I’ll give you a concrete example in the legal field. Big firms might have reasons to avoid labor-saving automation, because they bill by the hour. But a large fraction of legal work isn’t billed by the hour, it’s contingency work (where the firm gets a certain fraction of a recovery) or fixed fee work. If you’re getting paid 1/3 of the amount you recover (a typical contingency fee) you have enormous incentives to do as little work to get a good result as you can. But those firms don’t use a lot of legal technology either, because it’s just not very good and not very useful.
The bulk of legal practice is about dealing with case-specific facts and legal wrinkles. And machine learning tends not to be useful for that, at least in current forms.
For example, the idea of using document classification to reduce review costs has been around for a long time. But it took a long time to get any traction. Some of that was about familiarity, but a lot of it was about the original systems being designed to solve the wrong problem. The first products were designed to treat the job as a fairly straightforward binary classification problem. They generally accomplished that task very well. The problem was you had to have a serious case of techie tunnel vision to ever think that legal document classification was just a straightforward binary classification problem in the first place.
Nowadays there are newer versions of the technology that were designed by people with a more intimate understanding of the full business context of large-scale litigation, and consequently are solving a radically reframed version of the problem. They are seeing much more traction.
There are a lot of great ML algorithms, even if you limit yourself to 10-20 year old ones, that aren't leveraged anywhere like how they could be because very few know how to build such a system by turning business problems into ML problems and training users to work effectively alongside the algorithm.
CRUD application development projects blow past deadlines and budgets frequently enough. ML projects have even greater risks.
Edit: I hope the people making the successful legal document management system you mentioned write about their experience.
https://www.theatlantic.com/business/archive/2009/06/elizabe...
In other words, medical bankruptcies have fallen in absolute terms, but you wouldn't know that by just looking at the %age of bankruptcies.
Fact is Americans have high personal cost and risk exposure relative to nearly all of the rest of the world.
Second, our system has making money as the priority, again in contrast to much of the world.
Finally, most of the world recognizes the inherent conflict of interest between for profit and sick/hurt people and both regulate that conflict to marginalize it, and make it so people have options that make sense.
My take, having been chewed up by our toxic healthcare system twice now (having a family does matter, lol), is the temporary dampening on cost and risk escalation starting the ACA brought to us is fading now, and issues are exceberated by the pandemic (demand for care crashing into variable supply), and shifted somewhat as large numbers of people fall into subsidy medicaid type programs due to job loss.
The honeymoon period is long over now, and the drive to "make the number" is going to be front and center and escalating from here.
TL;DR: We are not improving on this front at all. We need to.
I could go on at length about high student debt and it's impact on these discussions too.
The radiology control over labor, preserving income for it's members is totally real, and fron their point of view, necessary. They ask the legitimate question in the US: How can I afford to practice.
Most of the world does not put their medical people in positions to ask that question, with some exceptions, those being far more rare and easily discussed than most of the topic is here.
> Fact is Americans have high personal cost and risk exposure relative to nearly all of the rest of the world.
This is only true for some Americans, and increasingly very few. I actually found this tweet by a health policy expert to perfectly capture the status quo: https://twitter.com/CPopeHC/status/1234510323425652737
"American healthcare in short: ~60% (in good employer plans, generous state Medicaid, or M.Adv/Medigap) have the best healthcare in the world. ~30% have insurance with gaps/risk of big bills. ~10% uninsured must rely on uncompensated care, go without treatment, or risk bankruptcy
The strength of M4A proposals is that they begin with an understanding that the 40% exist and need things fixed. Their weakness is that they pretend that the 60% don't, and threaten to take away what they have."
The fact of the matter is that the majority of Americans have excellent, world class health coverage. The problem is that there exists a small percentage of Americans that are totally screwed, and this is a higher percentage than most other comparable countries. There are a couple reasons why, which brings me to...
> Second, our system has making money as the priority, again in contrast to much of the world.
