make sure you know what EDs are actually in-network for you so at least you're less likely to get nailed if you have a little time to work with and aren't being transported by EMS.
- SoftTalker 2y agoAvoid the healthcare establishment as much as you can in general. They are a business, and their motive is profit, they don't care about making you better. Same thing is true of elder care, assisted living, etc. it's all centered on draining old people of their wealth before they die. Do not go to the ER for a runny nose or a sore throat. You have an immune system. Go to bed and let your body recover. Take on responsibility for your own health: eat better, get to a healthy weight, exercise. If you have chronic conditions that must be managed medically, shop around, find practices that are still locally owned. They are out there.
- i80and 2y agoI know a surgeon who had their employer bought up by private equity. It's a disaster; the paperclipification of care
- giantg2 2y agoThe thing that doesn't get mentioned much in these conversations that I've personally seen play a big role is the regulation. When you have highly complex regulations, you end up consolidating practices. As regulations increase, the number of distinct providers/owners decrease. Many individuals don't want to run their own practice due to the complexities (insurance, etc) that exist beyond the work (treating people). It doesn't make a lot of sense to deal with the insurance, billing, recordkeepeing, etc for a single physician or two. They wouldn't be able to compete with the larger and more effiecent practices that have more bargaining power with insurance companies anyways.
- namdnay 2y agoRegulations for healthcare exist are complex in every developed country, but in most everything works fine for a fraction of the cost, so I don’t think that’s the main issue
- mrangle 2y agoIronically this statement glosses over the indisputable issue of the specifics of the paperwork volume, and the change in it over time. "Regulations exist everywhere" is far to general an argument to be meaningful in my opinion. Humans are forever limited by time and their labor capacity within it.
- parineum 2y agoRegulation is where protectionism and corruption manifest. Regulation is a tool that can be used for many ends. It's not very helpful to speak about them collectively.
- thfuran 2y agoBut they obviously aren't the exact same set of regulations everywhere.
- JamesBarney 2y agoMeasuring burdensomeness of regulation by number of laws is an incredibly poor measure. Though I'd still be surprised if many countries healthcare laws were as complex as our own. For example All doctors require 1 year of schooling 2 year 5 years 10 years 20 years. Each is 1 law but has each also has very different level of burdensomeness.
- AIorNot 2y agoI hate private equity they bought our company and proceeded to nickel and dime it -
- 404mm 2y agoI live in north Texas, and the situation here is pretty much on par with the article. Urgent Care & Emergency Room combos are here on every corner. It’s a lucrative business, so it makes sense that private equity firms are gobbling it up. But I think the more interesting problem here is one level up. Why are there so many of them? I see two possible reasons: 1. Anytime one of my family members gets sick, it’s rather hard to make an appointment with the primary care provider. They are usually booked, and it takes a day or two to get in. 2. Bills from the primary care providers tend to be significantly higher than a bill from urgent care. Anytime I go to a doctor, it’s around $300 for a basic consultation visit. Any problem easily adds $50-100 to it. My typical bill from an urgent care visit for sickness is around $150. Both places are in-network. Anyway, that’s my experience.
- titanomachy 2y ago$300 is your part of a regular doctor visit? Or the total bill? Do you have one of those high-deductible plans designed to discourage people from seeking any healthcare?
- ghaff 2y agoWhen I was covered by an employer plan, a lot of people seemed to gravitate towards high deductible plans because they were cheaper so long as you didn't consume a lot of healthcare. (Personally, I never did but a lot of people were adamant that you saved money that way.)
- nilawafer 2y agoIsn’t huge profits the definition of success in capitalism? As a capitalist society shouldn’t there be cheers instead of complaining? This part I don’t understand about American culture.
- alan-hn 2y agoThis is because its the profit focus of capitalism that is exactly the problem Its a disconnect powered by propaganda of the definition of "success"
- mattnewton 2y agoHuge profits mean a lot of value is being captured. That can be because of a large amount of value being created, which is successful capitalism, but it can also mean a lot of rent is being extracted from an existing value stream. Not saying this is the later case, but when people are critical of large profits they usually are critical of the later, where they believe that the value being created has not really gone up, it’s just being funneled away to rent seekers now. This is especially true for things that are seen as “essentials” where buying is fairly mandatory and so prices are inelastic, like housing, food and medical care. If these markets become uncompetitive consumers can’t just walk away from rising prices. So rising profits + the same value being generated point to the market being uncompetitive and are not celebrated in the way rising profits + new value are.
