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My impression is a lot of US health care problems are caused in part by a sort of unholy combination of restricted competition and access, together with profit

My impression is a lot of US health care problems are caused in part by a sort of unholy combination of restricted competition and access, together with profit driven market participants. So you end up with this marketplace constricted by overregulation — some well-meaning but often basically occurring because of protectionist moats and regulatory capture — increasingly controlled by profiteers trying to extract as much money as possible, with patients at the bottom, providers in the middle, and executives at the top. I think the problems with monopolies in the US are broad in scope but it hits healthcare especially hard because of how grotesquely distorted it is. I'm not surprised by this finding, although I find in economics and healthcare forums the results tend to be misused (at least in my opinion), because it gets used to argue against any deregulation or cost cutting, instead of cost cutting of the type that tends to happen for the benefit of investors and shareholders, rather than cost cutting of the type that increases healthcare options and access.

palmotea 1y ago
> So you end up with this marketplace constricted by overregulation — some well-meaning but often basically occurring because of protectionist moats and regulatory capture Don't hand-wave your claim of overregulation, be specific and name the regulations you think should go away.
- pfdietz 1y ago
  > Don't hand-wave your claim of overregulation, be specific and name the regulations you think should go away. Regulations that prevent construction of new hospitals without some sort of "demonstration of need".
  - myrmidon 1y ago
    How would higher hospital density help quell healthcare costs, though? Isn't that just more infrastructure, administration overhead and staffing that victims have to pay for, in the end?
    - wat10000 1y ago
      Where would you expect bananas to be cheaper: a town with five grocery stores, or a town with one?
      - ceejayoz 1y ago
        I mean, that depends. A town with ten people and five grocery stores will be inefficient, and probably have very expensive produce as a result.
        wat10000 1y ago
        A town with ten people won't have five grocery stores in the first place. Nobody's going to spend a bunch of money to open a store in a place where there isn't a customer base to support it.
        ceejayoz 1y ago
        > Nobody's going to spend a bunch of money to open a store in a place where there isn't a customer base to support it. Tell that to the waves of cupcake shops, craft breweries, and now cannabis dispensaries in my area.
        wat10000 1y ago
        Right, luxury items are definitely an apt analogy here. Man, people really do love to argue, huh.
        ceejayoz 1y ago
        The point is that business decisions aren't magically correct. People can, and do, open stores in oversaturated markets. When your cupcake shop flops, that's sad; when hospitals close, that can be devastating to a community. It makes at least theoretical sense for states to try and prevent that impact.
  - h2zizzle 1y ago
    Oh, well that's BS. Urgent care clinics have proliferated like crazy over the post decade or so. The supply to fill the vast majority of urgent medical needs which hospital ERs used to have to carry alone is there. But it's true that that supply often goes unused. Why? Because ERs HAVE to tend to and stabilize patients when they present; UCCs can turn you away if you can't demonstrate the ability to pay. The problem is not restrictions on medical facility construction, it's inefficient use of what we already have. In general, America has an issue with defaulting to "building new", as if we have an everlasting greenfield, rather than careful provisioning of the already overbuilt infrastructure base. Capitalists love being freed of prior obligations, with no regard for how they contribute to an even more unwieldy set of obligations in the future. Enough. You can't just do as you like. Help solve the actual problem.
    - pfdietz 1y ago
      BS, eh? https://www.health.ny.gov/facilities/cons/ https://www.health.ny.gov/facilities/cons/
      - alostpuppy 1y ago
        That’s just New York, yeah? Does every state have similar regulations?
        pfdietz 1y ago
        So, unless every state has a regulation, that regulation doesn't exist and has no effect? Any other goal lines you want to redraw? Let's get that out of the way now instead of going back and forth. (To answer: in my personal experience Illinois also has such a regulation.)
        ch4s3 1y ago
        Slightly more than half have CoN laws and other states have a number of restrictions of facility construction that complicate building smaller clinics.
      - kotaKat 1y ago
  - jasonlotito 1y ago
    This doesn't solve the issue presented in the study. PE hospitals exists in states with and without these restrictions. So while CON might be an issue, it doesn't reconcile the issue of PE. In fact, PE priorities is exactly one of the things CON was setup to handle. Regardless, you have to explain how removing CON solves the PE issue mentioned when states without CON had the same issues.
    - RHSeeger 1y ago
      You seem to be under the mistaken impression that - There is a specific list of regulations that cause the problem - Each regulation in that list is present everywhere the problem exists Neither one of those are true. Instead, there are many regulations and, combined, they add up to causing the problems. The specific regulations can and do vary by location; but the result is the same.
      - 20after4 1y ago
        I think the problem is obsessive optimization of profit at the expense of literally everything else. Greed is bad, especially in a field that is at least in theory centered on taking care of people. You can't take care of someone by exploiting them for the maximum possible profit.
      - jasonlotito 1y ago
        > You seem... No. You are 100% wrong. The context of this discussion is PE. So comments discussing this involve PE. So while you are correct in general, you are wrong specifically. In light of that, I stand by what I said: you have to explain how removing CON solves the PE issue mentioned when states without CON had the same issues. Maybe this isn't possible, but then we accept that this is not an answer to PE, which again, topic of conversation.
- viscountchocula 1y ago
  Certificate of Need: basically, prove to regulators that there is enough "need" before opening up new facilities. https://en.wikipedia.org/wiki/Certificate_of_need https://en.wikipedia.org/wiki/Certificate_of_need
  - bilbo0s 1y ago
    As someone already pointed out, PE owned hospitals are in states with, and in states without, CON requirements. Certainly on the face of that fact it would appear the existence, or nonexistence, of CON requirements has no effect on PE hospitals charging more and having far inferior outcomes. Do you have a hypothesis as to why CON requirements are driving inferior outcomes and increased cost metrics at PE owned hospitals? (A hypothesis that accounts for the fact that PE owned hospitals underperform even in the absence of CON requirements.) Serious question. I'm trying to get my head around this.
