14 ms·

Brave Care Has Closed

71 points by godisdad 2y ago

toomuchtodo 2y ago
Kudos to their founders and team for trying to disrupt this space. https://www.ycombinator.com/companies/brave-care https://www.ycombinator.com/companies/brave-care https://www.bizjournals.com/portland/news/2021/10/07/brave-care-25m.html https://www.bizjournals.com/portland/news/2021/10/07/brave-c... | https://archive.today/Qd8fQ https://archive.today/Qd8fQ https://techcrunch.com/2019/09/09/yc-backed-brave-care-raises-5-million-for-pediatric-urgent-care-clinics/ https://techcrunch.com/2019/09/09/yc-backed-brave-care-raise...
- xyst 2y ago
  Very difficult to disrupt American healthcare when health insurance companies determine your rates, direct pay patients often the most vulnerable, and instead of focusing on patient care you have to focus on stupid administrative tasks to deal with different types of health insurance plans/pharmacy benefit managers/vendors. Thanks to decades of neo-liberalism (the idea of deregulation and "free market" economy). Americans have allowed corporations to form massive entities (in health insurance, UHC + optum bank + optima rx comes to mind) to the point of manipulating the price to their advantage. Then you have to deal with some companies that deny a majority of your claims in hopes that you (the patient and/or healthcare provider) give up (delay, deny, defend policies) or pay out of pocket for treatment. American healthcare industry is a fucking mess.
  - toomuchtodo 2y ago
    Yep. https://news.ycombinator.com/item?id=42495074 https://news.ycombinator.com/item?id=42495074
  - donw 2y ago
    ... are you joking? Healthcare is one of the most regulated industries in the United States. Want to be a doctor? You've got the aptitude, the knowledge, the mindset, and the will, but a government-guaranteed cartel of medical schools won't let you in, so too damn bad. Learn to code. Want to open a clinic? You really only need about a half-million in hardware to operate at the level of a 1980s hospital, but regulatory compliance will push your annual opex into the millions as a baseline, not to mention having to deal with the nightmare that is health insurance. Those "massive entities" you mentioned are entirely protected from competition by force of law. You know why healthcare used to be cheap? Nobody had insurance. Anyone that had the aptitude and wanted to be a doctor basically could. You went to the hospital, paid your bill, and that was that. I'm not saying "zero regulation, caveat emptor!", but over the past hundred years, the precise opposite of "deregulation" has happened across every aspect of American life.
    - vasco 2y ago
      How come it's cheaper in places where everyone has insurance?
      - rqtwteye 2y ago
        Because everybody besides the US regulates prices.
      - speakfreely 2y ago
        Because there's a single payor that tells providers how much things are going to cost. The short answer for why US healthcare is so expensive is that Americans are economically disconnected from the price of the healthcare they are consuming. There is absolutely no free market system happening there because almost all the costs are hidden behind insurance schemes.
      - estebarb 2y ago
        The problem is private insurance companies + private hospitals. They shouldn't exist. Healthcare is an inelastic service: people will pay everything to get it. So private hospitals in a free market are pushed to bill their services as higher as possible. Actually, their prices would go to infinity, if not limited by people total savings and earnings. So, here the insurance companies make the problem worse: they give people access to "infinite" credit. So you can pay for those exorbitant prices. But with insurance you just increased the pool of money people can use for health, so private hospitals can and will increase their pricing. Add more free market competition and you get the disaster of the USA healthcare system. Because of that reason, basic economics, is that for profit Healthcare cannot work long term. The only way to make it work is making it a public service. But in USA politicians will cry that is comunism, so they won't do it. And the USA Healthcare problem doesn't limit itself to USA. As americans are unable to pay for healthcare there, they started doing medical tourism, which is making health prices in other countries more expensive too.
        donw 2y ago
        Japan has private insurance companies and private hospitals, many of them, and does just fine.
  - snitty 2y ago
    >Americans have allowed corporations to form massive entities (in health insurance, UHC + optum bank + optima rx comes to mind) This is more an anti-trust problem than deregulation. In the 80s Robert Bork and some others led a charge within the court system to rewrite federal anti-trust law without actually rewriting the laws. The result was that merger/acquisition guidelines were loosened, and the focus was on whether the result would cause the consumer to pay more money. And thanks to the way health care is paid for, it's a little complicated to make that case.
    - dragonwriter 2y ago
      > This is more an anti-trust problem than deregulation Loosened antitrust rules are a subset of deregulation, it can’t be any less deregulation than it is a matter of (too loose) antitrust.
  - tyre 2y ago
    If you want to do the hard work of automating and abstracting the "fucking mess" of the financial layer of American healthcare, we're hiring: https://jobs.lever.co/juniperplatform https://jobs.lever.co/juniperplatform Or email me: chris@juniperplatform.com
    - t-writescode 2y ago
      Grr. Genuinely tempting, but I didn't wish it had to be in NY, nor hybrid :(
      - mikebonnell 2y ago
        Huge +1 to that; make remote an option and expand your talent pool
        tyre 2y ago
        It’s definitely a trade-off. My team at Stripe was scattered all over, during COVID our company was fully remote, and prior to that I worked remotely on a presidential campaign. All of those were great experiences and, in their own ways, necessarily/understandably remote. Compared to the early days at Gusto and my own startup, though, in-person has very real benefits that (in my opinion) are worth the challenges in hiring. I don’t know that it will always be true and can’t rule out that we’re wrong. Having internal users and domain experts there in person makes a huge difference. It’s not impossible to do remotely, and maybe the tradeoff doesn’t make sense forever, but it’s worked well thus far.