- grecy 2y agoI think Americans were always happy with profit because they got a share, they had jobs, etc. it was good for everyone. Now they’re learning first hand what happens when it escalates to outright greed and hoarding, and that life gets pretty shitty for the very vast majority when this happens to the basic needs of a decent life (groceries, education, healthcare, safety, roads, transit)
- deleted 2y ago[deleted]
- vouaobrasil 2y agoThe success of capitalism is to allow basic trade in smaller communities. Once it scales to the anonymity of the large corporation and the specialist of wealth extraction, it becomes malignant.
- NickNaraghi 2y agoFor anyone looking for more information about the game dynamics of the “profit-obsessed monster” and why it is inevitable in our current economic system, I highly recommend the following Scott Alexander piece: https://www.slatestarcodexabridged.com/Meditations-On-Moloch https://www.slatestarcodexabridged.com/Meditations-On-Moloch
- projectileboy 2y agoI have said this a million times and I will say it again: anyone who thinks the US healthcare system isn’t a flaming train wreck hasn’t used it much. Or is rich enough enough not to care.
- jerrycabbage 2y agoThis is also due to inequality which leads to more and more of the same. There just aren't many ways entrepreneurs can add value. It is easier to capture it from assets needed by lower classes. Get a wealth tax to fix this or at least tax the wealth out of the rich.
- jerrycabbage 2y agoFuneral homes and anything else not run by a single professional has had this treatment. This is due to inequality. The wealthy have nowhere left to invest but things like this which raise costs for the lower classes. Taxing wealthy far more is the only solution but people have a hard time voting in their interests. We're doomed.
- throwawayUS9 2y agoSell everything in the US and move to a cheaper country like India. You will have free health care.
- gavi 2y agoI have aging parents in India, and I can tell you firsthand—healthcare there is far from cheap. In fact, prices have surged, and many people are now accustomed to the higher costs, thanks to rampant price gouging during the COVID pandemic.
- throwaway5752 2y agoPrivate equity is no longer doing its job, to the extent if ever had one. If there were a poorly run company, private equity could use its own money to acquire it, restructure it to be more efficient and valuable, and capture cash flow while owning it and profit from taking it public again. They would make money, the economy would be improved, and a healthy new public company would build more public wealth. This is a bit idealized, but something closer to this really did happen. Now they use raise money from rich people and operate more as alternative investment management, take over efficient operations, strip them, use leverage in the opposite direct (acquisition targets take loans and transfer the money back to PE). We end up with worse services, unsustainable and over-leveraged businesses, money transfer from the public to the wealthy from increased welfare and bankruptcies, and a worse economy because of changes to the velocity wealth returns to the economy from private fortunes. This stinks when it is the Office Depot or Friendly's, but it is a massive problem for residential real estate, delivery of medical care, medicine, and basic food production. You would think that the brilliant folks at KKR, Carlysle, Blackstone, and others would read their classics and know the story of the ancien régime and Romanovs.
- toast0 2y ago> Private equity is no longer doing its job, to the extent if ever had one. Private equity's job is to take a slowly failing company, extract the value, and turn it into a suddenly failed company. See department stores in the 90s, Circuit City, ToysRUs and restaurant chains more recently. This is a win for the former owners who get cash for their business and can blame the failure on PE, rather than admit it was on a path to fail slowly. This is a win for PE, because they can often extract enough value to make a good profit. It's a win for Spirit stores, because they get great locations like the old Circuit City that still has those maroon tiles up in 2024 and the old ToysRUs that still has the R up. When a sector of business is being bought by PE left and right, it's a sign of unhealthy businesses and the owners want out.
- arrobbiato 2y agoIt would be great to see some real solutions to the menace of private equity, or at least to see these solutions discussed in the mainstream public discourse. Which is a good reason to vote third party, if you're in the US: they might never win, but if they get enough votes, eventually their ideas will be heard (unless and until they too get co-opted by lobbyists from Vanguard and Blackrock).
- _1tem 2y agoIs there anything that private equity doesn't decimate? Is there any industry that is made better by these rent-seekers?
- jnwatson 2y agoI had an interesting experience in the ER lately that caused me to do some research. The average ER wait time across DC was 5 hours and 29 minutes. That's across all hospitals.