    - SkyBelow 1y ago
      Sample hypothesis with only minimal amount of knowledge on it. PEs seek to make profit, and are looking for places where they can either raise prices or lower costs (which will quickly correlate with worse outcomes) while not losing customers (yes, you could call them patients, but PE will view them as customers), or at least losing so few that the overall numbers result in more profit. One way of doing this is looking for barriers to competition/moats. CON is just one type of moat, and so is one factor PEs evaluate, but the presence or absence of other moats can still override the presence or absence of this one moat. One could try to work this out from data with some sort of regression, but with so many possible moats and a relatively limited number of data points, it would be easy to overfit the data. In comparison, non-PE hospitals might have some profit motive (or keeping to budgets, not going bankrupt, ect.), but will be less driven by this mentality and thus their relationships to moats will be more complex, and so something like a CON requirement won't be as fully exploited to raise prices or lower costs. This also fails to account for other ways that PE can seek to make money, which involves more complex parts of law and financing that I'm not well versed on (I've ready some things about real estate, but don't know enough to fairly analyze the claims).
- betaby 1y ago
  In the USA/Canada number of doctors minted is caped by the cartel of doctors. That costs non-trivial money and lives lost. Source: https://thedailyeconomy.org/article/how-congress-created-the-doctor-shortage/ https://thedailyeconomy.org/article/how-congress-created-the... and many others
  - insane_dreamer 1y ago
    That’s not a regulatory issue
    - topkai22 1y ago
      Since the government (federal or state/local) authorizes those organizations to certify physicians and restricts medical care to only those who have been certified, it is.
    - nick__m 1y ago
      What kind of issue it is then ? If a regulation permits the doctors associations to set the allowed number of doctors residency, naively it is a regulatory issue.
      - insane_dreamer 1y ago
        It's a funding issue. There aren't enough residency slots available given the number of medical school grads. Residency is a requirement to get a medical license--which is issued by the states, not the federal gov. The reason there aren't enough residency slots is because they are heavily subsidized by the federal gov and they put a cap on the funding. No one else wants to foot the bill, so the slots remain limited, thus the licenses remains limited.
    - tptacek 1y ago
      It obviously is. A federal government policy decision caps the number of doctors we have, and another federal government policy decision restricts a huge number of basic medical services to those doctors.
- johnisgood 1y ago
  FDA drug approval processes and insurance regulations.
  - palmotea 1y ago
    > FDA drug approval processes What, specifically? Just abolish them all, and return to the pre-1938 status quo (e.g. marketing radium water to cure what ails ya)? Or specific reforms to make the drug approval processes more effective? https://en.wikipedia.org/wiki/Radithor https://en.wikipedia.org/wiki/Radithor
    - cogman10 1y ago
      Best way to make the entire process more efficient would be centralizing R&D and approval and nationalizing the manufacturing of drugs. MAYBE you could license out the rights to produce drugs on 10 or 20 year license agreements. Turn it into a pure R&D effort and not one driven by profit.
      - ajmurmann 1y ago
        Who is gonna decide how the R&D money gets spent? What's their skin in the game and their feedback mechanism? Why will they do a better job picking what to research than current pharmaceutical companies?
        cogman10 1y ago
        > Who is gonna decide how the R&D money gets spent? Same way the NHS previously funded medical research. Grants and grant review. You can expand that department and effort. > What's their skin in the game and their feedback mechanism? Believe it or not, some people just want to research and look into cures for diseases. Shocking I know. Feedback can be reviews of their work and blackballing bad actors that consistently kick out bad research. > Why will they do a better job picking what to research than current pharmaceutical companies? Because they already are. Pharmaceuticals aren't doing the majority of research, they are taking NHS funded research and running it through FDA approval. Ozempic, for example, didn't come from pharmaceutical research, it came from grant research into lizard spit.
- mothballed 1y ago
  [flagged]
  - hiddencost 1y ago
    Hoodrats?
    - mothballed 1y ago
      Source: worked ~1 year in an inner city ER alongside a doctor seeing every case. Yes it was the hoodrats abusing the system.
      - habinero 1y ago
        Working all of one year before you got fired doesn't make you an expert, sorry. It's probably best you moved on from healthcare, you don't seem suited for it with your attitude.
        mothballed 1y ago
        Unfortunately my attitude is the only one that will actually help you fix things because I'm bringing you a sober view of what the situation is. And people much "better suited for it" who worked in inner city ER generally had even less rosy thoughts than I did, if you want to defer to "experts" it's hilarious you would think this is unusual takeaway and that my opinion wasn't formed in large part by the experts thinking the very same thing (which of course they are never going to tell to the patients, you're probably not going to hear it unless you actually work in an ER and are close and comfortable enough with doctors for them to risk themselves to tell you what they really think as it's totally unacceptable to say it publicly).
        habinero 1y ago
        Sure, buddy. "Everyone thinks this way, they just don't say it" has been the rallying cry of people with bad minority opinions forever.
- kriops 1y ago
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- potato3732842 1y ago
  That's like saying "it's ok if I shit in the river, it's a big river". When a million other people do it you've got a water quality problem. Each and every one of these regulations can in abstract, be justified by some useful idiot looking at only the first and second order inputs and outputs and not looking at the totality of the effects. Nobody with a brain would defend shitting in the river, but here you are asking for individual turds so that they may be justified on the basis that the individual dropping them was relieved and their individual impact on water quality was minor.
  - scott_w 1y ago
    No it's not. Shitting in a river is always a net negative. Regulations can be positive, negative, or ineffective. Trying to "just count" the regulations to determine quality completely discards this critical dimension and betrays an almost childlike view of the world.
    - potato3732842 1y ago
