My boyfriend woke up one day to find out they couldn't pee. After a few ER visits and an MRI, they determined he had Stage 2 bladder cancer. However, because they had the audacity to seek immediate medical treatment for a life threatening health issue, they have now been saddled with thousands of dollars in medical debt. I had to personally dip into my earnings from my Big Tech internship to help pay some of it off. Luckily through their job they have some of the best medical insurance in the state and have been getting treatment at UT Southwestern. They pay little, but there was an instance where one of their physicians had to appeal to insurance to get a scan done (thankfully the insurance acquiesced). It doesn't make sense and all this debate around single payer healthcare is just obfuscation and distraction from investigating actual solutions. The vast majority of doctors genuinely want to help people and are more I interested in practicing the skills they've honed for decades rather than deal with faceless automata at health insurance companies who deny claims upon a mere glance. As long as people like Rick Scott can not only get away with introducing inefficiencies in the system, but defraud people and get away with it with no consequences other than personal enrichment, we are doomed.
> The vast majority of doctors genuinely want to help people and are more I interested in practicing the skills they've honed for decades rather than deal with faceless automata at health insurance companies who deny claims upon a mere glance.
Not only that, but doctors also have to fight tooth and nail to get reimbursed by insurance companies (some worse than others... I have doctors who won't even take UHC anymore because the reimbursement rates are too low to break even on practice costs). So we end up with this bizarre arrangement where patients get their wallets drained and doctors have to hunt down their paychecks for services provided... all while the middleman gets richer.
I hope your boyfriend's doing okay. Dealing with a major medical issue like cancer is already hard enough on its own without the added financial nightmare in this country, but at least it sounds like they're in good hands between you and the doctors they're seeing.
Not an ad hominem attack or a microaggression, but hopefully constructive criticism. Your use of the "them" pronoun makes the post confusing. Does it refer to "they," presumably the doctors, the employer (job), the insurance, UT Southwestern, or to the gendered "boyfriend." Since you already decided to use a gendered noun, perhaps use it instead of the "they/them" or use a matching gendered pronoun "he/him" to distinguish the particular person from the other "them."
I'm glad that your boyfriend has a wonderful and caring person like you to lean on.
> They pay little, but there was an instance where one of their physicians had to appeal to insurance to get a scan done (thankfully the insurance acquiesced). It doesn't make sense and all this debate around single payer healthcare is just obfuscation and distraction from investigating actual solutions.
Single payer is literally a complete solution to the problem you’re mentioning before.
So why is it obfuscation and distraction? Especially when single payer systems in Europe have proven to have better outcomes at a fraction of the cost?
I find the thought process here fascinating. Single Payer, which is actually delivering results in nearly every other developed country is an “obfuscation” and we need to find “actual solutions”. Doing what every other country that doesn’t seem to have the problem in question is not an “actual solution”. No, we must invent one out of thin air or it doesn’t count.
This seems like a Not Invented Here syndrome taken to its extreme.
Why with single payer would there not still be instances of treatment being denied?
>rather than deal with faceless automata at health insurance companies
Would this not be replaced with faceless automata in government?
Just look at how the VA is run and complains about it. Looking at that I have exactly zero confidence in the government being able to run things better than the shit show at the insurance companies.
Businesses do need to compete with and overthrow the current middlemen in the medical world. It's just difficult and a very slow process.
Great article but the author is missing the fact that this is all designed on purpose. The insurance system is designed around a consistent strategy called “don’t pay out”.
The USA spends more GDP on healthcare than any country on earth and the insurance companies are immensely profitable.
Every company involved is making money off the status quo and wants to maintain the current system. when a patient comes along who isn’t desirable and profitable, they’re screwed.
This is all well documented in research about modern USA healthcare and health economics. None of this is an accident and the fact that this situation persists should be a national embarrassment.
It was somewhat surprising to see the author come up with "we need standardized interfaces between actors" rather than "we solve this with public healthcare for everyone".
But to be fair, you can easily get lost in bureaucracy in public healthcare too, and private health insurance exists in countries with public health too.
I should add that I’m glad the author wrote this as an account of their family experience and I have great sympathy for them, having seen similar experiences up close.
Health insurance profits are capped by government. They aren’t immensely profitable in the strictest sense of the word. That’s why they had to refund premiums during COVID.
> The USA spends more GDP on healthcare than any country on earth and the insurance companies are immensely profitable.
Yes, from the recent report of 2020 [1]:
The health insurance industry continued its tremendous growth trend as it experienced a significant increase in net earnings to $31 billion and an increase in the profit margin to 3.8% in 2020 compared to net earnings of $22 billion and a profit margin of 3% in 2019.
These humongous profit margins of 3.8% can no longer... Wait, what? Three point frickin eight percent? That's what passes for "immensely profitable", really? Maybe there's some other place we should look for greedy capitalists that stole our money than in 3.8% profit margins?
This is surprisingly not really the case a lot of the time, including this case, Anthem would have actually saved money had the mother been transferred out of the hospital.
Instead insurance are allowed to set premiums based on how much they payed last year plus a percentage. So the only way to charge more is to pay out more which sounds insane.
That's not necessarily true. If all the for profit insurance companies reduced their profit margins prices wouldn't go down that significantly. I think it's mainly the extreme inefficiency and much higher labor costs.
There are entities in the US that have the power to change this, and in the end, it’s congress and senators. But those to not act on something that apparently every soul in the US would benefit from, because politics, lobbying, etc. The power is there, it’s just not being wielded, and it seems that the reason is because these people are more afraid of vested interests than they are of you, the people. I would like to understand why and what would be a solution.
“Standardizing an interface between health care providers and insurance companies would be a huge win. No matter how badly designed, it would be better than the current mess, and save several percent of US GDP.”
Solving the sorts of problems highlighted in the article (from 2017) is well-recognized, by elected officials in 2023, as a priority of their constituents.
However, neither of the initiatives linked above will systematically address the underlying issues, which are:
1. Conflicting and overlapping objectives between federal, state and local governments, as well as between the different branches of government.
2. Partially privatized administration of government programs, such as Medicare. This inevitably results in further conflicts of objectives, and incentivizes gaming the system.
