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The whole system is infuriating. Even when you assume a free market is what you want, it's pretty clear that this is far away from a free market. Unless you vie

The whole system is infuriating. Even when you assume a free market is what you want, it's pretty clear that this is far away from a free market. Unless you view non-competitive monopolies as free market. I don't understand why vertical integration is not made illegal. An insurer should not own a PBM or providers. They all should have an adverse relationship so they put cost pressure on each other. Also, providers should charge the same prices for the same procedures no matter who pays. Ideally everybody should be mandated to follow Medicare prices. If these prices are too low to survive, then there should be a discussion about adjusting the prices. The whole system is basically a huge bureaucracy that wastes a lot of money but some of the waste is enough profit for a lot of people to fight tooth and nail to keep the status quo.

matthest 2y ago
[flagged]
- lowbloodsugar 2y ago
  lol. No we’re dealing with unregulated capitalism.
  - matthest 2y ago
    [flagged]
    - dh2022 2y ago
      I think you are describing free markets, not capitalism. Capitalism means accumulation of capital through any means possible. Sometimes monopolies are examples of capitalism.
      - robertlagrant 2y ago
        [flagged]
      - matthest 2y ago
        I guess it depends on which definition you use at this point, but Adam Smith's original definition of capitalism fundamentally required free markets. Of course, what we have today is not Adam Smith's capitalism.
    - fzeroracer 2y ago
      > This makes it extremely difficult for new competitors to enter the space. Which means the existing players can collude to raise prices. > That's not capitalism. Capitalism requires heavy competition. Think restaurants for example. Extreme competition drives prices down and keeps prices fair for consumers. No, that absolutely is capitalism. No True Scotsmanning capitalism when we see this as an end result of capitalism doesn't work as an argument. For example, in the gig economy which is largely unregulated we see incumbents to the market get destroyed by economy of scale. Did you know Austin had its own non-profit ride-sharing app called RideAustin? Did you know that it blew up after Uber and Lyft completely pushed it out of the market? I could go on with other examples of these issues. Like for example Bartells in Seattle being bought out by Rite Aid only to be decimated by Rite Aids shitty practices, with little to no ability for incumbents to fill the void due to the costs of rent and rising bootstrap costs. Or the way grocery companies merge and combine until we have five different brands all operating under the same owner. Capitalism is controlled by the winners who have the most capital. Competition only vaguely exists as a way for capital to exert control.
      - matthest 2y ago
        Those are valid examples, but conflated with the problem that there is limited competition in all the industries you mentioned. Which makes monopolies much easier for the existing companies with power. Counter examples of capitalist industries that have lasted centuries without corporate concentration: restaurants, spas, bars, tailors, car washes, barbers, almost anywhere small businesses exist. Adam Smith's original capitalism required free markets, which fundamentally require high competition, low barriers to entry. The low barriers to entry component is missing from the examples you described, which is theoretically where government should step in (and lower those barriers for new companies looking to enter the market). In healthcare, however, government is essentially working with the companies to raise barriers to entry.
        fzeroracer 2y ago
        There's limited competition in the gig economy? I don't know what you think a free market is supposed to look like then because the gig economy is fully unregulated outside of a couple states and the barrier to entry was being able to write an app on your phone. You literally cannot get more unregulated than that. What is your vision here?
lovich 2y ago
> I don't understand why vertical integration is not made illegal. Well I decided that would be extremely inconvenient for me if that was the case, so I’m going to call this “bad regulation”, and say it’s against the “Free Market” so if you support it you are a communist. If later on I decide this is good for me, then I will call it “good regulation” that supports the “Free Market” and you are in the clear. All sarcasm aside, if you don’t define what your minimum set of regulations are for you to consider it a “Free Market”, then you are consigning yourself to endless bike shedding over what a “Free Market” really is
jimt1234 2y ago
I can't speak for all providers, but I can say that, in many cases they're getting squeezed by the insurance companies, too. My girlfriend is a provider of services for young people with disabilities. The insurance companies fully dictate how much she can charge (how much the insurance companies will pay) and even what specific services she can provide (what they'll specifically pay for). It's infuriating. Up until about 7 years ago, she was fully funded by the state through the California Department of Education, and it was simple. She met with a single person from the state monthly, they reviewed her billable hours, made some corrections here and there, and she got paid. Simple. When private insurance was introduced it became a nightmare. She had to hire a full-time employee just to manage billing with the insurance companies. One insurer won't even talk to providers at all. Nothing. Nada. She has to fax them. Yes, fax. And their fax machine only answers during business hours; it's powered-off outside of business hours. Why? Because fuck you, that's why. It's obvious that the insurance companies make it as difficult as possible for providers to get paid, which is not too different from patients. Weird...not.
- pimlottc 2y ago
  > And their fax machine only answers during business hours; it's powered-off outside of business hours. Why? In some cases, privacy laws require that fax machines be actively monitored so that sensitive personal information is not just left sitting around in the open for hours. Yes, there could probably be alleviated with sort form of purely digital fax system, but for regular fax machines, this could be why they are only available during staffed hours.
- rqtwteye 2y ago
  It's almost the same when you deal with billing departments in hospitals. They give you the runaround, "lose" things repeatedly, ignore you. The whole US health system is abusive but there is so much money flowing around that it's worth it to many participants. I know doctors who complain about their workload but they would never consider moving from 600k salary to 400k in exchange for a straight 40 hour week.
toast0 2y ago
I dunno, I used to have Kaiser which is vertically integrated and the nice thing was there wasn't the thing where the Doctor says we should do X, but your insurance won't pay for it, so we'll do Y. Or my favorite where the doctor writes a prescription, and the pharmacy doesn't fill it because it's not covered, and you have to convey what is covered to the doctor so they can write that instead. Kaiser would sometimes tell me that we have to try X first before we do Y, but then the X's worked sometimes, so it seemed like they were asking for reasonable things to reduce cost.
- droopyEyelids 2y ago
  I think kaiser is pretty widely regarded as the best experience possible with healthcare in the USA. Unfortunately its not widely available
  - Taikonerd 2y ago
    There are other organizations with the same "payvider" model (combining payer and provider). For example, Geisinger and Intermountain. It's slowly getting more popular. "Unlike the traditional healthcare model, which often pits payers against providers in a bid to control costs, the payvider model merges these roles..." - https://www.neudesic.com/blog/the-rise-of-the-payvider/ https://www.neudesic.com/blog/the-rise-of-the-payvider/