      >Shitting in a river is always a net negative It beats anything open air by miles. Sure, an outhouse would be better but river > street. >Trying to "just count" the regulations to determine quality completely discards this critical dimension and betrays an almost childlike view of the world. You're grasping at straws here. I am under no obligation to give such an infantile opinion (the one I initially replied to) a response at length. This is not the venue for such minutia.
      - scott_w 1y ago
        > I am under no obligation to give such an infantile opinion Responding with “I know you are but what am I?” is just proving my point.
- deleted 1y ago
  [deleted]
- pfdietz 1y ago
  Another issue is the requirement that doctors adhere to "standard of care" regardless of cost. If they don't, they are subject to malpractice lawsuits. Elsewhere, quality of a good or service is traded against cost. But in medicine, there's a cost ratchet as ever more expensive and marginally more performant treatments are introduced.
  - bilbo0s 1y ago
    This is another example of a requirement that both PE owned and non PE owned hospitals, presumably, followed.e (I would hope neither of them were ignoring standards of care in the treatment of patients.) Yet the metrics are substandard at only the PE owned hospitals. So you would need to outline how this requirement unduly burdened the PE owned hospital relative to the non PE owned hospital for it to be the cause of the discrepancy. There may be such a reason, but you haven't outlined it in your post.
- mimikatz 1y ago
  Let nurses do more, let them write some prescriptions, let them open up a shop that puts casts on people with broken bones and minor things which they mostly do anyways.
- landl0rd 1y ago
  - The AMA froze the number of med schools for decades even as residency availability increased. - The majority of states still maintain "certificate of need" laws for new hospitals, ambulance providers, etc. - The AMA holds a state-enforced monopoly over physicians. - Many states still limit NPs/PAs, requiring physician supervision for things for which those people were trained. - Lack of interstate reciprocity in licensing means mobility is constrained and supply can't follow demand. - Costly medical equipment usually requires first-party repairs; mfgs claim a third-party modification (repair) constitutes remanufacturing under FDA regs. - Stark law makes e.g. physician/hospital value-based care arrangements very hard. It's quite strict and everyone has to tiptoe around it a bit. There's also the huge problem of malpractice insurance costs due to insane tort settlements. Awards need to be capped yesterday because it's too easy to talk a jury into bankrupting people over things that legitimately just sometimes happen. I'm guessing others could give you an even better list. Some of those are a bigger deal than others but it's a huge issue. Insurance net margins just aren't high enough to blame it and drug costs aren't enough of our total healthcare spend to be at fault. It comes down to humans being too expensive. There remain many areas of care where we can't cut man-hours down without sacrificing safety and quality. As such, we should reduce the insane byzantine co-ordination and compliance overhead.
  - dimal 1y ago
    Don’t forget that the AMA has a monopoly on billing codes. Medicare defines the billing value of every procedure as Relative Value Units (RVUs). Then Medicare defers to AMA’s guidance on what these values should be. Insurers default to RVUs x multiplier. So the AMA has the ability to set prices. Oh, and patient value isn’t considered for these units. They are explicitly defined as input driven, so a procedure that is less costly to perform but has higher value to the patient will be billed at a lower value. Hospitals are incentivized to choose procedures that they can bill at a higher rate, and so because of these perverse incentives, they necessarily will ignore cheaper more effective treatments and choose the more expensive ones. I’m a lefty, but the older I get the less I believe in the old New Deal style leftism I’ve been sold my whole life. As systems get more complex, they simply become a way to obfuscate oligarchic control.
- maxerickson 1y ago
  Certificates of need. To reduce costs, we supposedly perfectly plan capacity and prevent over investment. Should also probably drop requiring an ER for Medicare certification and just directly subsidize ERs.
- derbOac 1y ago
  Others have kind of mentioned a lot of things I might anyway, and it's hard to summarize what I think is necessary. But to summarize, I think there needs to be a deregulation of licensing or practice laws to allow other types of providers to do more, of the sort they are perfectly capable of doing (and that studies show they can do) — pharmacists, psychologists, and optometrists are just some examples — and I think there needs to be more flexibility and diversity in terms of provider types and degree paths. My guess is there are many types of providers we can't even envision right now because there's such a rigid schema about what healthcare professionals should look like. I also think, for example, there are probably a lot of cases where someone could go from a PA -> MD degree without returning to do a second degree; I might be wrong about that but these are the types of things that should be encouraged at least as experiments. I also generally think there's a lot of choice that could be encouraged in terms of drug access. I generally think people should be able to buy medications and drugs without a prescription, or at least under the monitoring of a pharmacist or something, or at least in most cases. I can think of medications that there have literally been papers written saying that they are safe to give without a prescription decades ago and they still require a prescription; there's also medications that people take for years safely, and it seems kinda absurd to require them to get a prescription for them. My thoughts about the FDA itself are complex and could probably an essay in itself. I'm very in favor of public healthcare, and public healthcare institutions but I also feel a lot should be deregulated or reregulated toward greater openness, choice, and competition. There's probably a lot of areas where there should be more regulation too I suppose — I think antitrust principles should be applied to insurance and hospital consolidation more often.
baq 1y ago
'Your appendix is my pension plan dividend'
giancarlostoro 1y ago
I summarize it with one word after talking to a hospital billing manager. Subsidized costs. If you cant pay someone else will be receive marked up prices. On top of that and bear with me, but the way health insurance works feels like you gotta be in the right “mob family” where each provider is different in leverage in conjunction with which employer you work for. They can just take hospitals out of their “network” if they dont lower costs, so small businesses dont get this level of leverage, but employers with large numbers of employees do. You could have someone with a drastically lower bill just because of where they work, not even related to how much they make mind you. It all goes back to your healthcare costs being subsidized by those who are left with the crappy end of the stick. I think transparency in hospital billing is drastically necessary. If not for every single surgery out there at least for all the really standard things that arent so complicated. I am not a doctor. I think healthcare can be fixed without throwing more government money at it, but we need people to understand it better and work out how to bring costs down. If you are not aware yet, if you think you need to go to the ER think about what you NEED, is your arm broken? This sounds crazy but find a lab that will xray your arm. It will cost way less, and sometimes the insurance will pay the full cost of labs for you since you saved them a fortune. It sounds dumb, but it could save you so much financially. If you are in more urgent needs dont waste any time go get the care you need.