        Aurornis 2y ago
        I’ve felt similarly. In-person has benefits, but across my career it’s been easier to assemble top-tier teams when hiring remote than in-person. For myself, I’m past the point of moving for companies. If they happen to be nearby I’ll make it work. If they’re not nearby, its either remote or I’m not at all interested anymore.
        t-writescode 2y ago
  - tptacek 2y ago
    Providers determine your rates. Insurers are companies providers recruit to collect their bills. In the entire US health care system, the providers are the only ones whose cash flows are capped by statute. A provider can charge whatever it wants; over 80% of an insurers cash flows have to go to the provider by statute. (The health care industry is a mess, I agree!)
    - duk3luk3 2y ago
      You seem to be implying that the providers set the prices, but isn't it true that insurers can pick and choose which providers they cover, and because of the large amount of patients they insure, they have a huge amount of negotiation power to exert downward pressure on what providers charge?
      - tptacek 2y ago
        No, that's not true. All the market power is with the providers, which is why they're responsible for something like 9x total health care spend in the US than all health insurers combined. Medicare is better than private insurers at regulating prices (to wit: when Anthem tried to adopt Medicare's rules for anesthesiology comp, they were excoriated, and the governor of New York proposed a statute preventing them from doing it). But they still wildly overpay for services; in fact, what they pay is not really materially different from what private insurers do (it's less, but not by that much).
        duk3luk3 2y ago
        > All the market power is with the providers How does that work? Do the providers have cartels that set prices?
        tptacek 2y ago
        Yes. I don't know if that's the primary factor that gives them their market power; it might be even simpler than that. But yes, they absolutely do. Unless you're Kaiser, in which case you're the insurer and most of the providers, which is the whole idea behind Kaiser. But every other insurer --- and overwhelmingly, Americans aren't on Kaiser --- is beholden to providers. And of course, Kaiser competes with providers for service providers and vendors.
  - Aurornis 2y ago
    > Very difficult to disrupt American healthcare when health insurance companies determine your rates, This isn’t unique to America. In countries with government healthcare, the government determines your rates. Typically government rates are lower than private insurance rates in the US, too. For as much as Americans like to complain about insurance companies, we actually get a lot more care and pay higher rates to providers than other countries. There’s a reason doctor pay in the United States is so much higher, among other things.
    - llamaimperative 2y ago
      What on earth We get a lot more care, pay higher rates, and have worse outcomes. That last bit is why people are pissed.
      - devonkim 2y ago
        I think we should add that the outcomes are worse at _all_ socioeconomic levels. The rich get screwed over as well in this system as well. It's unfortunate that so many of them have better overall outcomes and/or myopic experiences that many are emotionally invested in being _able_ to pay exorbitant amounts for more personalized care - regardless of the societal consequences - as an interpretation of "freedom." But hey, it's not like the US is a democracy exactly given that public opinion generally doesn't translate into policy changes anymore.
      - missedthecue 2y ago
        I don't think it's settled fact that the US has worse health outcomes. In fact, most data I see points to the opposite. Some people point out very lazy metrics like life expectancy while ignoring that 72% of Americans are overweight or obese according to the CDC. Rearrange healthcare/government insurance models all you want; it can't fix that.
        thrance 2y ago
        Life expectancy is still lower in the US than in western Europe.
- IG_Semmelweiss 2y ago
  Most people outside of healthcare will have a hard time disrupting anything until they realize the goverment has tilted the rules in favor of status-quo. Healthcare insurance in the US is heavily subsidized, and no number of revolutionary care delivery models will put you on level terms with the behemoth of US govt insurance subsidies. Your only hope as a non-provider is to come in with your own a-la-carte insurance that is able to take those subsidies, while you set your moat and innovate in the delivery front.
  - jmye 2y ago
    You will still lose on the insurance front. If you’re on the exchange, you’ll get absolutely hammered by risk-adjustment. If you’re not, you’ll never be able to sell to anyone. You’ll have to lock up huge amounts of capital, which will grow as you grow, that you can’t invest or use. It will just sit in an account in case you can’t pay claims. You’ll have to accept horrible contracts with provider systems in order to have network adequacy, and none of them will care about coding your patients, or responding when you’re trying to fix your codes. Health insurance is undisruptable, unless you’re ready to light billions of dollars on fire over several years, or take decades to do it by growing extremely slowly. The provider side is equally difficult, but I think it’s at least doable. Though you’re still screwed having to deal with CMS or insurance carriers.
    - noitpmeder 2y ago
      What's the path forward? Where do we go from here?
      - toomuchtodo 2y ago
        Congress fixes this or we continue to drag ourselves towards worse failure modes.
      - AtlasBarfed 2y ago
