7 ms·

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. Healt

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?
    - basementcat 2y ago
      > reform the FDA to make bringing drugs to market cheaper. We recently tried this with some vaccines and now a large segment of the population is now vaccine-hesitant. https://pmc.ncbi.nlm.nih.gov/articles/PMC10257562/ https://pmc.ncbi.nlm.nih.gov/articles/PMC10257562/ > Lawyers: caps caps caps so there isn’t costly malpractice insurance. Caps don’t always result in improved health outcomes. https://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?params=/context/facpub/article/2140/&path_info=121120_zeiler_hardcastle_caps_chapter_SSRN.pdf https://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?p... > Maybe would also necessitate a federal review board to weed out "bad doctors". This exists; each state medical board has a procedure for reviewing medical licenses. https://www.mbc.ca.gov/ https://www.mbc.ca.gov/
      - sverhagen 2y ago
        Didn't Jon Oliver do a bit on those review boards, pointing out how friendly to fellow doctors they generally are? I think when someone says that we need "a (federal) review board", I think they mean one that works, one with teeth.
      - franktankbank 2y ago
        > We recently tried this with some vaccines and now a large segment of the population is now vaccine-hesitant. Forced vaccination was the problem here.
    - forgetfreeman 2y ago
      > reform the FDA to make bringing drugs to market cheaper. Uh, definitely not. The drug discovery and trial process is every bit as complex and expensive as it is for a reason. If you're serious about lowering the cost of getting compounds through the pipeline the first thing that should go is private equity's growing chokehold on the provider practices that perform clinical studies.
  - blindriver 2y ago
    Dump $1 trillion into Kaiser and push it out to all 50 states. I have it in Bay Area and it’s mostly been great for me. It’s not the best but it also gets 90% of things right.
    - toast0 2y ago
      Kaiser is the one thing I miss the most having left the Bay Area. It has sort of moved in here, but it took over an existing group and afaik, it's not really integrated like it was down there; there's no Kaiser hospitals here, so hospital care is going to be a mess, and I'm not sure if they have pharmacies either. But, a lot of people don't like Kaiser. You have to be ok with getting good enough care, and not really be trying to seek 'the best' care. Integration is so nice though. I'm sure Kaiser never puts you in the situation where the Dr says I'm not sure which drug will be covered, let's try A, the pharmacist says A isn't covered, ask your Dr to write a script for B, and your Dr doesn't answer the phone so you have to decide to either pay $250 for A or wait over the weekend to start your kid's treatment.
    - deleted 2y ago
      [deleted]
    - asadotzler 2y ago
      There was a study comparing Kaiser Permanente with the UK's National Health Service (NHS) that found Kaiser achieved better performance at roughly the same cost. If we could use tax dollars to make Kaiser national, and scale that large without losing the efficiency and results, we'd be in darned good shape. Eliminate other private health insurance and if people want above and beyond service they can negotiate directly with providers and pay out of pocket for that.
      - Angostura 2y ago
        > There was a study comparing Kaiser Permanente with the UK's National Health Service (NHS) that found Kaiser achieved better performance at roughly the same cost. Linky?
      - tonyedgecombe 2y ago
  - whoitwas 2y ago
    Educate humans (not possible because they have to want to learn). Abolish Citizens United. Stop funding insurance. Put the insurance money to healthcare for all.
  - jmye 2y ago
    Vote and legislate. Doesn’t even have to be federal, since the exchanges are state run. But it’s a highly regulated industry (for good reason, this isn’t a place where deleting laws helps normal people), so you have to fix the regulation. The ACA killing pre-existing coverage denials was a great start, but you have to fix risk adjustment before anything else can happen, as it’s literally just a wealth transfer from new entrants to existing behemoths (I think it was well intentioned, and works well in MA, but is completely broken in the commercial market). Reinsurance fixes to address the fund lockup would also probably help, but they’d be tax-expensive and probably untenable. But it all starts with voting for people who want to fix it, and not for people who just want to burn it down or maintain the status quo.
  - dennis_jeeves2 2y ago
    Will be consider mostly irrational, but I'll mention it: Learn medicine, and practice outside of of the mainstream clandestinely (a past real world example would be abortion clinics on ships). It needs a group of committed/smart people to pull it off, so not easy. Also it cannot be offered to the public at large for several obvious reasons. As a general rule one cannot involve 'average' people in such an endeavor. All organization settle down to the lowest common denominator. When it come to large organizations in govt/health/etc. they are prone to increasing corruption and bureaucracy if average people are involved.
- refurb 2y ago
  Upvotes for highly accurate summary. The providers have leverage and the ones with the most will screw you over unless you’re big enough to throw some weight around. I honestly don’t see much change unless the government comes in and sets new rules that actually make sense.
  - jmye 2y ago
    Yeah, agreed. It has to start from legislation. And that legislation has to also address education - we have to make it easier and cheaper to become a doctor or mid-level, or we have to start trying to import a ton of providers.
