8 ms·

Very interesting case study in how simple changes lead to emergent complex systems. Who would have thought that taking health insurance away from the person and

Very interesting case study in how simple changes lead to emergent complex systems. Who would have thought that taking health insurance away from the person and assigning it to the employer would lead here? With every band-aid we put on the system, it just flows around and makes itself more complex. All of these systems, the paymaster, the insurance companies, the employers, the drug companies, the trial lawyers, etc -- they live in an ecosystem we have created over time. This ecosystem was continually adjusted to solve one problem, thereby creating more complexity for all other areas. For that reason, I do not believe a list of remedies is the way to go here. Especially trying to increase hospital taxes -- that has as much chance of working as spitting in the ocean increasing global sea levels. Whatever we do, we have to fight the complexity actively -- even if it doesn't directly lower costs. We can understand these things as basic software architecture principles. A couple of small suggestions: - Eliminate needless architectural tiers. Make it illegal for anybody but the patient to pay healthcare providers. If you have insurance, fine. The insurance company pays you, then you pay the provider. - Decouple the hospital (building and administrative staff) from the services being provided - Standardize components. Mandate that all services provided must be in a free and open market. That means open pricing (bidding), public consumer reporting, outsourcing if possible, and so forth. - Require interoperability. One provider cannot require that another provider be used. It's the provider's responsibility to interface with other providers - Establish naming conventions You get the idea. The point here is that we've been playing whack-a-mole. Some guy goes out and writes a wonderful article about the complexities and problems with the market. So new adjustments are made to fix them. They only create more problems, which some other guy goes out and writes about. Each iteration may take many years. Over time the amount of cruft and inefficiencies is staggering. If we continue with this strategy of fixing the problem it's just going to get worse. This method of problem solving hurts. Let's not do that anymore.

jivatmanx 14y ago
I'd add, the cost of medical education before one can practice in the U.S. has multiplied over the years and seems excessive compared to Europe, where medicine is traditionally a 6-year undergraduate program. As a result, doctors needs to get paid far more, especially specialists.
- robbiep 14y ago
  You're right about the cost however the time issue is changing in many places: Much of Europe: 6y med school then 4-6y specialist training (10-12 years) Cost: minimal depending on country Australia and the UK: 6 med school, or an undergrad and 4 years postgrad (min. 4y) + 2 years general training + 5-6 years specialist training (12-13 years) Cost (aus): 7k per year of undergrad study Pay (aus): 56k starting salary (up to 80 w/ overtime) The US/Canada: 4 years undergrad, 4 med school, 5-6 years training - 14 years Cost (us): 30-50k per year study Pay (us) : ~45k intern So the time taken to training completion is not drastically different (a year or two) but the total debt rung up does weigh on not just he doctors but everyone employed with a degree in the us: Having said that, it is often said that doctors in the US earn more than their colleagues overseas: this is not true; although the top 0.05% may have higher earning capacity on average the US doctor earns about the same as elsewhere (certainly between the US and Australia anyway) When you take int account lifetime debt and interest payments i feel that US doctors are getting a raw deal really
JulianMorrison 14y ago
Just switch to a national health service. The whole idea of paying as an individual, or having individual insurance, is just wrong. Society should insure society.
- jebblue 14y ago
  So the government can tell you how to run your own personal life health care like they can tell you how fast you can drive, how powerful (weak) your cell phone can be, etc.? That's not a world I want to live in. Isn't that the kind of world liberal loons thought Bush was going to lead us to? LOL too funny and too ironic. It seems liberals think as long as a liberal is in the Whitehouse then it's ok for government to take over our lives. Either way having our lives controlled by a conservative government or a liberal government; they are _still_ the Government which is supposed to be _us_!
  - cpleppert 14y ago
    >>So the government can tell you how to run your own personal life health care like they can tell you how fast you can drive, how powerful (weak) your cell phone can be, etc.? I'm not sure if some of that was supposed to be irony. In terms of healthcare, the government pays almost half of the cost of providing care in this country. Not only does it give massive tax breaks to employer provided health insurance plans it also directly writes the regulations that govern almost every aspect of healthcare. In a sense, the government is already running your healthcare if not outright paying for it or compensating the hospital then running the system that provides or incentivizes the structure of the health insurance plan you have.
    - jebblue 14y ago
      Breaks? One of the medications I was paying for on my personal plan recently is costing my new employer 3 times !!! what I was paying. Breaks? Puh-lease, are you brain-washed by deep thinkers like John Stewart?
  - baak 14y ago
    Somalia doesn't really have a functioning government. You could try there, if you don't like having your 'life controlled'.
joe_the_user 14y ago
Who would have thought that taking health insurance away from the person and assigning it to the employer would lead here? I would interject "who would think that a complex set of interlocking incentives would lead to improvements?" Who? The whole arrangement seems like Ayn Rand's bad acid trip despite there being many articulate and intelligent people who have bought Coolaid, with and without personal gain involved. Pile incentive on incentive till things are ready to break, rationally rearrange things up a bit till the process of exploiting perverse incentives takes hold again and things are once again ready to break. And this situation "interesting" only from the outside. The intellectual irony is lost those dying or having their lives ruined. A substantial portion of the country can see that marketization is simply something doesn't scale for medical care. State health care has pretty much been shown itself to be the only sensible way to organize health care in a modern industrialized society. That won't take us there because the population of opportunists who make tremendous profits from exploiting the present perverse incentives is huge and they have essentially completed regulator capture and virtual state capture. What will happen? It's mostly the relationship between a parasite and host. The parasite has an incentive to keep the host alive but an incentive to keep the host healthy. Sounds like the future.