        So my four pigs analogy, where insurance companies, drug/device companies, doctors/hospitals, and lawyers all feed at the trough, increase costs and point to someone else (although I will admit lawyers are probably the smallest cost component and the most blamed by the other three). There is a fifth one that imposes costs: our comprehensively unhealthy food, health, and lifestyle in America that capitalism feeds upon with addictive high-margin food and drink, with overworked workers that can barely have time to raise kids (our healthy demographics are due to immigration) much less a healthy lifestyle. The entertainment complex certainly doesn't help either. Providers: you need comprehensive family care to avoid specialist care being needed, an increase in supply of doctors, decreasing their educational loan burden (which strongly incentivizes specializataion, and a system that involves specialists). I think advanced AI systems can do much more day-to-day tracking and diagnosis/information, but of course that is a personal information nightmare. Actually I don't mean advanced. I think current AI is plenty good enough. Unfortunately only insurance companies will employ these systems or pay for them. Insurance: Probably need a medicare-for-all option. We were close to this with Obamacare but FUCKING JOE LIEBERMAN killed it. Exhibit A in why the Democrats with full control of government will never get anything done. Drug/Device companies: reduce patents, I don't know, maybe allow price negotiation (which is just mind blowing in a "free market" economy), reform the FDA to make bringing drugs to market cheaper. Lawyers: caps caps caps so there isn't costly malpractice insurance. Maybe would also necessitate a federal review board to weed out "bad doctors". But the biggest is probably governmental direction to actually get people to be able to eat and live active lives. Maybe GLP-1 will help, but the quiet time bomb of increasing obesity in Americans each decade is probably a sneaky large amount of our costs. Otherwise, on the nihilistic side, keep doing whatever our society is doing which is causing men to kill themselves in huge rates (soma ... uh... I mean opioids were also doing this as well) before they reach their ultra-expensive late stage of life. Anyway, none of that is happening (except, sadly, the nihilistic solution is the most realistically happening). Maybe setup huge provider networks across the border in Mexico and Canada served by high speed transit, so large portions of the world get health maintenance in functioning health care systems, and only do hospitalization and emergency care here?
readthenotes1 2y ago
Given the highly escalating price of medical care, it's astounding that a provider that isn't required by federal law to provide no-cost indigent care can go bankrupt. [1] makes it sound like they were assuming a never-ending stream of venture funding and didn't make a sustainable business. It'd be interesting to see where the money went. [1] https://www.oregonlive.com/business/2022/09/portland-pediatrics-startup-brave-care-lays-off-a-third-of-staff-citing-covid-and-market-turmoil.html https://www.oregonlive.com/business/2022/09/portland-pediatr...
- gerdesj 2y ago
  "federal law to provide no-cost indigent care" Could you explain "indigent" here, please. It looks like a typo.
  - BugsJustFindMe 2y ago
    They mean providing care to poor people.
  - btilly 2y ago
    Any homeless person can walk into an ER and get care. What will happen to the bills? Effectively it is no cost care for those who are sufficiently poor.
    - gerdesj 2y ago
      Cool - that sounds a bit like our NHS. You also said "What will happen to the bills?" - what does that mean? Cheers Jon
      - nradov 2y ago
        Some of the bills are just written off as bad debt. Essentially thrown away. But in many cases the hospital back office will work to get indigent patients enrolled in Medicaid and then send the bills to the state government.
xyst 2y ago
I never used this service but based on their site. It's aimed at pediatric care? With the decline in birth rates in the US, didn't seem like a sustainable model from the get go.
- lazyasciiart 2y ago
  Decline in birth rates is generally at least matched by an increase in per-child spending.
jawns 2y ago
Don't get the wrong idea about this announcement. The problem is not that pediatric urgent care is not a viable business. The problem is that it's not a great VC-funded business. VC investors are hoping for huge growth and eventually earning back multiples of their investment. That's going to be really hard to do in this segment of the health-care market. We've got a wonderful pediatric urgent-care place in our area, backed by the best children's hospital in our metro region, and it seems to be doing great. But does that mean it could ever grow at the rate needed to satisfy VC investors? Probably not.
- dgfitz 2y ago
  Geriatric care will be the gold rush of the 2040s. If I knew a solid way to invest in that, I would.
  - imperialdrive 2y ago
    2040's? It is happening, now.
  - bhouston 2y ago
    In Canada it has been the growth of old folks homes. I expect there will be a glut of them in 39 years or so. The companies behind them have likely made a killing.
  - sam0x17 2y ago
    This mindset (that it will be a goldrush) is why we can't have nice things. Can't trust capitalism to do this kind of stuff in a non-exploitative way
    - dgfitz 2y ago
      We don’t have nice things because congress sucks. Keep Blaming capitalism, that wall has lots of screams to bear yet.
      - fl0id 2y ago
nextworddev 2y ago
Zombie startups closing shop around year end for tax purposes I guess
- yieldcrv 2y ago
  VC tax loss harvesting? They need proof to mark down their investment to zero? Most taxpayers have to realize the loss to take a tax deduction against their gains, but some tax elections allow you to do the same without finding a buyer for the worthless shares, which narrows down the incentives Mark to Market election as well as non-profits some non-profit investors have stricter scrutiny as their charitable distribution requirement is based on net assets. so there is an incentive to arbitrarily mark malperforming investments down to lower values, but being able to get the business to announce their failure supports it better Just thinking out loud
godisdad 2y ago
OP here. I visited their clinics for my daughter several times when she was a toddler for ear aches and other ailments— I found the experience refreshing: instant online booking, no BS registration and online communication with staff was seamless. Very sad to see them go so abruptly. Up until this morning when I was told they were gone, I had no idea they were YC or otherwise VC funded. Just came here to pour one out for a genuinely helpful and pleasant medical company.
- hedora 2y ago