3. The only real way for the government to learn from failure, and adapt to it, is by creating a mountain of new regulations, which just makes everything more expensive / take longer.
4. Extreme caution, in regulated industries, around sharing information with external parties, due to liability concerns. This drives further consolidation.
None of those issues address the elephant in the room.
If you dismantle the incumbent system and introduce efficiencies that bring US health care spending in line with other developed countries, millions of health insurance workers would be out of their [parasitic] jobs. Which is politically untenable.
The underlying issue is incentive incompatibility. The health insurance industry is a behemoth 10x the size of the automotive industry, for example. You can imagine what kind of lobbying power they have as a result. And they are not interested in anything that destroys their jobs.
I can relate to this experience, having been through it with multiple parents/in-laws. One thing I’ve learned: We are fortunate to be in a city large enough to support a large hospital (actually more than one) with many associated specialists and clinics. If you can stay inside one of these, where people are looking at the same records system and have personal contacts in the various clinics and services, things go so much more smoothly. In other words, try to stay within a single tribe.
Sadly, when you’re discharged to an SNF or rehab, that’s always outside the tribe, and you get the situation described here. Haven’t found a cheat code there yet.
This has been my experience as well. My wife has end-stage kidney disease, and we have found that the system works (for us!) when we stay within our hospital system. We don't travel much, we keep to within a certain radius of the hospital we trust, and we make sure any new specialists are inside or at least connected to the same (Epic) system. That has solved the "no interface" issue and the issues described in the "Traditional life in the ruins of systematicity" segment.
We are also blessed to have a kidney specialist that, as part of this system, has some tenure and traction in this hospital system, and is -- in my opinion -- an incredible doctor and hospitalist who proactively navigates these systems on our behalf. I 100-percent realize that this doctor does not exist everywhere, and we are incredibly fortunate to have him on "our team".
In any setting -- ER/ED, inpatient, outpatient, clinic, urgent care -- when you talk with doctors and nurses, answer their questions, no matter how repetitive. Be kind, and understand that the person you're talking with _now_ has exactly 20 seconds of experience with your case and influence over a very small part of the system.
The phrase that has gotten me farthest is "Hey, I'm a dum dum, but." For example, everyone along the way was ready to tell me why what she had _wasn't_ a seizure, and I wasn't going to argue with them, but what I said instead was "I'm a dum dum, but it really looked like a seizure to me. Her fists clenched, I tried to unclench them but I couldn't. I rolled her onto her side because Seizure Protocol. She said herself she lost control of her muscle movements."
The best thing you can do (like the post author) is be an active, participating advocate for your loved one, the patient: Every. Single. Time.
I have so many thoughts about this after navigating a kidney transplant for my wife.
I will say, however, that all government interventions up to this point have made the healthcare and health finance systems of the USA worse and not better as most of these interventions were drafted and paid for by health/finance megacorporations. One example, medicare isn’t means tested in any way and insurance companies will force people to use it despite the insurance policy covering kidney transplants simply because the government offers money for renal failure. Meanwhile, the hospitals don’t even bill for treatment until the patient is on Medicare, because the hospital can charge the government far more money without consequence.
I'd be great with a baseline medicare for all system publicly funded across the board with the option to pay more for privately funded better options. Not going to get that, or anything close to that, are we? I give up America, you get the health care you're willing to prioritize. Not my problem any more.
That said, going out of network if you can and going to the places with the cases if you can are the only real current options for beating the odds. I speak from direct experience doing whatever it took to get my wife's cancer treated at MD Anderson. We won, at least for now, but it wasn't cheap.
Medicare for all is not a panacea and would cause dramatic breaks in care in other places. The fragmented private model sucks, but the belief that single-payer would fix much of anything is faulty.
Reform should happen, but it shouldn’t be based on a bumper sticker, and it should be thoughtful about the vast differences between SF, NYC, West Texas and Southern South Dakota. “Fixing” things for people in major cities while crippling/destroying rural care (more than it already has been) is a bad solution.
The problem is that a public option must necessarily spend a lot more of its focus on preventative care that keeps people from developing serious chronic illness in the first place, for budgetary reasons. There are a lot of people staking their career prestige, high pay, and lifestyles on Americans having the freedom to get sick, seriously sick, on a regular and consistent basis. I'm happy to throw them under the bus, but I imagine some will be more than happy to defend them.
"No matter how badly designed, it would be better than the current mess, and save several percent of US GDP"
Brilliant essay, with so many fantastic lines.
I am picking this one out because amongst the many perversions of 'the system' is that the crazy healthcare inefficiency is counted as a metric on GDP. Those thousands of wasted hours of wasted hospital activity, ultimately paid for by the tax payer, is counted as economic activity in the national economy.
What percentage of GDP is based on humans navigating broken systems in a 'pre-modern' way? Probably way too much
Having been on the inside of insurer, facility, and provider insurance systems doing automation work, author is almost right but misses the bespoke entity-entity contracts.
In short, "Can F1 send you to F2 to be paid by X?" turns on the following:
- Regulations / laws
- Contract with the insured (policy)
- Contract between X and F2
The last is essentially "anything X and F2 strike a deal on."
So answering the question definitively requires 3-way parsing of those things. Which is generally a unique 3-tuple for any given patient-provider/facility-insurer combination.
The closest you get to standardization is "We work with X a lot, so generally know how they work."
And as article notes: regulations / laws change years, policies generally remain somewhat stable (post-ACA standardization), and insurer-provider/facility contracts change whenever they're up for renewal.
In short, the system's complexity is what paralyzes it.
Which means simplification is the path forward.
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>> It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.
Also, GOD NO.
Healthcare is complex because it's required to be a 1:1 model of reality. All of reality. Shark bite while riding a train that gets hit by a plane reality.
The reason healthcare is still largely manually done is that it was originally manually done.
It's gotten to where it is by progressive automating... but started at "I start the morning with a stack of paper forms on my desk, and work through them, forwarding them on as needed."
We're not looking at a breakdown of the system, but an incomplete automation. (And part of the current bottleneck is the Cambrian explosion of medical specialists in the last 30 years)
I'd be interested what one, single change might help. Something intangible like independently curated complete health record in some normative form on a smart card.