- inferiorhuman 2y ago
  Health insurance is undisruptable Medical practices that may charge an annual fee but don't accept insurance — so-called concierge care are a thing. Not accepting insurance means you can operate with a significantly smaller support staff. Patients with a PPO style insurance plan may even have some of the expenses covered.
  - nradov 2y ago
    Concierge medicine can be a good option for affluent people who can afford it. But it only works with relatively low utilization and won't scale up to address any of the systemic problems in the US healthcare system.
    - Projectiboga 2y ago
      My wife's Doc tried that and quickly came crawling back to their patients who refused the $3,000 "concierge" fee here in Murry Hill Manhattan. If that model can't fly here I don't see where it could. Maybe affluent suburbs w fewer competitors?
- IG_Semmelweiss 2y ago
  I agree with your statement in general terms. But you can't enter into the industry as a startup, to get stuck in the general crud of status-quo. You are supposed to be disrupting things, right? The same applies to insurance. You can't take crap contracts that don't work for you, so maybe create a contract of your own based on 1st principles and going back to the definition of insurance.
  - nradov 2y ago
    That doesn't apply to health insurance. Due to HIPAA / ERISA / EMTALA / ACA and an alphabet soup of other federal and state laws and regulations a startup health insurance company would have very little freedom of action on creating new types of contracts. And this is an area where the laws are actually enforced.
helsinkiandrew 2y ago
> .. they realize the goverment has tilted the rules in favor of status-quo Or is it that the Healthcare industry has tilted the government into making rules that favor the status-quo?
- deleted 2y ago
  [deleted]
- pdpi 2y ago
  Both are true, but your phrasing shifts responsibility away from the government. Ultimately, it is the government, not the industry, that sets the rules, and it is the government, not the industry, that is accountable to us.
  - addicted 2y ago
    Or, it’s the voters. Even without the argument that ultimately voters are responsible for the government they get in a country with free and fair elections like the U.S., health insurance is a very direct example of voters explicitly opting for a worse option. The ACA was being written in 2009 and 2010 and the argument was whether it constrained the insurance industry too much or not enough. The very specific policy proposal on the table was the public option which would have allowed the govt to offer an insurance policy that would have effectively set a floor to the quality of policies the healthcare industry could offer and a ceiling on the cost. And the 2010 election fell right in the middle of the debate and American voters overwhelmingly chose the politicians arguing against the public option and for fewer restraints on the insurance industry. Beyond that you can just look at every other developed country in the world, and all of them have better healthcare because their voters constantly vote for politicians who offer better healthcare policy, as opposed to the U.S. where voters choose the opposite.
HillRat 2y ago
I don't know about "disruptive", since they were trying to enter, using conventional tactics, what is in general a mature market with pretty high barriers. Urgent care as a market combines a very small number of very large national chains (Concentra, MedExpress, etc.) with a lot of medium- and small-sized regional chains, about half owned by medical systems and half not. There's even an existing national-level pediatrics chain, PM Pediatric, which has about 100 locations. It's not an easy market to jump into; you spend a huge amount upfront on site construction (particularly if you're building standalone clinics outside of existing medical buildings, which is not unusual for urgent care), labor cost and complexity is high, and reimbursement cycles are long and painful. Healthcare chains scale like retail, not like software, with all the attendant cash management problems. It feels like they did offer a superior service with lots of effort put into getting into the community, but I question both their decision to try and build a custom EHR -- yes, EHRs suck, but once you start building your own, you're no longer a medical services company, you're now an EHR company -- and not to pursue a regional-centric expansion strategy aligned with local health systems via contract or JV, instead choosing to build a small number of clinics across the country, which goes against proven successful buildout strategies in healthcare. It's a shame they've gone under -- again, superior service, obviously a lot of care for their patients -- but "we went under because of cash management problems and inappropriate growth strategy" is a pretty standard story in the healthcare world.
- amyfp214 2y ago
  I agree it's not an easy market. Peds ER & pediatrician offices are already a thing catering to children, so I don't see the innovation there. Additionally it's long known pediatrics reimbursement and costs are just way less than adults. This also forks in with the immigration issue(s) in that demographically there are a much higher portion of not not non-documented peoples among children, which can introduce linguistic overhead/costs of time and money (mandatory requirement to speak all patients languages) as well as inability to pay beyond medicaid. Children are an attractive selling point for a company in the same way as cancer of some altruistic goal. Though here, although elder care exists, to me that seems like the market to disrupt and minimize costs in.