  We had basically the same experience with Kaiser Permanente in the SF Bay Area. Currently, there’s a doctor shortage problem (supposedly, they can’t hire, or there aren’t enough positions, depending on who you ask), which has caused issues with the quality of care (according to the doctors that went on strike over this, and personal experience). It’s unclear what the root cause or solution is. Anyway, you can get the experience you described, and it’s great until you hit an understaffed corner case health problem.
- dariusmonsef 2y ago
  Appreciate the pour. Glad you got great care for your daughter.
dr_ 2y ago
Sad to see a care organization like this shut down. But curious to understand what exactly they were disrupting? From the outset, looks like a pediatric clinic that accepts insurance (and has a cash pay option) - but this is how most pediatric clinics/urgent care that are not venture backed operate. There doesn’t seem to be a disruption in their revenue model (like a one medical style subscription service), and vbc doesn’t apply much to pediatric care. Not criticisms, just trying to understand what the goal was.
- dariusmonsef 2y ago
  There are 25 million ER visits a year for kids where the vast majority of those visits are not life-threatening and don’t require that level of care. An urgent care is 1/10 the cost of an ER and can create a better environment for the kid and family… so better care for 1/10th the cost.
anovikov 2y ago
Real way to fix healthcare: facilities based on repurposed container ships offshore near cities with lots of flights into them, to be outside of US regulations, staffed by physicians shuffled from Eastern Europe. Will offer more than an order of magnitude price advantage and will quickly squeeze the existing systems making it irrelevant until what's left of it is forced to change.
- kbelder 2y ago
  That is interesting, although improbable.
  - Yeul 2y ago
    Well my dentist is from Ukraine. I hope she doesn't go back.
- thrance 2y ago
  This seems extremely carbon intensive and would starve eastern Europe of the medical staff it probably needs. Also why would they charge an order of magnitude less when a 3% discount would be enough to attract patients? And how could a brain surgeon do his thing on a boat? This just seems comically bad.
- the_sleaze_ 2y ago
  only marginally different from just opening a luxury clinic in ie. Mexico with the exact same staff, which of course exists. My mom refuses to leave the US healthcare system despite the costs because 1. She pays for insurance, not surgery (in her mind) 2. regardless of the keening US healthcare system is the best in the world
jackcosgrove 2y ago
I have heard conflicting accounts of inefficiencies in the US healthcare system. One account is that the US has too many medical facilities in urban areas. In other words, there might be five hospitals each with its own radiology equipment. That equipment is idle some of the time, so you could close some of the imaging departments and leave just one or two for the metro area. That would obviously inconvenience some people, but the gist of the criticism is that the US duplicates medical capacity for the sake of convenience. The other criticism is that there are too few clinics and such. That's why there was a big push to open health clinics in pharmacies and urgent care locations recently. Now I know these aren't mutually exclusive; you can have too few clinics and too many hospitals. But I would like to know if anyone is more informed than I am what validity there is to each criticism. I'm curious what the truth is regarding the number and character of brick-and-mortar healthcare facilities in the US: too many? too few? Because it looks like this company was opening physical clinics.
- ketzu 2y ago
  > One account is that the US has too many medical facilities in urban areas. In other words, there might be five hospitals each with its own radiology equipment. That equipment is idle some of the time, so you could close some of the imaging departments and leave just one or two for the metro area. That would obviously inconvenience some people, but the gist of the criticism is that the US duplicates medical capacity for the sake of convenience. > The other criticism is that there are too few clinics and such. That's why there was a big push to open health clinics in pharmacies and urgent care locations recently. Funny enough, germany has the exact same two problems. * Too many small urban hospitals do too many things, but have no speciality, leading to high cost, underutilization and higher risk procedures. * Too few specialist doctors for checkups leading to long waiting times.
- inferiorhuman 2y ago
  I'm curious what the truth is regarding the number and character of brick-and-mortar healthcare facilities in the US: too many? too few? Because it looks like this company was opening physical clinics. Services are unevenly distributed and I wouldn't say there's too many providers in urban areas. Rural areas are underserved though (off the top of my head I can think of a movie and a TV series whose premise is rooted in lack of rural care). Even within urban areas care is uneven. Hospitals are concentrated in the more wealthy parts of San Francisco and the poorer (e.g. southeastern) parts see sparse coverage. One of the big points of contention when Sutter Health bought out St Luke's hospital in SF was that Sutter wanted to transition from primary care to more profitable specialties. This would've left the neighborhood bereft of primary care. In more rural areas you'll find that funding is a political football. As that funding wanes so does the level of care. On top of that the post-Roe v Wade environment encourages some folks to migrate towards urban areas in more "permissive" states. In terms of too much urban coverage. When I needed an ultrasound through UCSF I had to book it out months in advance. It's not clear to me that there is a ton of duplication there — more the point if I'd looked elsewhere I would've had to figure out what was/wasn't in network with my insurance provider. Last I looked Kaiser has a grand total of eight urgent care clinics in the Bay Area. There are nine counties in the Bay Area. That's efficient from a business standpoint but leaves plenty of customers out in the cold as Kaiser covers out-of-network services in very limited circumstances. Likewise, try to find a GP that accepts insurance and is taking new patience. When I checked eons ago UCSF had a nearly year long wait.