- joe_the_user 1y ago
  I disagree with your analysis. I think you are wrong. Health Care is a natural monopoly like an electrical system. Basically, a large portion of health care the creation of infrastructure that everyone benefits from. An MRI machine or whatever is benefit to everyone since everyone might need it even if only some people actually use it, etc. For that reason, the cost of procedures, infrastructure, etc, etc. are infinitely debatable and there is no true way to way to assign costs. And sure, the actual assignments are irrational but framing this "things are subsidized" has things exactly backwards. Here's scenario - suppose electrical companies weren't responsible for maintaining their own grids and homeowners had to individually maintain insurance in the event of a pylon going down. Suppose if you didn't have insurance and could be tagged as the last user of a substation, you could in-hoc for the entire cost of repairing a pylon or whatever. This would only approach the irrationality of private medicine but I think it illustrates the situation. (and the finance system might manage to put that in place too if we're not careful).
dev_l1x_be 1y ago
Yes, or government intervention that looks good on paper and disastrous in practice. Somehow people have this notion that healthcare should be treated differently than other service industries. I would argue that the least amount of government control yields to the best result. There is only the size limitations (antitrust) that had potentially good outcomes. We could simply ban m&a above a certain size and make the externalities have an impact on revenue and that would be probably enough.
- DarkNova6 1y ago
  Somehow US citizens have this notion that healthcare is a universal problem and that US-problems are not self inflicted. Everywhere else in the civilized world, you pay less and have better service. The US has the highest degree of industry meddling, most middlemen cashing out and the least governmental regulation. You are objectively being lied to.
thisislife2 1y ago
"Regulatory capture" is a nice euphemism for the problems that a corrupt political environment creates. It is corruption that really hampers the creation of a fair and competitive capitalistic market. Regulation can indeed be balanced to create a fair and competitive capitalistic environment. A great example of this was the telecom industry in India during Dr. Manmohan Singh's government. Both the economic and telecom policies created a very booming and competitive telecom industry in India, with many foreign and local businesses trying their best, to be the best. It also ensured that the technology was accessible and affordable to all, providing a further fillip to the indian economy that increased connectivity delivers in a society. Contrast that 2+ decades later with the current telecom industry scenario in India where only 3 major private players (and 1 government owned company) survives today due to flawed and corrupt policies of the Narendra Modi government. (As the government owned telecom enterprise now doesn't really "compete" with the private players, the 3 private players have already formed a cartel to dictate pricing, and keep gouging the public, with increased pricing, with the connivance of a government that believes in oligarchy vis the South Korea Chaebol model). And let's not ignore that regulation is necessary in a democracy because capitalists are only (rightly) focused on creating capital. But obviously they are not the only contributing members of a society (nor, do I dare say, the most important ones) and the rights and needs of others in a society are just as important in a democracy. That is why everyone today also realises that things like monopoly, hoarding or black marketing, for example, aren't good for the overall well-being of a society, even if that's how capitalists can derive "maximum" value (i.e. make the most profit). History says that imperialism is the capitalist model that delivered peak "efficiency" in terms of deriving the maximum "value" for the (low) capital invested in it. But obviously, imperialism, even in its limited form today, is not compatible with democracy or concepts of sovereignty.
- burnt-resistor 1y ago
  The problem in the US is there are too many rich people devoid of morals and less rich people who support them and are brainwashed into ideological opposition of most or all regulation and government without nuance. Furthermore, Americans in aggregate condone being ruled by extreme inhumanity, corruption, stupidity, and greed by lack of effective objection. It's like an old-school third-world country and Americans either don't realize how bad they have it or lack the courage to do anything about it.
someguynamedq 1y ago
Why are we talking about deregulation when the topic is the ill effects of unregulated rentier profit seeking behavior of PE firms? We need to make debt loading and dividend recapitalization of hospitals illegal. Let them hollow out Neiman Marcus and Dunkin doughnuts, I don't really care. But financial engineering should have no place in our healthcare system.
- tptacek 1y ago
  Because the PE firms are exploiting a broken regulatory system, obviously.
ben7799 1y ago
This actually sounds a lot like the US problems with energy (electrical, gas) infrastructure and also things like telephone and internet providers. They've almost always got a state approved monopoly or duopoly and then magically the state always allows them to raise their rates.
joe_the_user 1y ago
My impression is a lot of US health care problems are caused in part by a sort of unholy combination of restricted competition and access, together with profit driven market participants. That is not wrong, literally stated. But know a lot of hn people imagine that this means making things completely unregulated might be one reasonable alternative. The obvious problem in this case is scams and unsafely/deadly treatments. Here, one can point countries with functioning, lightly regulated systems. The problem is that these countries depend on cultural and institutional factors keeping people honest, keeping fake medicine at bay, and etc. But the US has a cultural of religious irrationality coupled with huge, profitable and predatory organizations (the ones soaking health care dollars as well as alternative medicine cults and scammers). Before the last hundred years of regulation, 1910 or so, unregulated US medicine was a deadly, heroin soaked shit show and if you back to that, all the "alternative" scammers along with Stackler types are ready to jump in to try to equal that situation.