Or, a legalism of a "first do no harm" nature which demands once a qualified professional determines you have cover and it's just an argument about who pays between competing covers, you get no-worse-off service choices immediately until they decide which one has primacy.
What do you mean "return to an NHS model"? The US never had anything of the sort.
To answer your question: Ban employers from paying for health insurance as a benefit. If individuals see directly how much it costs, that will put much more pressure on prices. And employees don't have to worry about losing their insurance if they lose their job.
Some other gradual options:
- end the AMA licensure monopoly, making doctors more plentiful lowers prices and increases quality
- reform the FDA approval process to make developing drugs and equipment cheaper
- cover preexisting conditions under Medicaid instead of forcing private insurers to
The one change I would suggest is switching to the HMO Capitation model.
The nice thing about it is that it can be done a bit at a time, you don't have to change the entire US at the same time.
No more fee for service, Doctors would go on salary, and without fee for service an entire insurance complication (making sure to pay exactly the right amount for services, no more, no less) evaporates.
The downside: You can only see Doctors inside the HMO network. A second downside is handling emergency out-of-network care (this part would get better as more of them exist, as they would sign sharing agreements with each other).
Note: The capitation part is critical, HMO without capitation is worthless.
"machine screws and futures contracts come in standard sizes, without which manufacturing and finance would be as inefficient as health care."
oh lord. the finance industry does not even have a standardized way to transmit prices of securities. there is an enormous amount of inefficiency in the most basic behind the scenes systems..
My only real hope is the generation born after 2010, who all grow up playing video games where you get universal basic income and free healthcare laying around on the street in crates and boxes. And those things both actually work, they are not bug ridden half-finished projects that constantly crash and break. They will hopefully try to implement these things once they gain power.
Same boat. Its so frustrating.
Blue Shield of California are criminals, truly. I've seen lots of great reporting by ProPublica, a reporter named Maya, they're fighting the good fight, have petitions you can sign and forms you can send.
Knowing little about this - a genuine suspicion is - is this a feature, not a bug? As in - doesn’t this arise out of an incentive for health insurance companies NOT to cover procedures? I can only imagine that this bureaucratic tangle reduces insurance coverage by a very significant percentage. Aka - the kind of communication inefficiency must be profitable, no?
> As in - doesn’t this arise out of an incentive for health insurance companies NOT to cover procedures?
It's not that they're incentivized to not cover procedures, it's that everyone is incentivized to cover their ass unless regulations are really explicit. Since suing insurance companies is impractical for most people, it's really hard to turn that ass-covering in your favor unless a regulator gets involved.
Even something as basic as sharing notes becomes an ass-covering exercise lest someone use those notes against the doctor in malpractice suit or the data accidentally leaks leading to a HIPAA violation.
It is a feature. People need to look at this from the same angle as dark patterns. The goal with all of these interconnected but disjointed systems is so that the person holding the bag is constantly changed.
It's unfortunate that the author of this article in question manages to take away the wrong impression.
> It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.
> Health care is notionally a profit-driven free market. This looks like an easy opportunity to make trillions of dollars by making the world better for everyone. Why doesn’t someone do that?
The thing they miss is that healthcare companies are already making trillions of dollars. They make trillions because the system they designed is working as intended. You look at other countries and how their healthcare systems work and you will see a vast difference in functionality and efficiency. Because they know healthcare being a for-profit driven industry with weak government controls leads to the shitshow we have in America.
One of the things I've observed from lots of interaction with Doctors is that that US health care is FUCKING AMAZING, and that drives up cost.
Everyone wants top quality health care, everyone wants tests, everyone wants scans, everyone wants to cover their fucking ass. Take multiple X-Rays when there is no good reason to, to prevent lawsuits. the guy who lied about taking Heroin gets a full lab workup for no good reason.
USA has top tier health care. It's simply not economical to give it to everyone who demands it, and Insurance companies are not dumb and believe everything that gets submitted.
“Standardizing an interface between health care providers and insurance companies would be a huge win.”
There is a government mandated interface and it’s found at http://www.x12.org in the form of the 837, 835, 276/277, and 271/272 among some others. There are also paper equivalents in the CMS1500 and CMS1450.
These are truly one of the main culprits of the problem because of how old, woefully inadequate, and rigid they are but cannot be easily changed as the speech between these two entities are highly regulated via these specs.
The HL7 Da Vinci Project has defined modern FHIR based standards for many interactions between payers and providers. Some of these standards are now incorporated into CMS/ONC interoperability rules.
US health care is fundamentally broken. Things like "standardizing the interface" are really just arranging deck chairs on the Titanic. The US spends the most on health care for fairly terrible outcomes.
Health insurance companies are rent-seekers. They provide absolutely no value. They are simply designed to siphon money to shareholders at the expense of people dyijng due to denied or insufficient coverage. They are literally merchants of death.
Did you know that lobbyists managed to sneak in a provision to the ACA (aka "Obamacare") that prohibited physician-owned hospitals? That's still in effect. That's what we get with this ridiculous system.
Even non-profit hospitals engage in similar behaviour to for-profit institutions because their executive are overpaid [1] and are incentivized not to spend money on healthcare and instead engage in fundraising and increasing funds under administration, a little like how elite colleges do.
Also unlike every other developed country the US government is prohibited by law from negotiating drug prices with one exception: in the Obama era the VA was allowed to negotiate prices and thus pays a lot less than, say, Medicare. It's even more ironic that most novel drugs are the result of Federal research dollars. The only research most pharamaceutical companies engage in is patent extension.
Last year, the IRA was passed that will allow in a few years the government to negotiate prices on a handful (8?) medicines and even that faces stiff opposition in Congress.
In US we already pool money for health insurance, like Australia, Canada, UK and the likes.
It’s just that a big chunk of that pool of money goes to middle men, some of who lobby heavily to law makers and media company to tell a story that we have the best healthcare.
US only works because we have other sectors of economy that generate a huge amount of wealth that even with such huge inefficiencies in healthcare, things move on.
US spends more every year on healthcare but its citizens’ life expectancy is decreasing. Post pandemic the trend is reversing.