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?
  - basementcat 2y ago
    > reform the FDA to make bringing drugs to market cheaper. We recently tried this with some vaccines and now a large segment of the population is now vaccine-hesitant. https://pmc.ncbi.nlm.nih.gov/articles/PMC10257562/ https://pmc.ncbi.nlm.nih.gov/articles/PMC10257562/ > Lawyers: caps caps caps so there isn’t costly malpractice insurance. Caps don’t always result in improved health outcomes. https://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?params=/context/facpub/article/2140/&path_info=121120_zeiler_hardcastle_caps_chapter_SSRN.pdf https://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?p... > Maybe would also necessitate a federal review board to weed out "bad doctors". This exists; each state medical board has a procedure for reviewing medical licenses. https://www.mbc.ca.gov/ https://www.mbc.ca.gov/
    - sverhagen 2y ago
      Didn't Jon Oliver do a bit on those review boards, pointing out how friendly to fellow doctors they generally are? I think when someone says that we need "a (federal) review board", I think they mean one that works, one with teeth.
    - franktankbank 2y ago
      > We recently tried this with some vaccines and now a large segment of the population is now vaccine-hesitant. Forced vaccination was the problem here.
  - forgetfreeman 2y ago
    > reform the FDA to make bringing drugs to market cheaper. Uh, definitely not. The drug discovery and trial process is every bit as complex and expensive as it is for a reason. If you're serious about lowering the cost of getting compounds through the pipeline the first thing that should go is private equity's growing chokehold on the provider practices that perform clinical studies.
- blindriver 2y ago
  Dump $1 trillion into Kaiser and push it out to all 50 states. I have it in Bay Area and it’s mostly been great for me. It’s not the best but it also gets 90% of things right.
  - toast0 2y ago
    Kaiser is the one thing I miss the most having left the Bay Area. It has sort of moved in here, but it took over an existing group and afaik, it's not really integrated like it was down there; there's no Kaiser hospitals here, so hospital care is going to be a mess, and I'm not sure if they have pharmacies either. But, a lot of people don't like Kaiser. You have to be ok with getting good enough care, and not really be trying to seek 'the best' care. Integration is so nice though. I'm sure Kaiser never puts you in the situation where the Dr says I'm not sure which drug will be covered, let's try A, the pharmacist says A isn't covered, ask your Dr to write a script for B, and your Dr doesn't answer the phone so you have to decide to either pay $250 for A or wait over the weekend to start your kid's treatment.
  - deleted 2y ago
    [deleted]
  - asadotzler 2y ago
    There was a study comparing Kaiser Permanente with the UK's National Health Service (NHS) that found Kaiser achieved better performance at roughly the same cost. If we could use tax dollars to make Kaiser national, and scale that large without losing the efficiency and results, we'd be in darned good shape. Eliminate other private health insurance and if people want above and beyond service they can negotiate directly with providers and pay out of pocket for that.
    - Angostura 2y ago
      > There was a study comparing Kaiser Permanente with the UK's National Health Service (NHS) that found Kaiser achieved better performance at roughly the same cost. Linky?
    - tonyedgecombe 2y ago
- whoitwas 2y ago
  Educate humans (not possible because they have to want to learn). Abolish Citizens United. Stop funding insurance. Put the insurance money to healthcare for all.
- jmye 2y ago
  Vote and legislate. Doesn’t even have to be federal, since the exchanges are state run. But it’s a highly regulated industry (for good reason, this isn’t a place where deleting laws helps normal people), so you have to fix the regulation. The ACA killing pre-existing coverage denials was a great start, but you have to fix risk adjustment before anything else can happen, as it’s literally just a wealth transfer from new entrants to existing behemoths (I think it was well intentioned, and works well in MA, but is completely broken in the commercial market). Reinsurance fixes to address the fund lockup would also probably help, but they’d be tax-expensive and probably untenable. But it all starts with voting for people who want to fix it, and not for people who just want to burn it down or maintain the status quo.
- dennis_jeeves2 2y ago
  Will be consider mostly irrational, but I'll mention it: Learn medicine, and practice outside of of the mainstream clandestinely (a past real world example would be abortion clinics on ships). It needs a group of committed/smart people to pull it off, so not easy. Also it cannot be offered to the public at large for several obvious reasons. As a general rule one cannot involve 'average' people in such an endeavor. All organization settle down to the lowest common denominator. When it come to large organizations in govt/health/etc. they are prone to increasing corruption and bureaucracy if average people are involved.
refurb 2y ago
Upvotes for highly accurate summary. The providers have leverage and the ones with the most will screw you over unless you’re big enough to throw some weight around. I honestly don’t see much change unless the government comes in and sets new rules that actually make sense.
- jmye 2y ago
  Yeah, agreed. It has to start from legislation. And that legislation has to also address education - we have to make it easier and cheaper to become a doctor or mid-level, or we have to start trying to import a ton of providers.
inferiorhuman 2y ago
Health insurance is undisruptable Medical practices that may charge an annual fee but don't accept insurance — so-called concierge care are a thing. Not accepting insurance means you can operate with a significantly smaller support staff. Patients with a PPO style insurance plan may even have some of the expenses covered.
- nradov 2y ago
  Concierge medicine can be a good option for affluent people who can afford it. But it only works with relatively low utilization and won't scale up to address any of the systemic problems in the US healthcare system.
  - Projectiboga 2y ago
    My wife's Doc tried that and quickly came crawling back to their patients who refused the $3,000 "concierge" fee here in Murry Hill Manhattan. If that model can't fly here I don't see where it could. Maybe affluent suburbs w fewer competitors?
IG_Semmelweiss 2y ago
I agree with your statement in general terms. But you can't enter into the industry as a startup, to get stuck in the general crud of status-quo. You are supposed to be disrupting things, right? The same applies to insurance. You can't take crap contracts that don't work for you, so maybe create a contract of your own based on 1st principles and going back to the definition of insurance.
- nradov 2y ago
  That doesn't apply to health insurance. Due to HIPAA / ERISA / EMTALA / ACA and an alphabet soup of other federal and state laws and regulations a startup health insurance company would have very little freedom of action on creating new types of contracts. And this is an area where the laws are actually enforced.