First of all, this is false insofar as not all health insurance in America is for-profit. Blue Cross Blue Shield, for example, are predominately 501 non-profits (with a few notable exceptions).
Second of all, while you're right that much of the world has public insurance companies that don't seek to "make money", there are a number of countries with world class healthcare that do have profit seeking insurance, many of them with purely private profit driven insurance companies: including Switzerland and the Netherlands. Some have a hybrid of public/private, including Germany (public/private mix), Singapore (public/private mix), etc. In fact, while many countries have a public insurance system, it is extraordinarily rare for countries to outright ban private insurance options.
Third of all, in America, health insurance is one of the most regulated industries in the country. After ACA was passed, there's a strict cap on profit margins that health insurers can enjoy. It's not too dissimilar from how private health insurance is regulated in Switzerland and the Netherlands, both of which have some of the best healthcare on the planet.
> Finally, most of the world recognizes the inherent conflict of interest between for profit and sick/hurt people and both regulate that conflict to marginalize it, and make it so people have options that make sense.
Again, as I mentioned above, this is not only not true, it's debatable if such an "inherent" conflict of interest even exists. By this logic, there should be an inherent conflict of interest between for profit food providers and "hungry/starving" people. The profit motive alone can't explain America's health outcomes, because there exists countries with fantastic healthcare systems (Switzerland, Netherlands) which are driven purely by private health insurance.
America actually has a pretty good apples-to-apples experiment of "profit seeking" vs "not profit seeking" insurance, ironically in Medicare Advantage. When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare, also cover Part D prescription drug benefits, and often include supplemental benefits that Original Medicare doesn't already cover. There are some interesting findings so far:
- 39% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly, that we expect by 2025, more seniors to be on a private plan than the public one. There's also great variance by State. In Florida, Pennsylvania, Wisconsin, Michigan, Minnesota, Oregon, Alabama, Hawaii, and Connecticut — nearly 50% of beneficiaries are on Medicare Advantage. By 2022, we expect more seniors in those States to be on a private plan than a public one. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about...
- For most beneficiaries, Medicare Advantage costs about 39% less than Original Medicare. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about...
- Medicare Advantage plans are, on average, of higher quality than the public Original Medicare. https://healthpayerintelligence.com/news/medicare-advantage-...
- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan. https://www.commonwealthfund.org/publications/issue-briefs/2...
So the reality is really more complicated than you're making it out to be.
From where I sit, the one thing that sets apart America from the rest of the world is not that health insurance can be profit driven (so do the Swiss and the Dutch, for example), it's that health insurance is coupled with employment. There's really no other peer nation for which this is the case, and a lot of the economics of health insurance look the way that they do because big employers buy most of the health insurance in today's market, and that has resulted in market distortions that hurt those that are unemployed. What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. Employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals.
Really? That is news to me, as a dual US|EU (Croatian) citizen, who is culturally American--but currently living in Croatia.
Even Croatia has a higher life expectancy than the United States. Yep, even those "eastern European countries" (that are within the European Union) that Americans refer to with derision, often have higher life expectancy than the United States.
See: https://www.reddit.com/r/croatia/comments/nuiyk1/hrvatska_sp...
Also, just in case you want to blame this on "lifestyle factors" (which means that this is a public health matter, which the United States has severely underfunded--locally, state, and nationally for more than a few decades now), the third leading cause of death is believed to be preventable medical errors. (The source I provide has been verified by several follow-up studies.)
See: https://www.bmj.com/content/353/bmj.i2139/rapid-responses
Also, you don't know what you are talking about here. I have studied healthcare systems worldwide for hundreds of hours.
Ironically the IMHE group that does the coronavirus projections is world renowned at producing this data. All of this data is open-access.
For starters (easy reading) this article is relevant: http://www.healthdata.org/news-release/how-healthy-will-we-b...
But, seriously, we have far from the best healthcare system in the world. That is not even remotely true. There are several countries where a woman can give birth and is less likely to die, compared to the US.
I wish you were joking.