palmotea 1y ago

> So you end up with this marketplace constricted by overregulation — some well-meaning but often basically occurring because of protectionist moats and regulatory capture Don't hand-wave your claim of overregulation, be specific and name the regulations you think should go away.

pfdietz 1y ago
> Don't hand-wave your claim of overregulation, be specific and name the regulations you think should go away. Regulations that prevent construction of new hospitals without some sort of "demonstration of need".
- myrmidon 1y ago
  How would higher hospital density help quell healthcare costs, though? Isn't that just more infrastructure, administration overhead and staffing that victims have to pay for, in the end?
  - wat10000 1y ago
    Where would you expect bananas to be cheaper: a town with five grocery stores, or a town with one?
    - ceejayoz 1y ago
      I mean, that depends. A town with ten people and five grocery stores will be inefficient, and probably have very expensive produce as a result.
      - wat10000 1y ago
        A town with ten people won't have five grocery stores in the first place. Nobody's going to spend a bunch of money to open a store in a place where there isn't a customer base to support it.
        ceejayoz 1y ago
        > Nobody's going to spend a bunch of money to open a store in a place where there isn't a customer base to support it. Tell that to the waves of cupcake shops, craft breweries, and now cannabis dispensaries in my area.
        wat10000 1y ago
        Right, luxury items are definitely an apt analogy here. Man, people really do love to argue, huh.
        ceejayoz 1y ago
        The point is that business decisions aren't magically correct. People can, and do, open stores in oversaturated markets. When your cupcake shop flops, that's sad; when hospitals close, that can be devastating to a community. It makes at least theoretical sense for states to try and prevent that impact.
- h2zizzle 1y ago
  Oh, well that's BS. Urgent care clinics have proliferated like crazy over the post decade or so. The supply to fill the vast majority of urgent medical needs which hospital ERs used to have to carry alone is there. But it's true that that supply often goes unused. Why? Because ERs HAVE to tend to and stabilize patients when they present; UCCs can turn you away if you can't demonstrate the ability to pay. The problem is not restrictions on medical facility construction, it's inefficient use of what we already have. In general, America has an issue with defaulting to "building new", as if we have an everlasting greenfield, rather than careful provisioning of the already overbuilt infrastructure base. Capitalists love being freed of prior obligations, with no regard for how they contribute to an even more unwieldy set of obligations in the future. Enough. You can't just do as you like. Help solve the actual problem.
  - pfdietz 1y ago
    BS, eh? https://www.health.ny.gov/facilities/cons/ https://www.health.ny.gov/facilities/cons/
    - alostpuppy 1y ago
      That’s just New York, yeah? Does every state have similar regulations?
      - pfdietz 1y ago
        So, unless every state has a regulation, that regulation doesn't exist and has no effect? Any other goal lines you want to redraw? Let's get that out of the way now instead of going back and forth. (To answer: in my personal experience Illinois also has such a regulation.)
      - ch4s3 1y ago
        Slightly more than half have CoN laws and other states have a number of restrictions of facility construction that complicate building smaller clinics.
    - kotaKat 1y ago
- jasonlotito 1y ago
  This doesn't solve the issue presented in the study. PE hospitals exists in states with and without these restrictions. So while CON might be an issue, it doesn't reconcile the issue of PE. In fact, PE priorities is exactly one of the things CON was setup to handle. Regardless, you have to explain how removing CON solves the PE issue mentioned when states without CON had the same issues.
  - RHSeeger 1y ago
    You seem to be under the mistaken impression that - There is a specific list of regulations that cause the problem - Each regulation in that list is present everywhere the problem exists Neither one of those are true. Instead, there are many regulations and, combined, they add up to causing the problems. The specific regulations can and do vary by location; but the result is the same.
    - 20after4 1y ago
      I think the problem is obsessive optimization of profit at the expense of literally everything else. Greed is bad, especially in a field that is at least in theory centered on taking care of people. You can't take care of someone by exploiting them for the maximum possible profit.
    - jasonlotito 1y ago
      > You seem... No. You are 100% wrong. The context of this discussion is PE. So comments discussing this involve PE. So while you are correct in general, you are wrong specifically. In light of that, I stand by what I said: you have to explain how removing CON solves the PE issue mentioned when states without CON had the same issues. Maybe this isn't possible, but then we accept that this is not an answer to PE, which again, topic of conversation.
viscountchocula 1y ago
Certificate of Need: basically, prove to regulators that there is enough "need" before opening up new facilities. https://en.wikipedia.org/wiki/Certificate_of_need https://en.wikipedia.org/wiki/Certificate_of_need
- bilbo0s 1y ago
  As someone already pointed out, PE owned hospitals are in states with, and in states without, CON requirements. Certainly on the face of that fact it would appear the existence, or nonexistence, of CON requirements has no effect on PE hospitals charging more and having far inferior outcomes. Do you have a hypothesis as to why CON requirements are driving inferior outcomes and increased cost metrics at PE owned hospitals? (A hypothesis that accounts for the fact that PE owned hospitals underperform even in the absence of CON requirements.) Serious question. I'm trying to get my head around this.
  - SkyBelow 1y ago