- chimert 2y agoMedian is better here. Average wait includes homeless people who use the waiting room for a warm nights sleep and similar outliers. They quickly get triaged and a free sandwich
- mcdow 2y agoNot so sure the median would be so far off here. Just earlier this week I spent about 4.5 hours in the ER in a Bay Area hospital. Not DC, but 5.5 hours doesn’t seem crazy to me.
- jaco6 2y agoThe problem with American healthcare is the attempt to compromise between healthcare as a universally available public utility and healthcare as a commodity on the private market. (Arguably this is a legacy of pre-modern healthcare, where hospitals were operated by charities run by nuns and funded by aristocrats and royal families, hence all the “Saint” names in hospitals nowadays). There’s a variety of weird examples of this mixed system: >Poor people use ERs for every day healthcare, usually they get away with paying nothing, no insurance >Working people with insurance pay more to enable this access for the destitute (or criminal) portion of the population >Old people are sort of entitled to free healthcare. They get medicare, but if they want everything, they have to pay for “supplements.” >Young people pay for the old people’s healthcare twice, on their payroll taxes and in the form of higher premiums. A 25 year old male should absolutely not have a $300/mo health premium. But he does, because his premium is paying for other’s care. This is a system pretending to be private, but it’s actually just inefficiently public. It would be more efficient to pay for it using taxes, both income and sales taxes, rather than letting some groups—the poor and the elderly—off the hook arbitrarily. Alternatively, abolish health insurance altogether—a notoriously inefficient and exploitative industry that does not suit the classic purpose of insurance (boat accidents and fires)—and see what happens. This is obviously a rather unpalatable option due to the chaos that would ensue, but it’s probably the best option.
- JamesBarney 2y ago> It would be more efficient to pay for it using taxes, both income and sales taxes, rather than letting some groups—the poor and the elderly—off the hook arbitrarily. I don't think this is true. Some countries with public healthcare are far more efficient than our system. But there are countries that have systems similar to ours that are far more efficient as well. We just have a really shitty system, and who pays for it isn't going to change that. It's a hard technocratic problem that doesn't have any easy answers. (Besides increasing the number of residency slots, removing the bachelor degree requirements and allowing foreign physicians to practice which are basically freebies.)
- ninalanyon 2y ago
- hn_version_0023 2y agoThe US Healthcare System is a cruel and unusual punishment.
- bmitc 2y agoCapitalism is ruining America. We're headed to where everything is buried behind oligarchical institutions.
- hintymad 2y agoA key question is why the free market does not work in this case. Many business are "profit obsessed", yet it does not mean they won't provide quality products or services at increasingly lower prices. What's different in the health care?
- mutatio 2y agoLikely because some core components of health care cannot be comoditised via technology, there's still vast human involvement from diagnosis to surgery, all the way to social support of the aged. Everything is getting stretched at the edges by aging populations in most of the developed world meaning medical and technological advances don't even touch the sides. I'm in the UK (NHS), I don't see a bright future for systems like the NHS or mostly private systems like the US. There's an extreme core cost which "systems" cannot make disappear.
- therealdrag0 2y agoIt’s not a free market
- musicale 2y ago> Meanwhile, to minimize costs, private equity-owned staffing firms often replaced more expensive physicians with nurse practitioners and physician associates. It was a move likely to worsen patient care: While these professionals do highly skilled work in a variety of clinical settings, the emergency department is one place where care outcomes are more likely to suffer if a doctor isn’t involved. Using more PAs and NPs seems like it could potentially be beneficial, since 1) they are cheaper than physicians (this could be attractive to patients if it lowered the bill for treatment), 2) the supply of physicians is more constrained (due to limits in med school and residency slots to avoid "oversupply", as well as longer training time), and 3) NPs and PAs may be well positioned to take care of many non-emergency patients in the ER, urgent care, non-life-threatening cases, etc. What might be helpful is a higher tier of ER-specialist NPs and PAs, as well as an adequate supply of ER physicians to treat the emergency patients in the ER who really need them.
- analog31 2y agoThe ER is to some extent a fictitious entity. Politicians took to blaming the poor for abusing their access to ER's. But healthcare is anything if not statistical. They can figure out how many patients walk into an ER, who could be served in an urgent care setting, and provide those services on site. In fact, the ER closest to my house works in exactly this way.
- kazinator 2y agoWow, doctors being treated like ... employees? That is outrageous! Don't these private equity firms know that docs are in a privileged social class, not touchable by menial rules like something having to be done in 25 minutes?