matthest 2y ago

[flagged]

lowbloodsugar 2y ago
lol. No we’re dealing with unregulated capitalism.
- matthest 2y ago
  [flagged]
  - dh2022 2y ago
    I think you are describing free markets, not capitalism. Capitalism means accumulation of capital through any means possible. Sometimes monopolies are examples of capitalism.
    - robertlagrant 2y ago
      [flagged]
    - matthest 2y ago
      I guess it depends on which definition you use at this point, but Adam Smith's original definition of capitalism fundamentally required free markets. Of course, what we have today is not Adam Smith's capitalism.
  - fzeroracer 2y ago
    > This makes it extremely difficult for new competitors to enter the space. Which means the existing players can collude to raise prices. > That's not capitalism. Capitalism requires heavy competition. Think restaurants for example. Extreme competition drives prices down and keeps prices fair for consumers. No, that absolutely is capitalism. No True Scotsmanning capitalism when we see this as an end result of capitalism doesn't work as an argument. For example, in the gig economy which is largely unregulated we see incumbents to the market get destroyed by economy of scale. Did you know Austin had its own non-profit ride-sharing app called RideAustin? Did you know that it blew up after Uber and Lyft completely pushed it out of the market? I could go on with other examples of these issues. Like for example Bartells in Seattle being bought out by Rite Aid only to be decimated by Rite Aids shitty practices, with little to no ability for incumbents to fill the void due to the costs of rent and rising bootstrap costs. Or the way grocery companies merge and combine until we have five different brands all operating under the same owner. Capitalism is controlled by the winners who have the most capital. Competition only vaguely exists as a way for capital to exert control.
    - matthest 2y ago
      Those are valid examples, but conflated with the problem that there is limited competition in all the industries you mentioned. Which makes monopolies much easier for the existing companies with power. Counter examples of capitalist industries that have lasted centuries without corporate concentration: restaurants, spas, bars, tailors, car washes, barbers, almost anywhere small businesses exist. Adam Smith's original capitalism required free markets, which fundamentally require high competition, low barriers to entry. The low barriers to entry component is missing from the examples you described, which is theoretically where government should step in (and lower those barriers for new companies looking to enter the market). In healthcare, however, government is essentially working with the companies to raise barriers to entry.
      - fzeroracer 2y ago
        There's limited competition in the gig economy? I don't know what you think a free market is supposed to look like then because the gig economy is fully unregulated outside of a couple states and the barrier to entry was being able to write an app on your phone. You literally cannot get more unregulated than that. What is your vision here?

