4 ms·

The 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 regul

The 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 ago
Regulations 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 ago
  Ironically 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 ago
  Regulation 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 ago
  But they obviously aren't the exact same set of regulations everywhere.
- JamesBarney 2y ago
  Measuring 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.
skhunted 2y ago
Many individuals don't want to run their own practice due to the complexities (insurance, etc) that exist beyond the work (treating people). It’s interesting that the one specific thing you mention is insurance. That particular complexity doesn’t come from regulation. It comes from the immoral insurance industry.
- thfuran 2y ago
  The federal government is one of the largest insurers, and dealing with them entails a lot of effort and expense.
- deleted 2y ago
  [deleted]
- VancouverMan 2y ago
  The widespread need for medical insurance only exists because regulation has introduced many artificial inefficiencies within the health care sector that in turn severely distort the pricing of medical services and medical products. We'd see far more reasonable pricing, and much less need for something like medical insurance, without the regulations that artificially limit the supply of practitioners and clinics, that prevent competition, and that introduce unnecessary costs, among other distortions.
  - skhunted 2y ago
    The fact that healthcare is far cheaper in every European country that has universal healthcare suggests that you are wrong.
    - AnthonyMouse 2y ago
      Healthcare is cheaper in every country everywhere regardless of whether they have public or private coverage. This implies that the difference isn't public vs. private, it's some other regulatory differences which are driving up costs in the US.
ryandrake 2y ago
> The thing that doesn't get mentioned much This gets mentioned every time. The regulation boogeyman always shows up. If only there were fewer rules... everyone could make more money, the little guy would be able to enter and play fast and loose, and nobody would do the wrongdoing those rules were meant to correct/prevent. Yes, there are regulations in health care. There are regulations in almost every industry, and yes, they can be a pain to deal with. Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on. As part of the general public, who are often the victims of business's negative externalities, I'm grateful that our government still manages to regulate businesses.
- mikem170 2y ago
  Then maybe the government (i.e. the public) should pay for more of these regulations, as opposed to unfunded mandates, which small operators cannot afford. In the example of the individual doctor's office, perhaps the government should provide software and billing systems to adhere to their mandated processes, inspectors, fund regulatory agencies, legislative support, etc. Otherwise regulatory capture can drive out much of the competition, potentially leaving us worse off than we could be otherwise.
- arcbyte 2y ago
  Tell me you don't know anything about healthcare without telling me... Sheesh. Doctors are medical technicians, not lawyers, and the more you bury them in (largely billing) regulations, the worse care you get and the less time with that doctor you get, and the more money you pay for worse healthcare.
- charleslmunger 2y ago
  >Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on. One such regulation is "certificate of need" laws, where you effectively need to ask the incumbent for permission to open your would-be competitor. https://spn.org/articles/certificate-of-need-laws/ https://spn.org/articles/certificate-of-need-laws/
- bluecalm 2y ago
Y_Y 2y ago
I'd actually be in favour of deregulating a lot of healthcare, but probably not for the same reasons as you. I think a cheap but unverified device/consultation/surgery is better than none at all (where only an unaffordable regulated option exists). But that's miles away from how society, even American society, functions. Without some mechanism to manage trust you can just remove the safeguards. It's actually quite possible to keep the safeguards and run a half-decent healthcare system, and this is surely much easier than finding a way to let people take calculated risks without causing mass deaths and a collapse in social cohesion.
SoftTalker 2y ago
There are one or two doctors here who operate individual cash-based practices. They don't deal with insurance companies or their paperwork. The seem to mostly focus on services that insurance is unlikely to cover anyway: weight loss, hormone therapy, but also still run a general/family practice. They stay in business so the model seems to be viable, but perhaps only because there are so few of them doing it.
ghaff 2y ago
It's not just regulation. You have electronic health record systems and the like that are often beneficial for consumers. My personal experience is that a lot of older docs, one doc practices, and the like hate this sort of thing. But I personally love the modern systems that a recent merger brought to my local hospital system. It's no longer about (maybe) faxes getting to the local lab for tests after calling them a week before the physical.
derbOac 2y ago
You're being downvoted but I wish you weren't. I've worked in healthcare, and pretty much my whole family does in all the professional roles you can think of. I have mixed feelings about this article and others like it because the motivation to strip the system of everything until profit is left is a serious problem throughout US healthcare. However, it's not unique to private equity — private regional monopolies, or even privately owned clinics and hospitals, can have a similar effect. These articles then have a way of shifting the focus away from the underlying administrative practices that result in these problems, and toward private equity per se. The regulation problem is real too, and I can give lots of examples. It's unlike a lot of other fields too in the scope and how ingrained it is in the system. EHRs are just one example: although well-intended, they were mandated with no "organic" roll-out, and pulled what was in-house staff and services and pushed it outside into large monopolies like EPIC (who are now the subject of an antitrust lawsuit IIRC). This happens over and over with all sorts of aspects of US healthcare. I also have problems with the focus of these types of articles — for whatever reason, they often start with or are centered around this kind of wistful new physician (or very old physician near retirement) longing for the romanticized old days where physicians were in charge and ran everything. Should that be the case though? Do we really need MDs to do and approve of everything? Aren't there things that are done as well by PAs, DNPs, and other types of providers that don't even exist yet because of how calcified the healthcare system is? Can't patients do more at home without a middleperson — e.g., needing to approve of some medication that the person has taken for decades without incident and is really truly pretty harmless in the grand scheme of things? The problem you described is very real. It's overregulated, in ways that incentivize large monopolies, either of clinic and hospital owners, or provider rent seeking guilds, infrastructure providers, etc. I guess I feel like these types of articles point to one type of problem, but then tend to implicitly suggest the solution is to just roll back time to some earlier era, not recognizing that that earlier era had a smaller patient population, with less regulation, less monopoly where there was no need to scrutinize whether a certain type of degree is really necessary, where there weren't huge hidden overhead costs of all these monopolies permeating down to the patient. Fixing US healthcare is going to require a bunch of things that collectively will cause pain for a lot of entrenched players: lots of antitrust lawsuits and laws, lots of deregulation aimed at giving patients more choice and self-care options, more public payer options, lots of eliminating or restructuring licensing requirements to create more types of providers, and so forth. They don't map on easily onto current US political party platforms either.
analog31 2y ago
Healthcare is essentially a creature of regulation. It owes its beginnings to the requirement that care must be effective.