Yes, and just like that health policy analyst, I can attest to it. I've read more than enough plan documents, and work with health actuaries every day.
> Also, just in case you want to blame this on "lifestyle factors" (which means that this is a public health matter, which the United States has severely underfunded--locally, state, and nationally for more than a few decades now), the third leading cause of death is believed to be preventable medical errors. (The source I provide has been verified by several follow-up studies.)
Actually, there's a fantastic analysis that addresses this point head on, even analyzing the IHME data: https://randomcriticalanalysis.com/2017/05/16/the-explanator...
The vast majority of the variance in average life expectancy is attributable to lifestyle factors. As long as you stay away from drugs, you don't participate in a gang, or you take the bus (or any public transit), you're on roughly equal footing with the rest of the OECD.
"The data suggests motor vehicle accidents, homicides, and drug overdose deaths can explain a large fraction of the US life expectancy gap as compared to several highly developed countries. Obviously this does not account for obesity, diabetes, (historical) smoking, and related lifestyle differences that are likely to have a pronounced negative affects on US life expectancy as compared to most other developed countries and which statistically explains the vast majority of the very large spatial differences in the United States."
> Also, you don't know what you are talking about here. I have studied healthcare systems worldwide for hundreds of hours.
Um, so have I. I literally work on health pricing systems, and have studied health policy. "For hundreds of hours" even, for whatever that's worth (not a lot, I assure you).
> But, seriously, we have far from the best healthcare system in the world. That is not even remotely true. There are several countries where a woman can give birth and is less likely to die, compared to the US.
I don't think I ever said that we have the best healthcare in the world. I agree that US healthcare is broken. All I'm pointing out to you is that the "profit motive" has nothing to do with that, as evidenced by counterfactuals in Switerland, Singapore, and the Netherlands; the former two of which actually have the best healthcare in the world.
https://www.rd.com/article/switzerland-worlds-best-healthcar...
https://www.forbes.com/sites/theapothecary/2011/04/29/why-sw...
https://www.bloomberg.com/graphics/infographics/most-efficie...
In my opinion, the profit motive has nothing to do with America's healthcare ills (no pun intended). It's the fact that it's tied to employment and purchased by employers. No other country is set up that way.
Personally, I defer to you, the person who actually understands the industry from the inside, in terms of having an opinion based in reality.
So often, these hand-wavy solutions which boil down to "we must remove the bad people preventing our utopia" (ie scapegoating) are masking wicked problems (https://en.m.wikipedia.org/wiki/Wicked_problem) that cross multiple thresholds of responsibility, incentive and jurisdiction.
Declaring hard problems to be caused intentionally by evil people has led to some of the most despicable acts in history.
So, part of your job is to analyze health benefits plans (health insurance plans) that Americans get. You also work daily with actuaries in the life sector, who assign dollar values to people's lives.
Yeah, like that really makes you a good source when it comes to the well-being and long-term outcomes of a country.
> In my opinion, the profit motive has nothing to do with America's healthcare ills (no pun intended). It's the fact that it's tied to employment and purchased by employers. No other country is set up that way.
Congratulations on coming up with that point. That is precisely why I left the US, as somebody with a rare disease that requires an orphan drug to survive.
I knew better than to stay in the US, in order to survive. In fact, there may be a major ACA Supreme Court decision coming soon. If not, it will be released in the next session. I refresh SCOTUSblog every morning, worrying for my fellow Americans, who could very well die from the outcome of the decision. Regardless, I never plan on living in the US ever again. It will never be "home" for me anymore.
Yes, exactly like health insurance actuaries at publicly run health insurance providers. We don't sit around trying to figure out how to make people die, like cartoon villains. We try to figure out how to make healthcare sustainable.
If you read what I had written, it's clear that not only do the private sector insurance providers perform comparable with public sector ones like Original Medicare, they can even out-perform them. So we can't conclude the "privateness" as the root cause of our problems, we have to consider other confounding variables.