lovich 2y ago

> I don't understand why vertical integration is not made illegal. Well I decided that would be extremely inconvenient for me if that was the case, so I’m going to call this “bad regulation”, and say it’s against the “Free Market” so if you support it you are a communist. If later on I decide this is good for me, then I will call it “good regulation” that supports the “Free Market” and you are in the clear. All sarcasm aside, if you don’t define what your minimum set of regulations are for you to consider it a “Free Market”, then you are consigning yourself to endless bike shedding over what a “Free Market” really is

jimt1234 2y ago

I can't speak for all providers, but I can say that, in many cases they're getting squeezed by the insurance companies, too. My girlfriend is a provider of services for young people with disabilities. The insurance companies fully dictate how much she can charge (how much the insurance companies will pay) and even what specific services she can provide (what they'll specifically pay for). It's infuriating. Up until about 7 years ago, she was fully funded by the state through the California Department of Education, and it was simple. She met with a single person from the state monthly, they reviewed her billable hours, made some corrections here and there, and she got paid. Simple. When private insurance was introduced it became a nightmare. She had to hire a full-time employee just to manage billing with the insurance companies. One insurer won't even talk to providers at all. Nothing. Nada. She has to fax them. Yes, fax. And their fax machine only answers during business hours; it's powered-off outside of business hours. Why? Because fuck you, that's why. It's obvious that the insurance companies make it as difficult as possible for providers to get paid, which is not too different from patients. Weird...not.

pimlottc 2y ago
> And their fax machine only answers during business hours; it's powered-off outside of business hours. Why? In some cases, privacy laws require that fax machines be actively monitored so that sensitive personal information is not just left sitting around in the open for hours. Yes, there could probably be alleviated with sort form of purely digital fax system, but for regular fax machines, this could be why they are only available during staffed hours.
rqtwteye 2y ago
It's almost the same when you deal with billing departments in hospitals. They give you the runaround, "lose" things repeatedly, ignore you. The whole US health system is abusive but there is so much money flowing around that it's worth it to many participants. I know doctors who complain about their workload but they would never consider moving from 600k salary to 400k in exchange for a straight 40 hour week.

toast0 2y ago

I dunno, I used to have Kaiser which is vertically integrated and the nice thing was there wasn't the thing where the Doctor says we should do X, but your insurance won't pay for it, so we'll do Y. Or my favorite where the doctor writes a prescription, and the pharmacy doesn't fill it because it's not covered, and you have to convey what is covered to the doctor so they can write that instead. Kaiser would sometimes tell me that we have to try X first before we do Y, but then the X's worked sometimes, so it seemed like they were asking for reasonable things to reduce cost.

droopyEyelids 2y ago
I think kaiser is pretty widely regarded as the best experience possible with healthcare in the USA. Unfortunately its not widely available
- Taikonerd 2y ago
  There are other organizations with the same "payvider" model (combining payer and provider). For example, Geisinger and Intermountain. It's slowly getting more popular. "Unlike the traditional healthcare model, which often pits payers against providers in a bid to control costs, the payvider model merges these roles..." - https://www.neudesic.com/blog/the-rise-of-the-payvider/ https://www.neudesic.com/blog/the-rise-of-the-payvider/