I fired my local hospital earlier this year. I had to get a biopsy and I did not receive my results in a timely manner because my specialist's office decided they needed to play phone tag with me instead of just sending me the results through the godawful amalgamation known as Epic.
The biopsy was indeterminate, and instead of immediately sending it out for a second opinion or molecular testing they decided to wait until I could see my specialist before giving me the options. I immediately told them to go for the second opinion and to check about insurance approval for molecular testing.
They had no idea how to bill me for molecular testing because the pathologist for some reason never suggested it in their report (which I later learned from another peer specialist at another hospital that molecular testing would have been written on the report for insurance approval purposes).
My insurance adamantly insisted that it would be covered, and then turned around and told my hospital that I would have to pay nearly six thousand dollars out of pocket.
The second opinion took three weeks, which concurred with the original pathology report and finally put the magic words "recommend molecular testing" on paper which got insurance to approve it. But rather than push it through, my specialist decided to play phone tag with me for a couple more days to make sure I was okay with the fifty dollar copay.
This entire process, from start to finish, took six and a half weeks to learn that the biopsy sample was benign and nothing to worry about. Now imagine if this were a serious thing and that I needed to have surgery as soon as possible. A six and a half week feedback loop to begin scheduling surgery (every surgeon for this issue in my area was booked at least five weeks out) may as well be a death sentence.
I've come to the conclusion that in this country, even if you are extremely proactive and aggressive about advocating for your own health, it's still not enough. You have to supplement this with something proactive like a full body examination in a foreign country (i.e. Japan's Ningen Dock system), otherwise you risk dying from the apathy and bureaucracy of the American medical system.
It is odd to write this and not in one's conclusions realize or call attention to how this "Whose responsibility is this?" problem all goes away with single payer. In countries with single payer healthcare, this problem never comes up.
I hate to be so cynical, but I'll suggest an alternate thesis to the article: the American for-profit healthcare system is functioning exactly as designed. If you consider its primary goal being extraction of capital instead of taking care of people's health, everything that was confusing starts to make sense.
> at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed. Meanwhile, many thousands of dollars were wasted on unnecessary hospitalization.
The money wasn't wasted -- the broken communication and intricate rule sets delay things for as long as possible, meanwhile the patient is charged, and someone is making a profit.
> On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.”
And here it is: when there was a credible threat that the money would stop flowing, the system acquiesced, insurmountable bureaucratic problems lifted.
> Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best.
Here lies an opportunity to rip the spine out of the entire scam. Steal the rule books, leverage a LLM with RAG or other information retrieval architecture, and get answers in minutes, not days. Offer this as a service to (relatively) seamlessly slice through the obscure-by-design bureaucracies -- only of course to be hindered by the entrenched players and the politicians they have lobbied, who will fight tooth and nail to maintain the status quo.
it’s more complex. The patient is at a higher level of care but they also aren’t paying a single penny for the additional stay. And the money isn’t coming from anthem to the hospital per se because they likely are paying under a diagnosis code and a lesser rate for additional days. The hospital is losing out on some opportunity costs possibly but if they needed the bed meaning they had patients to replace the current one being discharged suddenly the problem would be fixed after one manager phoned another.
After thinking about this a long time, and doing a lot of reading on the subject, here is my solution to American healthcare and perhaps in other countries with collapsing healthcare like the UK and Canada:
Most medical interventions, even ones that are serious like hip replacements, can be scheduled. It’s annoying while you are waiting, but it’s the rare case where emergency medical attention must be applied immediately.
All hospital systems should be deregulated - no more “certificates of need” and monopolist hospitals that can veto additional competition. If any entrepreneur wants to open a facility with licensed medical doctors, they should be able to service any and all ailments.
Finally, there will only be 2 official options for payment - retail and single payer. Single payer will kick in whenever bills go above $X, call it $50k. Retail will be out of pocket for anything lower, and people will shop for their own solutions. They can always buy additional insurance, and fund tax advantaged health savings account, but the single payer will not kick in until a catastrophic amount is reached.
The nightmare of medicine stems from the desire of doctors to be paid what they are worth, and the desire of government to cover everyone for “free” but never having enough money. We need to unshackle the market to let doctors get what they are worth, but drastically increase competition and the entrepreneurial animal instincts to destroy the bureaucratic mess that has bogged everything down.
Does this mean that someone with diabetes effectively has to pay 50k/yr for health insurance? Or do you mean diabetics can pay more than 50k/yr because no individual vial of insulin costs over 50k, so a diabetic is expected to pay for all of their insulin out of pocket for their entire life?
I can be down for this. To anyone who doesn't deal with the innards of US health insurance, this is better coverage than every health insurance plan in America despite the bar seeming so low.
I do think your bar for catastrophic is far too high and should probably be ~$10k cumulative spent in any span of time less than 12 months because $49k is ruinous to almost every American.
American healthcare is an easy target, plenty to criticize.
There are complicating factors here:
We culturally, societally, and philosophically don’t really know how to make decisions about end-of-life care, and death in general.
We also lack an agreed upon moral framework for how to care for people with diminished cognitive capacity (the extreme being permanent vegetative state).
A lot of money is spend on end-of-life care, trying to keep someone alive on their deathbed for an extra month or two, and people don't seem to want to talk about the diminishing returns of some of that care, and the opportunity costs - the other people that could have been helped more with those resources.
It's a thing, even if ignored. We're paying big premiums for that to insurance companies as part of our wages and taxes.
I wonder if other countries do significantly better?
Biggest surprise for me was that the best aspect of the healthcare system has been Medicare. Consistently helpful and all the communications were clearly designed with seniors in mind.
Very other aspect is characterized by innatention of obvious corporate motivations.
Soviet health care is like that. A friend is taking care of an elderly mother and to get anything done you have to network through associates, acquire medicines for medical procedures though 3rd party networks. Assemble your own surgical team etc. It’s a completely tribal and manual process. When done with western money you can get world class care though. I would assume similar things are possible in the USA if you are willing to pay out of pocket and have the right connections and millions of dollars. It’s just not visible to regular folks in the under 1%
I don't think anyone is saying that you cannot get the best healthcare on the planet if you have the required money. Lots of money.