    Sample hypothesis with only minimal amount of knowledge on it. PEs seek to make profit, and are looking for places where they can either raise prices or lower costs (which will quickly correlate with worse outcomes) while not losing customers (yes, you could call them patients, but PE will view them as customers), or at least losing so few that the overall numbers result in more profit. One way of doing this is looking for barriers to competition/moats. CON is just one type of moat, and so is one factor PEs evaluate, but the presence or absence of other moats can still override the presence or absence of this one moat. One could try to work this out from data with some sort of regression, but with so many possible moats and a relatively limited number of data points, it would be easy to overfit the data. In comparison, non-PE hospitals might have some profit motive (or keeping to budgets, not going bankrupt, ect.), but will be less driven by this mentality and thus their relationships to moats will be more complex, and so something like a CON requirement won't be as fully exploited to raise prices or lower costs. This also fails to account for other ways that PE can seek to make money, which involves more complex parts of law and financing that I'm not well versed on (I've ready some things about real estate, but don't know enough to fairly analyze the claims).
betaby 1y ago
In the USA/Canada number of doctors minted is caped by the cartel of doctors. That costs non-trivial money and lives lost. Source: https://thedailyeconomy.org/article/how-congress-created-the-doctor-shortage/ https://thedailyeconomy.org/article/how-congress-created-the... and many others
- insane_dreamer 1y ago
  That’s not a regulatory issue
  - topkai22 1y ago
    Since the government (federal or state/local) authorizes those organizations to certify physicians and restricts medical care to only those who have been certified, it is.
  - nick__m 1y ago
    What kind of issue it is then ? If a regulation permits the doctors associations to set the allowed number of doctors residency, naively it is a regulatory issue.
    - insane_dreamer 1y ago
      It's a funding issue. There aren't enough residency slots available given the number of medical school grads. Residency is a requirement to get a medical license--which is issued by the states, not the federal gov. The reason there aren't enough residency slots is because they are heavily subsidized by the federal gov and they put a cap on the funding. No one else wants to foot the bill, so the slots remain limited, thus the licenses remains limited.
  - tptacek 1y ago
    It obviously is. A federal government policy decision caps the number of doctors we have, and another federal government policy decision restricts a huge number of basic medical services to those doctors.
johnisgood 1y ago
FDA drug approval processes and insurance regulations.
- palmotea 1y ago
  > FDA drug approval processes What, specifically? Just abolish them all, and return to the pre-1938 status quo (e.g. marketing radium water to cure what ails ya)? Or specific reforms to make the drug approval processes more effective? https://en.wikipedia.org/wiki/Radithor https://en.wikipedia.org/wiki/Radithor
  - cogman10 1y ago
    Best way to make the entire process more efficient would be centralizing R&D and approval and nationalizing the manufacturing of drugs. MAYBE you could license out the rights to produce drugs on 10 or 20 year license agreements. Turn it into a pure R&D effort and not one driven by profit.
    - ajmurmann 1y ago
      Who is gonna decide how the R&D money gets spent? What's their skin in the game and their feedback mechanism? Why will they do a better job picking what to research than current pharmaceutical companies?
      - cogman10 1y ago
        > Who is gonna decide how the R&D money gets spent? Same way the NHS previously funded medical research. Grants and grant review. You can expand that department and effort. > What's their skin in the game and their feedback mechanism? Believe it or not, some people just want to research and look into cures for diseases. Shocking I know. Feedback can be reviews of their work and blackballing bad actors that consistently kick out bad research. > Why will they do a better job picking what to research than current pharmaceutical companies? Because they already are. Pharmaceuticals aren't doing the majority of research, they are taking NHS funded research and running it through FDA approval. Ozempic, for example, didn't come from pharmaceutical research, it came from grant research into lizard spit.
mothballed 1y ago
[flagged]
- hiddencost 1y ago
  Hoodrats?
  - mothballed 1y ago
    Source: worked ~1 year in an inner city ER alongside a doctor seeing every case. Yes it was the hoodrats abusing the system.
    - habinero 1y ago
      Working all of one year before you got fired doesn't make you an expert, sorry. It's probably best you moved on from healthcare, you don't seem suited for it with your attitude.
      - mothballed 1y ago
        Unfortunately my attitude is the only one that will actually help you fix things because I'm bringing you a sober view of what the situation is. And people much "better suited for it" who worked in inner city ER generally had even less rosy thoughts than I did, if you want to defer to "experts" it's hilarious you would think this is unusual takeaway and that my opinion wasn't formed in large part by the experts thinking the very same thing (which of course they are never going to tell to the patients, you're probably not going to hear it unless you actually work in an ER and are close and comfortable enough with doctors for them to risk themselves to tell you what they really think as it's totally unacceptable to say it publicly).
        habinero 1y ago
        Sure, buddy. "Everyone thinks this way, they just don't say it" has been the rallying cry of people with bad minority opinions forever.
kriops 1y ago
[flagged]
potato3732842 1y ago
That's like saying "it's ok if I shit in the river, it's a big river". When a million other people do it you've got a water quality problem. Each and every one of these regulations can in abstract, be justified by some useful idiot looking at only the first and second order inputs and outputs and not looking at the totality of the effects. Nobody with a brain would defend shitting in the river, but here you are asking for individual turds so that they may be justified on the basis that the individual dropping them was relieved and their individual impact on water quality was minor.
- scott_w 1y ago
  No it's not. Shitting in a river is always a net negative. Regulations can be positive, negative, or ineffective. Trying to "just count" the regulations to determine quality completely discards this critical dimension and betrays an almost childlike view of the world.