> Congratulations on coming up with that point. That is precisely why I left the US, as somebody with a rare disease that requires an orphan drug to survive.
Sorry to hear that, truly. In my opinion, the single most effective thing we can do to help folks like you is to decouple health insurance from employment, and I'm sticking around to try to make that happen. Hopefully you'll come back, and stay healthy.
I am off disability, but I can theoretically keep Medicare for life. I was always on traditional Medicare, and my orphan drug (a blood product) was covered under Part D for my condition. I was also insured as a "disabled dependent" via employer-based insurance, through my deceased father's retiree benefit--so it was secondary insurance--which functioned like a supplemental plan.
I have 2 rare immune-mediated neurological diseases affecting my peripheral nervous system (one of them being very rare--which means an HMO from a Medicare Advantage plan is a huge problem if I want to stay alive long term in the US--and generally, you cannot go back to traditional Medicare), plus type 1 diabetes. The very rare neurological disease is believed to have caused the autoimmunity leading to my diabetes diagnosis at age 5.
Anyways, I can tell you that the way things were set up in the US (prior authorizations, prescription formulary restrictions, quantity limits, networks, etc.) were certainly harming my health. I studied electrical engineering for undergraduate, and it is not like I am cannot handle bureaucratic and logistical nightmares.
But, there is a baseline level of stress and anxiety that is present in the US, and you do not have the realistic expectation that you will be cared for there. Not only that, it is a part-time job just to deal with insurance matters. This feeling is basically non-existent within most of the EU, including in places like Croatia. Croatians probably do have the best lifestyle in all of Europe, too.
It's just not worth it.
You're always able to go back to traditional Medicare, you just have to wait until the next open enrollment. In fact, after the first trial run with MedAdv, you can switch back before open enrollment if you want. Traditional Medicare is always an option.
Great to hear that you're staying healthy otherwise.
True, but the issue is that medical underwriting is allowed on Medigap (Part B supplemental plans). So, once you are on a Medicare Advantage Plan, you basically cannot effectively go back, due to being unable to obtain a Medigap plan (covering the 20% that part B does not cover), due to having pre-existing condtion(s). The financial consequences of not having a Medigap plan are quite severe for somebody who has a rare disease, if you know what I mean.
As you know, it is a loophole in the ACA. Because I was declared disabled before age 22 ("disabled adult child"), there is a way for me to get Medicaid, for life, effectively, through the Ticket-to-Work program, via the PASS (Plan to achieve self support). Even if I "make to much money to stay on Medicaid", at some point, the Pickle Amendment allows me to stay on it for life, due to the age I was declared disabled at.
But, there are issues with that too, since it is a form of "welfare". You can end up having to pay back the US government hardcore overall. You also get punished for being on Medicaid. For example, some states only allow you to have 4 medications covered by Medicaid. After the 4th active prescription, a type of "prior authorization" is sent to each and every doctor--for some government bureaucrat to make an arbitrary decision whether this medication is being "worthy of coverage".
You have not met that burden. Not even close.
The best case is a mixed environment, with a for profit portion that can address clear for profit cases well.
And those exist!
But, doing that sans a robust system that actually just delivers health care to sick people is crazy bad policy.
There is another argument in your favor out there, and that is consistent, transparent pricing. Or "Equal Pricing"
In Singapore, there are no real surprises and people have options that don't cause them to trade, homes for example, to get sick people they care about healthy again.
Here? Nothing but surprises!
And frankly, that being the case actually does support the difficult argument:
If making money is the priority, then making sick people healthy isn't.
On the other hand, if making sick people healthy is the top priority, and then we talk about money?
Very different scenarios.
The US is firmly entrenched in the former. Examples of the latter exist in the world and perform well.
The profit motive matters. How it's framed, what priority it has, and more all do contribute to the overall effectiveness and again that cost and risk exposure.
What? I absolutely have. I’m not sure what you’re on about. Switzerland is as close as it gets to a profit-driven purely private healthcare system. Indeed, the US was modeled off of it. The only difference between the two is that the former is based on a robust individual market while the latter is driven by group benefits.