71 points by godisdad 2y ago

Kudos to their founders and team for trying to disrupt this space. https://www.ycombinator.com/companies/brave-care https://www.ycombinator.com/companies/brave-care https://www.bizjournals.com/portland/news/2021/10/07/brave-care-25m.html https://www.bizjournals.com/portland/news/2021/10/07/brave-c... | https://archive.today/Qd8fQ https://archive.today/Qd8fQ https://techcrunch.com/2019/09/09/yc-backed-brave-care-raises-5-million-for-pediatric-urgent-care-clinics/ https://techcrunch.com/2019/09/09/yc-backed-brave-care-raise...

xyst 2y ago
Very difficult to disrupt American healthcare when health insurance companies determine your rates, direct pay patients often the most vulnerable, and instead of focusing on patient care you have to focus on stupid administrative tasks to deal with different types of health insurance plans/pharmacy benefit managers/vendors. Thanks to decades of neo-liberalism (the idea of deregulation and "free market" economy). Americans have allowed corporations to form massive entities (in health insurance, UHC + optum bank + optima rx comes to mind) to the point of manipulating the price to their advantage. Then you have to deal with some companies that deny a majority of your claims in hopes that you (the patient and/or healthcare provider) give up (delay, deny, defend policies) or pay out of pocket for treatment. American healthcare industry is a fucking mess.
- toomuchtodo 2y ago
  Yep. https://news.ycombinator.com/item?id=42495074 https://news.ycombinator.com/item?id=42495074
- donw 2y ago
  ... are you joking? Healthcare is one of the most regulated industries in the United States. Want to be a doctor? You've got the aptitude, the knowledge, the mindset, and the will, but a government-guaranteed cartel of medical schools won't let you in, so too damn bad. Learn to code. Want to open a clinic? You really only need about a half-million in hardware to operate at the level of a 1980s hospital, but regulatory compliance will push your annual opex into the millions as a baseline, not to mention having to deal with the nightmare that is health insurance. Those "massive entities" you mentioned are entirely protected from competition by force of law. You know why healthcare used to be cheap? Nobody had insurance. Anyone that had the aptitude and wanted to be a doctor basically could. You went to the hospital, paid your bill, and that was that. I'm not saying "zero regulation, caveat emptor!", but over the past hundred years, the precise opposite of "deregulation" has happened across every aspect of American life.
  - vasco 2y ago
    How come it's cheaper in places where everyone has insurance?
    - rqtwteye 2y ago
      Because everybody besides the US regulates prices.
    - speakfreely 2y ago
      Because there's a single payor that tells providers how much things are going to cost. The short answer for why US healthcare is so expensive is that Americans are economically disconnected from the price of the healthcare they are consuming. There is absolutely no free market system happening there because almost all the costs are hidden behind insurance schemes.
    - estebarb 2y ago
      The problem is private insurance companies + private hospitals. They shouldn't exist. Healthcare is an inelastic service: people will pay everything to get it. So private hospitals in a free market are pushed to bill their services as higher as possible. Actually, their prices would go to infinity, if not limited by people total savings and earnings. So, here the insurance companies make the problem worse: they give people access to "infinite" credit. So you can pay for those exorbitant prices. But with insurance you just increased the pool of money people can use for health, so private hospitals can and will increase their pricing. Add more free market competition and you get the disaster of the USA healthcare system. Because of that reason, basic economics, is that for profit Healthcare cannot work long term. The only way to make it work is making it a public service. But in USA politicians will cry that is comunism, so they won't do it. And the USA Healthcare problem doesn't limit itself to USA. As americans are unable to pay for healthcare there, they started doing medical tourism, which is making health prices in other countries more expensive too.
      - donw 2y ago
        Japan has private insurance companies and private hospitals, many of them, and does just fine.
- snitty 2y ago
  >Americans have allowed corporations to form massive entities (in health insurance, UHC + optum bank + optima rx comes to mind) This is more an anti-trust problem than deregulation. In the 80s Robert Bork and some others led a charge within the court system to rewrite federal anti-trust law without actually rewriting the laws. The result was that merger/acquisition guidelines were loosened, and the focus was on whether the result would cause the consumer to pay more money. And thanks to the way health care is paid for, it's a little complicated to make that case.
  - dragonwriter 2y ago
    > This is more an anti-trust problem than deregulation Loosened antitrust rules are a subset of deregulation, it can’t be any less deregulation than it is a matter of (too loose) antitrust.
- tyre 2y ago
  If you want to do the hard work of automating and abstracting the "fucking mess" of the financial layer of American healthcare, we're hiring: https://jobs.lever.co/juniperplatform https://jobs.lever.co/juniperplatform Or email me: chris@juniperplatform.com
  - t-writescode 2y ago
    Grr. Genuinely tempting, but I didn't wish it had to be in NY, nor hybrid :(
    - mikebonnell 2y ago
      Huge +1 to that; make remote an option and expand your talent pool
      - tyre 2y ago
        It’s definitely a trade-off. My team at Stripe was scattered all over, during COVID our company was fully remote, and prior to that I worked remotely on a presidential campaign. All of those were great experiences and, in their own ways, necessarily/understandably remote. Compared to the early days at Gusto and my own startup, though, in-person has very real benefits that (in my opinion) are worth the challenges in hiring. I don’t know that it will always be true and can’t rule out that we’re wrong. Having internal users and domain experts there in person makes a huge difference. It’s not impossible to do remotely, and maybe the tradeoff doesn’t make sense forever, but it’s worked well thus far.
        Aurornis 2y ago
        I’ve felt similarly. In-person has benefits, but across my career it’s been easier to assemble top-tier teams when hiring remote than in-person. For myself, I’m past the point of moving for companies. If they happen to be nearby I’ll make it work. If they’re not nearby, its either remote or I’m not at all interested anymore.
        t-writescode 2y ago
- tptacek 2y ago
  Providers determine your rates. Insurers are companies providers recruit to collect their bills. In the entire US health care system, the providers are the only ones whose cash flows are capped by statute. A provider can charge whatever it wants; over 80% of an insurers cash flows have to go to the provider by statute. (The health care industry is a mess, I agree!)
  - duk3luk3 2y ago
    You seem to be implying that the providers set the prices, but isn't it true that insurers can pick and choose which providers they cover, and because of the large amount of patients they insure, they have a huge amount of negotiation power to exert downward pressure on what providers charge?