The problem is that most people don't have that kind of money and the system as a whole is designed to take advantage of regular folks by not providing the care they need (regular care, not the best care).
I recently heard that hospitals still benefit from people who don't pay off their medical debt. They sell it for fraction of the amount and use the loss to offset earnings to dodge taxes. Prices of their services are inflated for this purpose (among others). It's better to have triple price, have insurer pay third of it and sell the debt of remaining two thirds as half-price. This way you get all the income and zero taxes. And if some chump patient decides to actually pay them they get ahead even more.
>It's better to have triple price, have insurer pay third of it and sell the debt of remaining two thirds as half-price. This way you get all the income and zero taxes.
I'm sorry but this sounds like someone invoking "they'll write it off" without knowing how write offs work. In that scenario your revenue will be 2/3rds of the list price. Taxes payable is dependent on your profit, not your revenue. Profit is revenue minus costs. Inflating the list price doesn't change anything in this equation, and thus won't affect your taxes payable.
When the subject of how bad the American healthcare system is, why is it that the European systems are always brought up as the ones to emulate and not those of some East Asian countries?
Stories I hear about Europe is that it’s affordable, but still slow and bureaucratic. You hear about some people even coming to the US (gasp!) to get expedited treatment.
Asia seems to be both affordable and also fast and efficient.
American healthcare is truly apocalyptic. It is the worst of all systems in the world. Even developing Asian countries have figured out better systems.
There is no one single root cause to fix here. The entire system needs to be uprooted - entire companies and shareholders will need to get wiped out. Unfortunately, ain't happening in ultra capitalist America.
America is not ultra-capitalist. American capitalism is hobbled by regulatory capture. Here and there it manages to briefly escape, e.g. Uber and Lyft, only to be recaptured again by redesigned regulation/enforcement to preserve, among others, the tax base (rents) and thus support the bureaucracies.
I would suggest just getting a concierge general practitioner instead of a "consultant". My father has one and I believe by paying a rate slightly above what the insurance companies are paying through the concierge system you can get amazing and wonderful care.
Like health care and anything, you get what you pay for.
I thought this was all more-or-less intentional because somehow at the end of the day it delivers more wealth to executives and shareholders. So any attempt to really overhaul it will be immediately met with rather intense campaigns to paint a saner healthcare system as socialist or expensive or somehow anti-American or just “guvmint bad.”
for people outside the sphere of US healthcare it can best be compared to the Warhammer 40,000 series Adeptus Administratum. Such is its immense size, that whole departments of the Administratum have been submerged by a sea of complex bureaucracy, becoming lost in loops of paper trails. Other departments have continued to dogmatically operate and carry out their founding function, even if the intent and requirement behind them no longer even exists.
Yeah, the “just do single-payer” people have no idea that identifying that “single payer” will take 40 years of bureaucratic infighting before we can crown the bureaucrats to helm the largest bureaucracy in human history.
I am not the one who normally says this, and I will admit I know little about US Health system ( I assume the complexity of it means no one really knows )
Given the insanity of it, and US being capitalist in nature, may be the best way to fix all of these isn't more regulation, but to deregulate the market so they could compete?
And on the topic, I am wondering if anyone knows a good site that compares the Medical System around the world?
I’m young enough to not have cared about healthcare pre Obama, but my understanding is the risk of less regulation is the “preexisting condition” trap where insurance companies basically price you out if you need a lot of medical attention.
That also involves insurance companies. I wonder how many of them have "exposure" on both sides of the medical business. So long as they can raise premiums/limit coverage they can seek rents. US medicine needs first and foremost transparency at every level. Transparency is in many ways obstructed by HIPAA. Sure, I wouldn't want even my largely unremarkable medical history plastered all over the Internet along with my more or less personally identifiable information or mined to target/discriminate against me, but there has to be a better way where we can use the information to lower costs and improve outcomes.
honestly this situation is quite common to cyber security and disclosure of vulnerabilities / problems that need fixing. rfc9116 (security.txt) is pretty useless; most of the time just some email inbox to /dev/null
knowing back channels, having the 'village' mindset is much better
andutu|2 years ago
spondylosaurus|2 years ago
Not only that, but doctors also have to fight tooth and nail to get reimbursed by insurance companies (some worse than others... I have doctors who won't even take UHC anymore because the reimbursement rates are too low to break even on practice costs). So we end up with this bizarre arrangement where patients get their wallets drained and doctors have to hunt down their paychecks for services provided... all while the middleman gets richer.
I hope your boyfriend's doing okay. Dealing with a major medical issue like cancer is already hard enough on its own without the added financial nightmare in this country, but at least it sounds like they're in good hands between you and the doctors they're seeing.
ufocia|2 years ago
I'm glad that your boyfriend has a wonderful and caring person like you to lean on.
unknown|2 years ago
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addicted|2 years ago
Single payer is literally a complete solution to the problem you’re mentioning before.
So why is it obfuscation and distraction? Especially when single payer systems in Europe have proven to have better outcomes at a fraction of the cost?
I find the thought process here fascinating. Single Payer, which is actually delivering results in nearly every other developed country is an “obfuscation” and we need to find “actual solutions”. Doing what every other country that doesn’t seem to have the problem in question is not an “actual solution”. No, we must invent one out of thin air or it doesn’t count.
This seems like a Not Invented Here syndrome taken to its extreme.
colechristensen|2 years ago
>rather than deal with faceless automata at health insurance companies
Would this not be replaced with faceless automata in government?
Just look at how the VA is run and complains about it. Looking at that I have exactly zero confidence in the government being able to run things better than the shit show at the insurance companies.
Businesses do need to compete with and overthrow the current middlemen in the medical world. It's just difficult and a very slow process.
2-718-281-828|2 years ago
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JoshGG|2 years ago
The USA spends more GDP on healthcare than any country on earth and the insurance companies are immensely profitable.
Every company involved is making money off the status quo and wants to maintain the current system. when a patient comes along who isn’t desirable and profitable, they’re screwed.
This is all well documented in research about modern USA healthcare and health economics. None of this is an accident and the fact that this situation persists should be a national embarrassment.
riffraff|2 years ago
But to be fair, you can easily get lost in bureaucracy in public healthcare too, and private health insurance exists in countries with public health too.