namdnay 2y ago

Regulations 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 ago
Ironically 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 ago
Regulation 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 ago
But they obviously aren't the exact same set of regulations everywhere.
JamesBarney 2y ago
Measuring 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.

skhunted 2y ago

Many individuals don't want to run their own practice due to the complexities (insurance, etc) that exist beyond the work (treating people). It’s interesting that the one specific thing you mention is insurance. That particular complexity doesn’t come from regulation. It comes from the immoral insurance industry.

thfuran 2y ago
The federal government is one of the largest insurers, and dealing with them entails a lot of effort and expense.
deleted 2y ago
[deleted]
VancouverMan 2y ago
The widespread need for medical insurance only exists because regulation has introduced many artificial inefficiencies within the health care sector that in turn severely distort the pricing of medical services and medical products. We'd see far more reasonable pricing, and much less need for something like medical insurance, without the regulations that artificially limit the supply of practitioners and clinics, that prevent competition, and that introduce unnecessary costs, among other distortions.
- skhunted 2y ago
  The fact that healthcare is far cheaper in every European country that has universal healthcare suggests that you are wrong.
  - AnthonyMouse 2y ago
    Healthcare is cheaper in every country everywhere regardless of whether they have public or private coverage. This implies that the difference isn't public vs. private, it's some other regulatory differences which are driving up costs in the US.

ryandrake 2y ago

> The thing that doesn't get mentioned much This gets mentioned every time. The regulation boogeyman always shows up. If only there were fewer rules... everyone could make more money, the little guy would be able to enter and play fast and loose, and nobody would do the wrongdoing those rules were meant to correct/prevent. Yes, there are regulations in health care. There are regulations in almost every industry, and yes, they can be a pain to deal with. Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on. As part of the general public, who are often the victims of business's negative externalities, I'm grateful that our government still manages to regulate businesses.