helsinkiandrew 2y ago

> .. they realize the goverment has tilted the rules in favor of status-quo Or is it that the Healthcare industry has tilted the government into making rules that favor the status-quo?

deleted 2y ago
[deleted]
pdpi 2y ago
Both are true, but your phrasing shifts responsibility away from the government. Ultimately, it is the government, not the industry, that sets the rules, and it is the government, not the industry, that is accountable to us.
- addicted 2y ago
  Or, it’s the voters. Even without the argument that ultimately voters are responsible for the government they get in a country with free and fair elections like the U.S., health insurance is a very direct example of voters explicitly opting for a worse option. The ACA was being written in 2009 and 2010 and the argument was whether it constrained the insurance industry too much or not enough. The very specific policy proposal on the table was the public option which would have allowed the govt to offer an insurance policy that would have effectively set a floor to the quality of policies the healthcare industry could offer and a ceiling on the cost. And the 2010 election fell right in the middle of the debate and American voters overwhelmingly chose the politicians arguing against the public option and for fewer restraints on the insurance industry. Beyond that you can just look at every other developed country in the world, and all of them have better healthcare because their voters constantly vote for politicians who offer better healthcare policy, as opposed to the U.S. where voters choose the opposite.

HillRat 2y ago

I don't know about "disruptive", since they were trying to enter, using conventional tactics, what is in general a mature market with pretty high barriers. Urgent care as a market combines a very small number of very large national chains (Concentra, MedExpress, etc.) with a lot of medium- and small-sized regional chains, about half owned by medical systems and half not. There's even an existing national-level pediatrics chain, PM Pediatric, which has about 100 locations. It's not an easy market to jump into; you spend a huge amount upfront on site construction (particularly if you're building standalone clinics outside of existing medical buildings, which is not unusual for urgent care), labor cost and complexity is high, and reimbursement cycles are long and painful. Healthcare chains scale like retail, not like software, with all the attendant cash management problems. It feels like they did offer a superior service with lots of effort put into getting into the community, but I question both their decision to try and build a custom EHR -- yes, EHRs suck, but once you start building your own, you're no longer a medical services company, you're now an EHR company -- and not to pursue a regional-centric expansion strategy aligned with local health systems via contract or JV, instead choosing to build a small number of clinics across the country, which goes against proven successful buildout strategies in healthcare. It's a shame they've gone under -- again, superior service, obviously a lot of care for their patients -- but "we went under because of cash management problems and inappropriate growth strategy" is a pretty standard story in the healthcare world.

amyfp214 2y ago
I agree it's not an easy market. Peds ER & pediatrician offices are already a thing catering to children, so I don't see the innovation there. Additionally it's long known pediatrics reimbursement and costs are just way less than adults. This also forks in with the immigration issue(s) in that demographically there are a much higher portion of not not non-documented peoples among children, which can introduce linguistic overhead/costs of time and money (mandatory requirement to speak all patients languages) as well as inability to pay beyond medicaid. Children are an attractive selling point for a company in the same way as cancer of some altruistic goal. Though here, although elder care exists, to me that seems like the market to disrupt and minimize costs in.