  - potato3732842 1y ago
    >Shitting in a river is always a net negative It beats anything open air by miles. Sure, an outhouse would be better but river > street. >Trying to "just count" the regulations to determine quality completely discards this critical dimension and betrays an almost childlike view of the world. You're grasping at straws here. I am under no obligation to give such an infantile opinion (the one I initially replied to) a response at length. This is not the venue for such minutia.
    - scott_w 1y ago
      > I am under no obligation to give such an infantile opinion Responding with “I know you are but what am I?” is just proving my point.
deleted 1y ago
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pfdietz 1y ago
Another issue is the requirement that doctors adhere to "standard of care" regardless of cost. If they don't, they are subject to malpractice lawsuits. Elsewhere, quality of a good or service is traded against cost. But in medicine, there's a cost ratchet as ever more expensive and marginally more performant treatments are introduced.
- bilbo0s 1y ago
  This is another example of a requirement that both PE owned and non PE owned hospitals, presumably, followed.e (I would hope neither of them were ignoring standards of care in the treatment of patients.) Yet the metrics are substandard at only the PE owned hospitals. So you would need to outline how this requirement unduly burdened the PE owned hospital relative to the non PE owned hospital for it to be the cause of the discrepancy. There may be such a reason, but you haven't outlined it in your post.
mimikatz 1y ago
Let nurses do more, let them write some prescriptions, let them open up a shop that puts casts on people with broken bones and minor things which they mostly do anyways.
landl0rd 1y ago
- The AMA froze the number of med schools for decades even as residency availability increased. - The majority of states still maintain "certificate of need" laws for new hospitals, ambulance providers, etc. - The AMA holds a state-enforced monopoly over physicians. - Many states still limit NPs/PAs, requiring physician supervision for things for which those people were trained. - Lack of interstate reciprocity in licensing means mobility is constrained and supply can't follow demand. - Costly medical equipment usually requires first-party repairs; mfgs claim a third-party modification (repair) constitutes remanufacturing under FDA regs. - Stark law makes e.g. physician/hospital value-based care arrangements very hard. It's quite strict and everyone has to tiptoe around it a bit. There's also the huge problem of malpractice insurance costs due to insane tort settlements. Awards need to be capped yesterday because it's too easy to talk a jury into bankrupting people over things that legitimately just sometimes happen. I'm guessing others could give you an even better list. Some of those are a bigger deal than others but it's a huge issue. Insurance net margins just aren't high enough to blame it and drug costs aren't enough of our total healthcare spend to be at fault. It comes down to humans being too expensive. There remain many areas of care where we can't cut man-hours down without sacrificing safety and quality. As such, we should reduce the insane byzantine co-ordination and compliance overhead.
- dimal 1y ago
  Don’t forget that the AMA has a monopoly on billing codes. Medicare defines the billing value of every procedure as Relative Value Units (RVUs). Then Medicare defers to AMA’s guidance on what these values should be. Insurers default to RVUs x multiplier. So the AMA has the ability to set prices. Oh, and patient value isn’t considered for these units. They are explicitly defined as input driven, so a procedure that is less costly to perform but has higher value to the patient will be billed at a lower value. Hospitals are incentivized to choose procedures that they can bill at a higher rate, and so because of these perverse incentives, they necessarily will ignore cheaper more effective treatments and choose the more expensive ones. I’m a lefty, but the older I get the less I believe in the old New Deal style leftism I’ve been sold my whole life. As systems get more complex, they simply become a way to obfuscate oligarchic control.
maxerickson 1y ago
Certificates of need. To reduce costs, we supposedly perfectly plan capacity and prevent over investment. Should also probably drop requiring an ER for Medicare certification and just directly subsidize ERs.
derbOac 1y ago
Others have kind of mentioned a lot of things I might anyway, and it's hard to summarize what I think is necessary. But to summarize, I think there needs to be a deregulation of licensing or practice laws to allow other types of providers to do more, of the sort they are perfectly capable of doing (and that studies show they can do) — pharmacists, psychologists, and optometrists are just some examples — and I think there needs to be more flexibility and diversity in terms of provider types and degree paths. My guess is there are many types of providers we can't even envision right now because there's such a rigid schema about what healthcare professionals should look like. I also think, for example, there are probably a lot of cases where someone could go from a PA -> MD degree without returning to do a second degree; I might be wrong about that but these are the types of things that should be encouraged at least as experiments. I also generally think there's a lot of choice that could be encouraged in terms of drug access. I generally think people should be able to buy medications and drugs without a prescription, or at least under the monitoring of a pharmacist or something, or at least in most cases. I can think of medications that there have literally been papers written saying that they are safe to give without a prescription decades ago and they still require a prescription; there's also medications that people take for years safely, and it seems kinda absurd to require them to get a prescription for them. My thoughts about the FDA itself are complex and could probably an essay in itself. I'm very in favor of public healthcare, and public healthcare institutions but I also feel a lot should be deregulated or reregulated toward greater openness, choice, and competition. There's probably a lot of areas where there should be more regulation too I suppose — I think antitrust principles should be applied to insurance and hospital consolidation more often.