> But doing that sans a robust system that actually just delivers health care to sick people is just bad policy
I don’t think anybody is suggesting not delivering health care to sick people. The question is whether the private sector can provide an actuarial product.
> In Singapore, there are no real surprises
Agree, Singapore’s healthcare system is excellent, and price transparency is very important. The reason the US system is devoid of price transparency is because the majority of Americans simply don’t care about prices, since they have little skin in the game. This is true for old people on Original Medicare, poor people on Medicaid, as well as employed people on generous group plans. If none of those describe you, then you’re unfortunately SOL. THAT’S the problem. Not the profit motive.
> If making money is the priority, then making sick people healthy isn’t
Again, it’s a cute pithy quote, but that’s not how the real world works. If making money is a priority, then feeding hungry people isn’t. If making money is a priority, then providing cheap clothing and shelter isn’t. It’s impossible to understand how the world works through such a simplistic lens.
As I showed you above, the Medicare A/B test is illuminating. Medicare Advantage payers are primarily in the business of making money, and yet their members are on average healthier, have higher quality plans, and at lower cost.
World hunger anyone! It's a real thing.
We have it because making money is a higher priority than feeding people is.
Cheers, I have other things to do, and did enjoy this discussion!
Feeding people is 100% the priority, which is why the vast majority of people in the first world have access to food primarily produced by a predominately private food industry.
The US is in the top 5 in the world for food security: https://www.worldatlas.com/articles/the-world-s-best-countri...
To the extent that there exists poor people unable to afford food, that’s a problem solved by welfare and subsidies, not by nationalizing food supply chains.
Apply that to healthcare.
This isn't true when feeding people is the _100% priority_, like in a big crisis, as a major war. The market flies out of the window and doesn't return before after the war is over since it just can't reliably produce goods in way that is appropriate for a crisis.
When the crisis is over however, the game of profit based production is restarted again.
Unable to afford the doctor = making money is a higher priority.
Many food banks will give people who want food, food. Few questions, sometimes no questions asked.
It is rare to have similar access to health care.
Where did I mention nationalize?
I did not do that, and meant to not do that.
> It is rare to have similar access to health care.
No it’s not, you just described Medicaid. The Venn diagram of people that rely on food banks for food and people on Medicaid is basically a circle.
Also, it’s debatable if food banks are a superior way of getting food to poor people, vs expanding food stamps and/or a UBI which can then be used at grocery stores.
> Where did I mention nationalize?
You seem to be attacking the profit motive as a mechanism by which to provision goods and services for which there is highly inelastic demand. My point is that if you think that the way we provision food is workable, then the concept of private healthcare with subsidies (basically the Swiss model and MAdv) should be as well. In both of those models, profit and “making money” is still key.
You are saying a for profit system can work. You are about pricing in that scenario too. Fair enough. Given your perspective, your position on this is understandable. It is not agreeable, in my view.
Our way of provisioning food could be improved significantly. Food differs from health care significantly. Secondky, that we have food banks at all is deplorable and embarrassing.
That is all I care to entertain on that largely useless comparison.
I am attacking the profit motive in health care specifically because it carries an inherent conflict of interest and is poorly aligned with markets.
In any case, I am going to stop here for real, and just make it clear I do oppose health care as a market and do so because people do not have control over their need to participate and we all know what happens in a must buy, cannot walk away from the deal scenario: lowest value for the most possible dollars.
That comes up ALL the time and is why most of the world has removed that conflict of interest from the task of fixing sick or hurt people.
Not sure what you're talking about. Medicaid is extraordinarily generous. The only questions that are asked are in determining whether one qualifies to enroll in Medicaid, but once you're in, you pay almost nothing. Even prescription drugs are capped at $75, no matter how rare or fancy.
> Food differs from health care significantly
I disagree. Both are examples of critical goods/services without which humans die. They both factor into long-term health and quality of life.