jivatmanx 14y ago

I'd add, the cost of medical education before one can practice in the U.S. has multiplied over the years and seems excessive compared to Europe, where medicine is traditionally a 6-year undergraduate program. As a result, doctors needs to get paid far more, especially specialists.

robbiep 14y ago
You're right about the cost however the time issue is changing in many places: Much of Europe: 6y med school then 4-6y specialist training (10-12 years) Cost: minimal depending on country Australia and the UK: 6 med school, or an undergrad and 4 years postgrad (min. 4y) + 2 years general training + 5-6 years specialist training (12-13 years) Cost (aus): 7k per year of undergrad study Pay (aus): 56k starting salary (up to 80 w/ overtime) The US/Canada: 4 years undergrad, 4 med school, 5-6 years training - 14 years Cost (us): 30-50k per year study Pay (us) : ~45k intern So the time taken to training completion is not drastically different (a year or two) but the total debt rung up does weigh on not just he doctors but everyone employed with a degree in the us: Having said that, it is often said that doctors in the US earn more than their colleagues overseas: this is not true; although the top 0.05% may have higher earning capacity on average the US doctor earns about the same as elsewhere (certainly between the US and Australia anyway) When you take int account lifetime debt and interest payments i feel that US doctors are getting a raw deal really

JulianMorrison 14y ago

Just switch to a national health service. The whole idea of paying as an individual, or having individual insurance, is just wrong. Society should insure society.

jebblue 14y ago
So the government can tell you how to run your own personal life health care like they can tell you how fast you can drive, how powerful (weak) your cell phone can be, etc.? That's not a world I want to live in. Isn't that the kind of world liberal loons thought Bush was going to lead us to? LOL too funny and too ironic. It seems liberals think as long as a liberal is in the Whitehouse then it's ok for government to take over our lives. Either way having our lives controlled by a conservative government or a liberal government; they are _still_ the Government which is supposed to be _us_!
- cpleppert 14y ago
  >>So the government can tell you how to run your own personal life health care like they can tell you how fast you can drive, how powerful (weak) your cell phone can be, etc.? I'm not sure if some of that was supposed to be irony. In terms of healthcare, the government pays almost half of the cost of providing care in this country. Not only does it give massive tax breaks to employer provided health insurance plans it also directly writes the regulations that govern almost every aspect of healthcare. In a sense, the government is already running your healthcare if not outright paying for it or compensating the hospital then running the system that provides or incentivizes the structure of the health insurance plan you have.
  - jebblue 14y ago
    Breaks? One of the medications I was paying for on my personal plan recently is costing my new employer 3 times !!! what I was paying. Breaks? Puh-lease, are you brain-washed by deep thinkers like John Stewart?
- baak 14y ago
  Somalia doesn't really have a functioning government. You could try there, if you don't like having your 'life controlled'.

joe_the_user 14y ago

Who would have thought that taking health insurance away from the person and assigning it to the employer would lead here? I would interject "who would think that a complex set of interlocking incentives would lead to improvements?" Who? The whole arrangement seems like Ayn Rand's bad acid trip despite there being many articulate and intelligent people who have bought Coolaid, with and without personal gain involved. Pile incentive on incentive till things are ready to break, rationally rearrange things up a bit till the process of exploiting perverse incentives takes hold again and things are once again ready to break. And this situation "interesting" only from the outside. The intellectual irony is lost those dying or having their lives ruined. A substantial portion of the country can see that marketization is simply something doesn't scale for medical care. State health care has pretty much been shown itself to be the only sensible way to organize health care in a modern industrialized society. That won't take us there because the population of opportunists who make tremendous profits from exploiting the present perverse incentives is huge and they have essentially completed regulator capture and virtual state capture. What will happen? It's mostly the relationship between a parasite and host. The parasite has an incentive to keep the host alive but an incentive to keep the host healthy. Sounds like the future.