    - tptacek 2y ago
      No, that's not true. All the market power is with the providers, which is why they're responsible for something like 9x total health care spend in the US than all health insurers combined. Medicare is better than private insurers at regulating prices (to wit: when Anthem tried to adopt Medicare's rules for anesthesiology comp, they were excoriated, and the governor of New York proposed a statute preventing them from doing it). But they still wildly overpay for services; in fact, what they pay is not really materially different from what private insurers do (it's less, but not by that much).
      - duk3luk3 2y ago
        > All the market power is with the providers How does that work? Do the providers have cartels that set prices?
        tptacek 2y ago
        Yes. I don't know if that's the primary factor that gives them their market power; it might be even simpler than that. But yes, they absolutely do. Unless you're Kaiser, in which case you're the insurer and most of the providers, which is the whole idea behind Kaiser. But every other insurer --- and overwhelmingly, Americans aren't on Kaiser --- is beholden to providers. And of course, Kaiser competes with providers for service providers and vendors.
- Aurornis 2y ago
  > Very difficult to disrupt American healthcare when health insurance companies determine your rates, This isn’t unique to America. In countries with government healthcare, the government determines your rates. Typically government rates are lower than private insurance rates in the US, too. For as much as Americans like to complain about insurance companies, we actually get a lot more care and pay higher rates to providers than other countries. There’s a reason doctor pay in the United States is so much higher, among other things.
  - llamaimperative 2y ago
    What on earth We get a lot more care, pay higher rates, and have worse outcomes. That last bit is why people are pissed.
    - devonkim 2y ago
      I think we should add that the outcomes are worse at _all_ socioeconomic levels. The rich get screwed over as well in this system as well. It's unfortunate that so many of them have better overall outcomes and/or myopic experiences that many are emotionally invested in being _able_ to pay exorbitant amounts for more personalized care - regardless of the societal consequences - as an interpretation of "freedom." But hey, it's not like the US is a democracy exactly given that public opinion generally doesn't translate into policy changes anymore.
    - missedthecue 2y ago
      I don't think it's settled fact that the US has worse health outcomes. In fact, most data I see points to the opposite. Some people point out very lazy metrics like life expectancy while ignoring that 72% of Americans are overweight or obese according to the CDC. Rearrange healthcare/government insurance models all you want; it can't fix that.
      - thrance 2y ago
        Life expectancy is still lower in the US than in western Europe.
IG_Semmelweiss 2y ago
Most people outside of healthcare will have a hard time disrupting anything until they realize the goverment has tilted the rules in favor of status-quo. Healthcare insurance in the US is heavily subsidized, and no number of revolutionary care delivery models will put you on level terms with the behemoth of US govt insurance subsidies. Your only hope as a non-provider is to come in with your own a-la-carte insurance that is able to take those subsidies, while you set your moat and innovate in the delivery front.
- jmye 2y ago
  You will still lose on the insurance front. If you’re on the exchange, you’ll get absolutely hammered by risk-adjustment. If you’re not, you’ll never be able to sell to anyone. You’ll have to lock up huge amounts of capital, which will grow as you grow, that you can’t invest or use. It will just sit in an account in case you can’t pay claims. You’ll have to accept horrible contracts with provider systems in order to have network adequacy, and none of them will care about coding your patients, or responding when you’re trying to fix your codes. Health insurance is undisruptable, unless you’re ready to light billions of dollars on fire over several years, or take decades to do it by growing extremely slowly. The provider side is equally difficult, but I think it’s at least doable. Though you’re still screwed having to deal with CMS or insurance carriers.
  - noitpmeder 2y ago
    What's the path forward? Where do we go from here?
    - toomuchtodo 2y ago
      Congress fixes this or we continue to drag ourselves towards worse failure modes.
    - AtlasBarfed 2y ago
      So my four pigs analogy, where insurance companies, drug/device companies, doctors/hospitals, and lawyers all feed at the trough, increase costs and point to someone else (although I will admit lawyers are probably the smallest cost component and the most blamed by the other three). There is a fifth one that imposes costs: our comprehensively unhealthy food, health, and lifestyle in America that capitalism feeds upon with addictive high-margin food and drink, with overworked workers that can barely have time to raise kids (our healthy demographics are due to immigration) much less a healthy lifestyle. The entertainment complex certainly doesn't help either. Providers: you need comprehensive family care to avoid specialist care being needed, an increase in supply of doctors, decreasing their educational loan burden (which strongly incentivizes specializataion, and a system that involves specialists). I think advanced AI systems can do much more day-to-day tracking and diagnosis/information, but of course that is a personal information nightmare. Actually I don't mean advanced. I think current AI is plenty good enough. Unfortunately only insurance companies will employ these systems or pay for them. Insurance: Probably need a medicare-for-all option. We were close to this with Obamacare but FUCKING JOE LIEBERMAN killed it. Exhibit A in why the Democrats with full control of government will never get anything done. Drug/Device companies: reduce patents, I don't know, maybe allow price negotiation (which is just mind blowing in a "free market" economy), reform the FDA to make bringing drugs to market cheaper. Lawyers: caps caps caps so there isn't costly malpractice insurance. Maybe would also necessitate a federal review board to weed out "bad doctors". But the biggest is probably governmental direction to actually get people to be able to eat and live active lives. Maybe GLP-1 will help, but the quiet time bomb of increasing obesity in Americans each decade is probably a sneaky large amount of our costs. Otherwise, on the nihilistic side, keep doing whatever our society is doing which is causing men to kill themselves in huge rates (soma ... uh... I mean opioids were also doing this as well) before they reach their ultra-expensive late stage of life. Anyway, none of that is happening (except, sadly, the nihilistic solution is the most realistically happening). Maybe setup huge provider networks across the border in Mexico and Canada served by high speed transit, so large portions of the world get health maintenance in functioning health care systems, and only do hospitalization and emergency care here?