baq 1y ago

'Your appendix is my pension plan dividend'

giancarlostoro 1y ago

I summarize it with one word after talking to a hospital billing manager. Subsidized costs. If you cant pay someone else will be receive marked up prices. On top of that and bear with me, but the way health insurance works feels like you gotta be in the right “mob family” where each provider is different in leverage in conjunction with which employer you work for. They can just take hospitals out of their “network” if they dont lower costs, so small businesses dont get this level of leverage, but employers with large numbers of employees do. You could have someone with a drastically lower bill just because of where they work, not even related to how much they make mind you. It all goes back to your healthcare costs being subsidized by those who are left with the crappy end of the stick. I think transparency in hospital billing is drastically necessary. If not for every single surgery out there at least for all the really standard things that arent so complicated. I am not a doctor. I think healthcare can be fixed without throwing more government money at it, but we need people to understand it better and work out how to bring costs down. If you are not aware yet, if you think you need to go to the ER think about what you NEED, is your arm broken? This sounds crazy but find a lab that will xray your arm. It will cost way less, and sometimes the insurance will pay the full cost of labs for you since you saved them a fortune. It sounds dumb, but it could save you so much financially. If you are in more urgent needs dont waste any time go get the care you need.

joe_the_user 1y ago
I disagree with your analysis. I think you are wrong. Health Care is a natural monopoly like an electrical system. Basically, a large portion of health care the creation of infrastructure that everyone benefits from. An MRI machine or whatever is benefit to everyone since everyone might need it even if only some people actually use it, etc. For that reason, the cost of procedures, infrastructure, etc, etc. are infinitely debatable and there is no true way to way to assign costs. And sure, the actual assignments are irrational but framing this "things are subsidized" has things exactly backwards. Here's scenario - suppose electrical companies weren't responsible for maintaining their own grids and homeowners had to individually maintain insurance in the event of a pylon going down. Suppose if you didn't have insurance and could be tagged as the last user of a substation, you could in-hoc for the entire cost of repairing a pylon or whatever. This would only approach the irrationality of private medicine but I think it illustrates the situation. (and the finance system might manage to put that in place too if we're not careful).

dev_l1x_be 1y ago

Yes, or government intervention that looks good on paper and disastrous in practice. Somehow people have this notion that healthcare should be treated differently than other service industries. I would argue that the least amount of government control yields to the best result. There is only the size limitations (antitrust) that had potentially good outcomes. We could simply ban m&a above a certain size and make the externalities have an impact on revenue and that would be probably enough.

DarkNova6 1y ago
Somehow US citizens have this notion that healthcare is a universal problem and that US-problems are not self inflicted. Everywhere else in the civilized world, you pay less and have better service. The US has the highest degree of industry meddling, most middlemen cashing out and the least governmental regulation. You are objectively being lied to.

thisislife2 1y ago

"Regulatory capture" is a nice euphemism for the problems that a corrupt political environment creates. It is corruption that really hampers the creation of a fair and competitive capitalistic market. Regulation can indeed be balanced to create a fair and competitive capitalistic environment. A great example of this was the telecom industry in India during Dr. Manmohan Singh's government. Both the economic and telecom policies created a very booming and competitive telecom industry in India, with many foreign and local businesses trying their best, to be the best. It also ensured that the technology was accessible and affordable to all, providing a further fillip to the indian economy that increased connectivity delivers in a society. Contrast that 2+ decades later with the current telecom industry scenario in India where only 3 major private players (and 1 government owned company) survives today due to flawed and corrupt policies of the Narendra Modi government. (As the government owned telecom enterprise now doesn't really "compete" with the private players, the 3 private players have already formed a cartel to dictate pricing, and keep gouging the public, with increased pricing, with the connivance of a government that believes in oligarchy vis the South Korea Chaebol model). And let's not ignore that regulation is necessary in a democracy because capitalists are only (rightly) focused on creating capital. But obviously they are not the only contributing members of a society (nor, do I dare say, the most important ones) and the rights and needs of others in a society are just as important in a democracy. That is why everyone today also realises that things like monopoly, hoarding or black marketing, for example, aren't good for the overall well-being of a society, even if that's how capitalists can derive "maximum" value (i.e. make the most profit). History says that imperialism is the capitalist model that delivered peak "efficiency" in terms of deriving the maximum "value" for the (low) capital invested in it. But obviously, imperialism, even in its limited form today, is not compatible with democracy or concepts of sovereignty.

burnt-resistor 1y ago
The problem in the US is there are too many rich people devoid of morals and less rich people who support them and are brainwashed into ideological opposition of most or all regulation and government without nuance. Furthermore, Americans in aggregate condone being ruled by extreme inhumanity, corruption, stupidity, and greed by lack of effective objection. It's like an old-school third-world country and Americans either don't realize how bad they have it or lack the courage to do anything about it.

someguynamedq 1y ago

Why are we talking about deregulation when the topic is the ill effects of unregulated rentier profit seeking behavior of PE firms? We need to make debt loading and dividend recapitalization of hospitals illegal. Let them hollow out Neiman Marcus and Dunkin doughnuts, I don't really care. But financial engineering should have no place in our healthcare system.

tptacek 1y ago
Because the PE firms are exploiting a broken regulatory system, obviously.

ben7799 1y ago

This actually sounds a lot like the US problems with energy (electrical, gas) infrastructure and also things like telephone and internet providers. They've almost always got a state approved monopoly or duopoly and then magically the state always allows them to raise their rates.

joe_the_user 1y ago

My impression is a lot of US health care problems are caused in part by a sort of unholy combination of restricted competition and access, together with profit driven market participants. That is not wrong, literally stated. But know a lot of hn people imagine that this means making things completely unregulated might be one reasonable alternative. The obvious problem in this case is scams and unsafely/deadly treatments. Here, one can point countries with functioning, lightly regulated systems. The problem is that these countries depend on cultural and institutional factors keeping people honest, keeping fake medicine at bay, and etc. But the US has a cultural of religious irrationality coupled with huge, profitable and predatory organizations (the ones soaking health care dollars as well as alternative medicine cults and scammers). Before the last hundred years of regulation, 1910 or so, unregulated US medicine was a deadly, heroin soaked shit show and if you back to that, all the "alternative" scammers along with Stackler types are ready to jump in to try to equal that situation.