Post-apocalyptic life in American health care

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.

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.

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.

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.

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

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)