JoshGG|2 years ago
thallium205|2 years ago
smsm42|2 years ago
Yes, from the recent report of 2020 [1]:
The health insurance industry continued its tremendous growth trend as it experienced a significant increase in net earnings to $31 billion and an increase in the profit margin to 3.8% in 2020 compared to net earnings of $22 billion and a profit margin of 3% in 2019.
These humongous profit margins of 3.8% can no longer... Wait, what? Three point frickin eight percent? That's what passes for "immensely profitable", really? Maybe there's some other place we should look for greedy capitalists that stole our money than in 3.8% profit margins?
[1] https://content.naic.org/sites/default/files/inline-files/20...
cwmma|2 years ago
Instead insurance are allowed to set premiums based on how much they payed last year plus a percentage. So the only way to charge more is to pay out more which sounds insane.
qwytw|2 years ago
That's not necessarily true. If all the for profit insurance companies reduced their profit margins prices wouldn't go down that significantly. I think it's mainly the extreme inefficiency and much higher labor costs.
gloryjulio|2 years ago
Even Buffet commented that he should have just invested in healthcare earlier on and he would make even more money
figassis|2 years ago
samirunni|2 years ago
A new regulation was actually proposed by the federal government a year ago to do that: https://www.cms.gov/priorities/key-initiatives/burden-reduct...
There’s also a new program to reduce fragmentation for dementia care in particular: https://www.cms.gov/priorities/innovation/innovation-models/...
Solving the sorts of problems highlighted in the article (from 2017) is well-recognized, by elected officials in 2023, as a priority of their constituents.
However, neither of the initiatives linked above will systematically address the underlying issues, which are:
1. Conflicting and overlapping objectives between federal, state and local governments, as well as between the different branches of government.
2. Partially privatized administration of government programs, such as Medicare. This inevitably results in further conflicts of objectives, and incentivizes gaming the system.
3. The only real way for the government to learn from failure, and adapt to it, is by creating a mountain of new regulations, which just makes everything more expensive / take longer.
4. Extreme caution, in regulated industries, around sharing information with external parties, due to liability concerns. This drives further consolidation.
antisthenes|2 years ago
If you dismantle the incumbent system and introduce efficiencies that bring US health care spending in line with other developed countries, millions of health insurance workers would be out of their [parasitic] jobs. Which is politically untenable.
The underlying issue is incentive incompatibility. The health insurance industry is a behemoth 10x the size of the automotive industry, for example. You can imagine what kind of lobbying power they have as a result. And they are not interested in anything that destroys their jobs.
wrs|2 years ago
Sadly, when you’re discharged to an SNF or rehab, that’s always outside the tribe, and you get the situation described here. Haven’t found a cheat code there yet.
mrtomservo|2 years ago
We are also blessed to have a kidney specialist that, as part of this system, has some tenure and traction in this hospital system, and is -- in my opinion -- an incredible doctor and hospitalist who proactively navigates these systems on our behalf. I 100-percent realize that this doctor does not exist everywhere, and we are incredibly fortunate to have him on "our team".
In any setting -- ER/ED, inpatient, outpatient, clinic, urgent care -- when you talk with doctors and nurses, answer their questions, no matter how repetitive. Be kind, and understand that the person you're talking with _now_ has exactly 20 seconds of experience with your case and influence over a very small part of the system.
The phrase that has gotten me farthest is "Hey, I'm a dum dum, but." For example, everyone along the way was ready to tell me why what she had _wasn't_ a seizure, and I wasn't going to argue with them, but what I said instead was "I'm a dum dum, but it really looked like a seizure to me. Her fists clenched, I tried to unclench them but I couldn't. I rolled her onto her side because Seizure Protocol. She said herself she lost control of her muscle movements."
The best thing you can do (like the post author) is be an active, participating advocate for your loved one, the patient: Every. Single. Time.
BirAdam|2 years ago
I will say, however, that all government interventions up to this point have made the healthcare and health finance systems of the USA worse and not better as most of these interventions were drafted and paid for by health/finance megacorporations. One example, medicare isn’t means tested in any way and insurance companies will force people to use it despite the insurance policy covering kidney transplants simply because the government offers money for renal failure. Meanwhile, the hospitals don’t even bill for treatment until the patient is on Medicare, because the hospital can charge the government far more money without consequence.
BeefDinnerPurge|2 years ago
That said, going out of network if you can and going to the places with the cases if you can are the only real current options for beating the odds. I speak from direct experience doing whatever it took to get my wife's cancer treated at MD Anderson. We won, at least for now, but it wasn't cheap.
unknown|2 years ago
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jmye|2 years ago
Reform should happen, but it shouldn’t be based on a bumper sticker, and it should be thoughtful about the vast differences between SF, NYC, West Texas and Southern South Dakota. “Fixing” things for people in major cities while crippling/destroying rural care (more than it already has been) is a bad solution.
underlipton|2 years ago
EDIT: Geez, here's one now: https://news.ycombinator.com/item?id=38759502
hunglee2|2 years ago
Brilliant essay, with so many fantastic lines.
I am picking this one out because amongst the many perversions of 'the system' is that the crazy healthcare inefficiency is counted as a metric on GDP. Those thousands of wasted hours of wasted hospital activity, ultimately paid for by the tax payer, is counted as economic activity in the national economy.
What percentage of GDP is based on humans navigating broken systems in a 'pre-modern' way? Probably way too much
ethbr1|2 years ago
In short, "Can F1 send you to F2 to be paid by X?" turns on the following:
The last is essentially "anything X and F2 strike a deal on."So answering the question definitively requires 3-way parsing of those things. Which is generally a unique 3-tuple for any given patient-provider/facility-insurer combination.
The closest you get to standardization is "We work with X a lot, so generally know how they work."
And as article notes: regulations / laws change years, policies generally remain somewhat stable (post-ACA standardization), and insurer-provider/facility contracts change whenever they're up for renewal.
In short, the system's complexity is what paralyzes it.
Which means simplification is the path forward.
---
>> It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.
Also, GOD NO.