readthenotes1 2y ago

Given the highly escalating price of medical care, it's astounding that a provider that isn't required by federal law to provide no-cost indigent care can go bankrupt. [1] makes it sound like they were assuming a never-ending stream of venture funding and didn't make a sustainable business. It'd be interesting to see where the money went. [1] https://www.oregonlive.com/business/2022/09/portland-pediatrics-startup-brave-care-lays-off-a-third-of-staff-citing-covid-and-market-turmoil.html https://www.oregonlive.com/business/2022/09/portland-pediatr...

gerdesj 2y ago
"federal law to provide no-cost indigent care" Could you explain "indigent" here, please. It looks like a typo.
- BugsJustFindMe 2y ago
  They mean providing care to poor people.
- btilly 2y ago
  Any homeless person can walk into an ER and get care. What will happen to the bills? Effectively it is no cost care for those who are sufficiently poor.
  - gerdesj 2y ago
    Cool - that sounds a bit like our NHS. You also said "What will happen to the bills?" - what does that mean? Cheers Jon
    - nradov 2y ago
      Some of the bills are just written off as bad debt. Essentially thrown away. But in many cases the hospital back office will work to get indigent patients enrolled in Medicaid and then send the bills to the state government.

xyst 2y ago

I never used this service but based on their site. It's aimed at pediatric care? With the decline in birth rates in the US, didn't seem like a sustainable model from the get go.

lazyasciiart 2y ago
Decline in birth rates is generally at least matched by an increase in per-child spending.

jawns 2y ago

Don't get the wrong idea about this announcement. The problem is not that pediatric urgent care is not a viable business. The problem is that it's not a great VC-funded business. VC investors are hoping for huge growth and eventually earning back multiples of their investment. That's going to be really hard to do in this segment of the health-care market. We've got a wonderful pediatric urgent-care place in our area, backed by the best children's hospital in our metro region, and it seems to be doing great. But does that mean it could ever grow at the rate needed to satisfy VC investors? Probably not.

dgfitz 2y ago
Geriatric care will be the gold rush of the 2040s. If I knew a solid way to invest in that, I would.
- imperialdrive 2y ago
  2040's? It is happening, now.
- bhouston 2y ago
  In Canada it has been the growth of old folks homes. I expect there will be a glut of them in 39 years or so. The companies behind them have likely made a killing.
- sam0x17 2y ago
  This mindset (that it will be a goldrush) is why we can't have nice things. Can't trust capitalism to do this kind of stuff in a non-exploitative way
  - dgfitz 2y ago
    We don’t have nice things because congress sucks. Keep Blaming capitalism, that wall has lots of screams to bear yet.
    - fl0id 2y ago

nextworddev 2y ago

Zombie startups closing shop around year end for tax purposes I guess

yieldcrv 2y ago
VC tax loss harvesting? They need proof to mark down their investment to zero? Most taxpayers have to realize the loss to take a tax deduction against their gains, but some tax elections allow you to do the same without finding a buyer for the worthless shares, which narrows down the incentives Mark to Market election as well as non-profits some non-profit investors have stricter scrutiny as their charitable distribution requirement is based on net assets. so there is an incentive to arbitrarily mark malperforming investments down to lower values, but being able to get the business to announce their failure supports it better Just thinking out loud

godisdad 2y ago

OP here. I visited their clinics for my daughter several times when she was a toddler for ear aches and other ailments— I found the experience refreshing: instant online booking, no BS registration and online communication with staff was seamless. Very sad to see them go so abruptly. Up until this morning when I was told they were gone, I had no idea they were YC or otherwise VC funded. Just came here to pour one out for a genuinely helpful and pleasant medical company.