mikem170 2y ago
Then maybe the government (i.e. the public) should pay for more of these regulations, as opposed to unfunded mandates, which small operators cannot afford. In the example of the individual doctor's office, perhaps the government should provide software and billing systems to adhere to their mandated processes, inspectors, fund regulatory agencies, legislative support, etc. Otherwise regulatory capture can drive out much of the competition, potentially leaving us worse off than we could be otherwise.
arcbyte 2y ago
Tell me you don't know anything about healthcare without telling me... Sheesh. Doctors are medical technicians, not lawyers, and the more you bury them in (largely billing) regulations, the worse care you get and the less time with that doctor you get, and the more money you pay for worse healthcare.
charleslmunger 2y ago
>Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on. One such regulation is "certificate of need" laws, where you effectively need to ask the incumbent for permission to open your would-be competitor. https://spn.org/articles/certificate-of-need-laws/ https://spn.org/articles/certificate-of-need-laws/
bluecalm 2y ago

Y_Y 2y ago

I'd actually be in favour of deregulating a lot of healthcare, but probably not for the same reasons as you. I think a cheap but unverified device/consultation/surgery is better than none at all (where only an unaffordable regulated option exists). But that's miles away from how society, even American society, functions. Without some mechanism to manage trust you can just remove the safeguards. It's actually quite possible to keep the safeguards and run a half-decent healthcare system, and this is surely much easier than finding a way to let people take calculated risks without causing mass deaths and a collapse in social cohesion.

SoftTalker 2y ago

There are one or two doctors here who operate individual cash-based practices. They don't deal with insurance companies or their paperwork. The seem to mostly focus on services that insurance is unlikely to cover anyway: weight loss, hormone therapy, but also still run a general/family practice. They stay in business so the model seems to be viable, but perhaps only because there are so few of them doing it.

ghaff 2y ago

It's not just regulation. You have electronic health record systems and the like that are often beneficial for consumers. My personal experience is that a lot of older docs, one doc practices, and the like hate this sort of thing. But I personally love the modern systems that a recent merger brought to my local hospital system. It's no longer about (maybe) faxes getting to the local lab for tests after calling them a week before the physical.

derbOac 2y ago

You're being downvoted but I wish you weren't. I've worked in healthcare, and pretty much my whole family does in all the professional roles you can think of. I have mixed feelings about this article and others like it because the motivation to strip the system of everything until profit is left is a serious problem throughout US healthcare. However, it's not unique to private equity — private regional monopolies, or even privately owned clinics and hospitals, can have a similar effect. These articles then have a way of shifting the focus away from the underlying administrative practices that result in these problems, and toward private equity per se. The regulation problem is real too, and I can give lots of examples. It's unlike a lot of other fields too in the scope and how ingrained it is in the system. EHRs are just one example: although well-intended, they were mandated with no "organic" roll-out, and pulled what was in-house staff and services and pushed it outside into large monopolies like EPIC (who are now the subject of an antitrust lawsuit IIRC). This happens over and over with all sorts of aspects of US healthcare. I also have problems with the focus of these types of articles — for whatever reason, they often start with or are centered around this kind of wistful new physician (or very old physician near retirement) longing for the romanticized old days where physicians were in charge and ran everything. Should that be the case though? Do we really need MDs to do and approve of everything? Aren't there things that are done as well by PAs, DNPs, and other types of providers that don't even exist yet because of how calcified the healthcare system is? Can't patients do more at home without a middleperson — e.g., needing to approve of some medication that the person has taken for decades without incident and is really truly pretty harmless in the grand scheme of things? The problem you described is very real. It's overregulated, in ways that incentivize large monopolies, either of clinic and hospital owners, or provider rent seeking guilds, infrastructure providers, etc. I guess I feel like these types of articles point to one type of problem, but then tend to implicitly suggest the solution is to just roll back time to some earlier era, not recognizing that that earlier era had a smaller patient population, with less regulation, less monopoly where there was no need to scrutinize whether a certain type of degree is really necessary, where there weren't huge hidden overhead costs of all these monopolies permeating down to the patient. Fixing US healthcare is going to require a bunch of things that collectively will cause pain for a lot of entrenched players: lots of antitrust lawsuits and laws, lots of deregulation aimed at giving patients more choice and self-care options, more public payer options, lots of eliminating or restructuring licensing requirements to create more types of providers, and so forth. They don't map on easily onto current US political party platforms either.

analog31 2y ago

Healthcare is essentially a creature of regulation. It owes its beginnings to the requirement that care must be effective.