Healthcare is complex because it's required to be a 1:1 model of reality. All of reality. Shark bite while riding a train that gets hit by a plane reality.
The reason healthcare is still largely manually done is that it was originally manually done.
It's gotten to where it is by progressive automating... but started at "I start the morning with a stack of paper forms on my desk, and work through them, forwarding them on as needed."
We're not looking at a breakdown of the system, but an incomplete automation. (And part of the current bottleneck is the Cambrian explosion of medical specialists in the last 30 years)
ggm|2 years ago
Or, a legalism of a "first do no harm" nature which demands once a qualified professional determines you have cover and it's just an argument about who pays between competing covers, you get no-worse-off service choices immediately until they decide which one has primacy.
Or my favourite: return to an NHS model.
pitaj|2 years ago
To answer your question: Ban employers from paying for health insurance as a benefit. If individuals see directly how much it costs, that will put much more pressure on prices. And employees don't have to worry about losing their insurance if they lose their job.
Some other gradual options:
- end the AMA licensure monopoly, making doctors more plentiful lowers prices and increases quality
- reform the FDA approval process to make developing drugs and equipment cheaper
- cover preexisting conditions under Medicaid instead of forcing private insurers to
ars|2 years ago
The nice thing about it is that it can be done a bit at a time, you don't have to change the entire US at the same time.
No more fee for service, Doctors would go on salary, and without fee for service an entire insurance complication (making sure to pay exactly the right amount for services, no more, no less) evaporates.
The downside: You can only see Doctors inside the HMO network. A second downside is handling emergency out-of-network care (this part would get better as more of them exist, as they would sign sharing agreements with each other).
Note: The capitation part is critical, HMO without capitation is worthless.
iancmceachern|2 years ago
https://www.propublica.org/article/health-insurance-denials-...
dilyevsky|2 years ago
doubloon|2 years ago
oh lord. the finance industry does not even have a standardized way to transmit prices of securities. there is an enormous amount of inefficiency in the most basic behind the scenes systems..
My only real hope is the generation born after 2010, who all grow up playing video games where you get universal basic income and free healthcare laying around on the street in crates and boxes. And those things both actually work, they are not bug ridden half-finished projects that constantly crash and break. They will hopefully try to implement these things once they gain power.
iancmceachern|2 years ago
brenschluss|2 years ago
throwup238|2 years ago
It's not that they're incentivized to not cover procedures, it's that everyone is incentivized to cover their ass unless regulations are really explicit. Since suing insurance companies is impractical for most people, it's really hard to turn that ass-covering in your favor unless a regulator gets involved.
Even something as basic as sharing notes becomes an ass-covering exercise lest someone use those notes against the doctor in malpractice suit or the data accidentally leaks leading to a HIPAA violation.
fzeroracer|2 years ago
It's unfortunate that the author of this article in question manages to take away the wrong impression.
> It’s obvious how to fix health care. Just make everything run systematically, like FedEx or Amazon. There are no technical or business obstacles to this. Anyone who understands IT and/or business can see how to do it.
> Health care is notionally a profit-driven free market. This looks like an easy opportunity to make trillions of dollars by making the world better for everyone. Why doesn’t someone do that?
The thing they miss is that healthcare companies are already making trillions of dollars. They make trillions because the system they designed is working as intended. You look at other countries and how their healthcare systems work and you will see a vast difference in functionality and efficiency. Because they know healthcare being a for-profit driven industry with weak government controls leads to the shitshow we have in America.
tekla|2 years ago
Everyone wants top quality health care, everyone wants tests, everyone wants scans, everyone wants to cover their fucking ass. Take multiple X-Rays when there is no good reason to, to prevent lawsuits. the guy who lied about taking Heroin gets a full lab workup for no good reason.
USA has top tier health care. It's simply not economical to give it to everyone who demands it, and Insurance companies are not dumb and believe everything that gets submitted.
thallium205|2 years ago
There is a government mandated interface and it’s found at http://www.x12.org in the form of the 837, 835, 276/277, and 271/272 among some others. There are also paper equivalents in the CMS1500 and CMS1450.
These are truly one of the main culprits of the problem because of how old, woefully inadequate, and rigid they are but cannot be easily changed as the speech between these two entities are highly regulated via these specs.
nradov|2 years ago
https://www.hl7.org/about/davinci/
unknown|2 years ago
[deleted]
jmyeet|2 years ago
Health insurance companies are rent-seekers. They provide absolutely no value. They are simply designed to siphon money to shareholders at the expense of people dyijng due to denied or insufficient coverage. They are literally merchants of death.
Did you know that lobbyists managed to sneak in a provision to the ACA (aka "Obamacare") that prohibited physician-owned hospitals? That's still in effect. That's what we get with this ridiculous system.
Even non-profit hospitals engage in similar behaviour to for-profit institutions because their executive are overpaid [1] and are incentivized not to spend money on healthcare and instead engage in fundraising and increasing funds under administration, a little like how elite colleges do.
Also unlike every other developed country the US government is prohibited by law from negotiating drug prices with one exception: in the Obama era the VA was allowed to negotiate prices and thus pays a lot less than, say, Medicare. It's even more ironic that most novel drugs are the result of Federal research dollars. The only research most pharamaceutical companies engage in is patent extension.
Last year, the IRA was passed that will allow in a few years the government to negotiate prices on a handful (8?) medicines and even that faces stiff opposition in Congress.
This system needs to be scrapped.
[1]: https://revcycleintelligence.com/news/how-nonprofit-hospital...
nojvek|2 years ago
It’s just that a big chunk of that pool of money goes to middle men, some of who lobby heavily to law makers and media company to tell a story that we have the best healthcare.
US only works because we have other sectors of economy that generate a huge amount of wealth that even with such huge inefficiencies in healthcare, things move on.
US spends more every year on healthcare but its citizens’ life expectancy is decreasing. Post pandemic the trend is reversing.
https://www.healthsystemtracker.org/chart-collection/u-s-lif...
Some folks have figured out how to suck money and soul at a grand scale.
rkho|2 years ago
The biopsy was indeterminate, and instead of immediately sending it out for a second opinion or molecular testing they decided to wait until I could see my specialist before giving me the options. I immediately told them to go for the second opinion and to check about insurance approval for molecular testing.