hedora 2y ago
We had basically the same experience with Kaiser Permanente in the SF Bay Area. Currently, there’s a doctor shortage problem (supposedly, they can’t hire, or there aren’t enough positions, depending on who you ask), which has caused issues with the quality of care (according to the doctors that went on strike over this, and personal experience). It’s unclear what the root cause or solution is. Anyway, you can get the experience you described, and it’s great until you hit an understaffed corner case health problem.
dariusmonsef 2y ago
Appreciate the pour. Glad you got great care for your daughter.

dr_ 2y ago

Sad to see a care organization like this shut down. But curious to understand what exactly they were disrupting? From the outset, looks like a pediatric clinic that accepts insurance (and has a cash pay option) - but this is how most pediatric clinics/urgent care that are not venture backed operate. There doesn’t seem to be a disruption in their revenue model (like a one medical style subscription service), and vbc doesn’t apply much to pediatric care. Not criticisms, just trying to understand what the goal was.

dariusmonsef 2y ago
There are 25 million ER visits a year for kids where the vast majority of those visits are not life-threatening and don’t require that level of care. An urgent care is 1/10 the cost of an ER and can create a better environment for the kid and family… so better care for 1/10th the cost.

anovikov 2y ago

Real way to fix healthcare: facilities based on repurposed container ships offshore near cities with lots of flights into them, to be outside of US regulations, staffed by physicians shuffled from Eastern Europe. Will offer more than an order of magnitude price advantage and will quickly squeeze the existing systems making it irrelevant until what's left of it is forced to change.

kbelder 2y ago
That is interesting, although improbable.
- Yeul 2y ago
  Well my dentist is from Ukraine. I hope she doesn't go back.
thrance 2y ago
This seems extremely carbon intensive and would starve eastern Europe of the medical staff it probably needs. Also why would they charge an order of magnitude less when a 3% discount would be enough to attract patients? And how could a brain surgeon do his thing on a boat? This just seems comically bad.
the_sleaze_ 2y ago
only marginally different from just opening a luxury clinic in ie. Mexico with the exact same staff, which of course exists. My mom refuses to leave the US healthcare system despite the costs because 1. She pays for insurance, not surgery (in her mind) 2. regardless of the keening US healthcare system is the best in the world

jackcosgrove 2y ago

I have heard conflicting accounts of inefficiencies in the US healthcare system. One account is that the US has too many medical facilities in urban areas. In other words, there might be five hospitals each with its own radiology equipment. That equipment is idle some of the time, so you could close some of the imaging departments and leave just one or two for the metro area. That would obviously inconvenience some people, but the gist of the criticism is that the US duplicates medical capacity for the sake of convenience. The other criticism is that there are too few clinics and such. That's why there was a big push to open health clinics in pharmacies and urgent care locations recently. Now I know these aren't mutually exclusive; you can have too few clinics and too many hospitals. But I would like to know if anyone is more informed than I am what validity there is to each criticism. I'm curious what the truth is regarding the number and character of brick-and-mortar healthcare facilities in the US: too many? too few? Because it looks like this company was opening physical clinics.

ketzu 2y ago
> One account is that the US has too many medical facilities in urban areas. In other words, there might be five hospitals each with its own radiology equipment. That equipment is idle some of the time, so you could close some of the imaging departments and leave just one or two for the metro area. That would obviously inconvenience some people, but the gist of the criticism is that the US duplicates medical capacity for the sake of convenience. > The other criticism is that there are too few clinics and such. That's why there was a big push to open health clinics in pharmacies and urgent care locations recently. Funny enough, germany has the exact same two problems. * Too many small urban hospitals do too many things, but have no speciality, leading to high cost, underutilization and higher risk procedures. * Too few specialist doctors for checkups leading to long waiting times.
inferiorhuman 2y ago
I'm curious what the truth is regarding the number and character of brick-and-mortar healthcare facilities in the US: too many? too few? Because it looks like this company was opening physical clinics. Services are unevenly distributed and I wouldn't say there's too many providers in urban areas. Rural areas are underserved though (off the top of my head I can think of a movie and a TV series whose premise is rooted in lack of rural care). Even within urban areas care is uneven. Hospitals are concentrated in the more wealthy parts of San Francisco and the poorer (e.g. southeastern) parts see sparse coverage. One of the big points of contention when Sutter Health bought out St Luke's hospital in SF was that Sutter wanted to transition from primary care to more profitable specialties. This would've left the neighborhood bereft of primary care. In more rural areas you'll find that funding is a political football. As that funding wanes so does the level of care. On top of that the post-Roe v Wade environment encourages some folks to migrate towards urban areas in more "permissive" states. In terms of too much urban coverage. When I needed an ultrasound through UCSF I had to book it out months in advance. It's not clear to me that there is a ton of duplication there — more the point if I'd looked elsewhere I would've had to figure out what was/wasn't in network with my insurance provider. Last I looked Kaiser has a grand total of eight urgent care clinics in the Bay Area. There are nine counties in the Bay Area. That's efficient from a business standpoint but leaves plenty of customers out in the cold as Kaiser covers out-of-network services in very limited circumstances. Likewise, try to find a GP that accepts insurance and is taking new patience. When I checked eons ago UCSF had a nearly year long wait.