They had no idea how to bill me for molecular testing because the pathologist for some reason never suggested it in their report (which I later learned from another peer specialist at another hospital that molecular testing would have been written on the report for insurance approval purposes).
My insurance adamantly insisted that it would be covered, and then turned around and told my hospital that I would have to pay nearly six thousand dollars out of pocket.
The second opinion took three weeks, which concurred with the original pathology report and finally put the magic words "recommend molecular testing" on paper which got insurance to approve it. But rather than push it through, my specialist decided to play phone tag with me for a couple more days to make sure I was okay with the fifty dollar copay.
This entire process, from start to finish, took six and a half weeks to learn that the biopsy sample was benign and nothing to worry about. Now imagine if this were a serious thing and that I needed to have surgery as soon as possible. A six and a half week feedback loop to begin scheduling surgery (every surgeon for this issue in my area was booked at least five weeks out) may as well be a death sentence.
I've come to the conclusion that in this country, even if you are extremely proactive and aggressive about advocating for your own health, it's still not enough. You have to supplement this with something proactive like a full body examination in a foreign country (i.e. Japan's Ningen Dock system), otherwise you risk dying from the apathy and bureaucracy of the American medical system.
Chinjut|2 years ago
btbuildem|2 years ago
> at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed. Meanwhile, many thousands of dollars were wasted on unnecessary hospitalization.
The money wasn't wasted -- the broken communication and intricate rule sets delay things for as long as possible, meanwhile the patient is charged, and someone is making a profit.
> On day six, I said “if she doesn’t go to a SNF today, I’m taking her home—the risk of her dying there seems less now than the risk of her dying here.” That got results: the other SNF agreed to take her “on spec.”
And here it is: when there was a credible threat that the money would stop flowing, the system acquiesced, insurmountable bureaucratic problems lifted.
> Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to reconcile federal, state, and local legislation, plus the rules of three federal regulatory agencies, nine state agencies, and fifteen local agencies. All those are vague and conflicting and constantly changing, but Anthem’s rule-writing department does their best.
Here lies an opportunity to rip the spine out of the entire scam. Steal the rule books, leverage a LLM with RAG or other information retrieval architecture, and get answers in minutes, not days. Offer this as a service to (relatively) seamlessly slice through the obscure-by-design bureaucracies -- only of course to be hindered by the entrenched players and the politicians they have lobbied, who will fight tooth and nail to maintain the status quo.
gdegxdrgr|2 years ago
monero-xmr|2 years ago
Most medical interventions, even ones that are serious like hip replacements, can be scheduled. It’s annoying while you are waiting, but it’s the rare case where emergency medical attention must be applied immediately.
All hospital systems should be deregulated - no more “certificates of need” and monopolist hospitals that can veto additional competition. If any entrepreneur wants to open a facility with licensed medical doctors, they should be able to service any and all ailments.
Finally, there will only be 2 official options for payment - retail and single payer. Single payer will kick in whenever bills go above $X, call it $50k. Retail will be out of pocket for anything lower, and people will shop for their own solutions. They can always buy additional insurance, and fund tax advantaged health savings account, but the single payer will not kick in until a catastrophic amount is reached.
The nightmare of medicine stems from the desire of doctors to be paid what they are worth, and the desire of government to cover everyone for “free” but never having enough money. We need to unshackle the market to let doctors get what they are worth, but drastically increase competition and the entrepreneurial animal instincts to destroy the bureaucratic mess that has bogged everything down.
SamoyedFurFluff|2 years ago
Spivak|2 years ago
I do think your bar for catastrophic is far too high and should probably be ~$10k cumulative spent in any span of time less than 12 months because $49k is ruinous to almost every American.
aranchelk|2 years ago
There are complicating factors here:
We culturally, societally, and philosophically don’t really know how to make decisions about end-of-life care, and death in general.
We also lack an agreed upon moral framework for how to care for people with diminished cognitive capacity (the extreme being permanent vegetative state).
mikem170|2 years ago
It's a thing, even if ignored. We're paying big premiums for that to insurance companies as part of our wages and taxes.
I wonder if other countries do significantly better?
chrisbrandow|2 years ago
Biggest surprise for me was that the best aspect of the healthcare system has been Medicare. Consistently helpful and all the communications were clearly designed with seniors in mind.
Very other aspect is characterized by innatention of obvious corporate motivations.
nothercastle|2 years ago
x86x87|2 years ago
The problem is that most people don't have that kind of money and the system as a whole is designed to take advantage of regular folks by not providing the care they need (regular care, not the best care).
scotty79|2 years ago
Does it sound plausible?
gruez|2 years ago
I'm sorry but this sounds like someone invoking "they'll write it off" without knowing how write offs work. In that scenario your revenue will be 2/3rds of the list price. Taxes payable is dependent on your profit, not your revenue. Profit is revenue minus costs. Inflating the list price doesn't change anything in this equation, and thus won't affect your taxes payable.
decafninja|2 years ago
Stories I hear about Europe is that it’s affordable, but still slow and bureaucratic. You hear about some people even coming to the US (gasp!) to get expedited treatment.
Asia seems to be both affordable and also fast and efficient.
nine_zeros|2 years ago
There is no one single root cause to fix here. The entire system needs to be uprooted - entire companies and shareholders will need to get wiped out. Unfortunately, ain't happening in ultra capitalist America.
For other countries, there is still hope.
ufocia|2 years ago
daft_pink|2 years ago
Like health care and anything, you get what you pay for.
chasing|2 years ago
nimbius|2 years ago
peyton|2 years ago
ksec|2 years ago
Given the insanity of it, and US being capitalist in nature, may be the best way to fix all of these isn't more regulation, but to deregulate the market so they could compete?
And on the topic, I am wondering if anyone knows a good site that compares the Medical System around the world?
lbotos|2 years ago
So basically if you are poor you just… suffer
Waterluvian|2 years ago
ufocia|2 years ago
nazgulnarsil|2 years ago
ufocia|2 years ago
h4sh|2 years ago
knowing back channels, having the 'village' mindset is much better