> Secondky, that we have food banks at all is deplorable and embarrassing.
I completely agree. While I've been extolling the virtues of pricing systems to provision goods and services, I've also made it clear that welfare is extremely important. The US currently extends welfare to low income people, through SNAP/EBT food stamps, Section 8 Housing vouchers, and EITC. In my opinion, there's still room to further expand the generosity of these systems, and even consolidate them into a basic income.
It's worth disentangling welfare from public vs private, because it's easy to conflate the two. It's entirely possible to rely on private markets to bring down prices and increase availability, while using publicly funded welfare to enable access for those less fortunate.
I disagree on cost and risk exposure. Ask around both employer and employee about cost growth this last decade, for example... not getting lower, often are digit increases.
Regulation?
Well, the cap that limits margin dollars is easily dealt with by owning more of the chain of care. Opponents of this tepid method of cost control predicted it and it has happened. They can do billing with themselves and it works like tax shelters do and film studio accounting do to show compliant profit numbers.
From where I sit, being one of the really screwed set, I found some of what you put here clarifying, but did not find myself sold on the idea we are improving at all.
In fact, one way to differentiate the US profit motive from the rest of the developed world, is our continuing move toward market based care despite a lot of information
I don't think we're improving either; as long as we have an employer mandate and privileged tax treatment for group health insurance plans, I don't see this changing any time soon. All I'm saying is that the market/private nature of it has little to do with it. It's the "employer sponsored" nature of it that has everything to do with it.
> In fact, one way to differentiate the US profit motive from the rest of the developed world, is our continuing move toward market based care despite a lot of information
That the US is somehow undifferentiated in its pursuit of market based healthcare is not true at all; see Switzerland and the Netherlands. Both have purely private health insurance systems, and there's no sign of that changing any time soon, and both enjoy excellent health outcomes with broad approval of their respective healthcare systems. They're almost exactly as regulated as the US health insurance market, except with one glaring difference: the private health insurance is predominately purchased on the individual market. (https://www.forbes.com/sites/theapothecary/2011/04/29/why-sw...)
Not only that, Singapore has one of the most market-driven healthcare systems on the planet, and enjoys the status of being the most efficient healthcare system with some of the best outcomes:
https://www.bloomberg.com/graphics/infographics/most-efficie...
I appreciate that. And still do not agree.
Either the goal is fixing sick people, delivering care, or it is not.
If the US were to improve DRAMATICALLY on labor policy, among many areas needing improvement, perhaps we could show for profit being able to work.
Fair enough.
That's an odd dichotomy. You could apply this to literally any good or service. With food, either your goal is nourishing hungry people, or it is not; and yet the private sector provides food just fine.
At the end of the day, price signals and market forces ensure that producers meet the needs of consumers. There are certainly instances of market failures, especially in the case of externalities. But with healthcare, there's really no evidence that markets and the private sector cannot deliver world class healthcare, and in fact we see evidence to the contrary, both domestically (in Medicare Advantage) as well as globally (in Switzerland and the Netherlands).
Not only is it interesting, it's reality.
You are making a market argument fundamentally.
With food, for example, people have lots of options, and while the need for food is absolute, wants for food can be ignored and or vary widely. Food wants is a great market. People can participate or not. They can prepare their own food or not.
Food needs are not as good of a market, though again, people have options, and are rarely in a must buy scenario.
That difference matters.
Notably, there is a cap on how big of a risk there is in the whole thing, and it's not all that big of a risk.
With food, one can end up in a weak scenario where one gets the least value for the most dollars. But, it's not typically life changing, and there are a lot of options for most people in most cases.
Contrast that with health care.
Let's talk about wants first, just like food. Cosmetics are a great example. People can choose not to do it. They may have options, depending on what the scenario is. This makes for a reasonable market. And, depending, people can make their own. I did that for a prosthetic a while back. Saved thousands of dollars. But, that is rare more than not. Still, we could empower people to some degree like we do with food.
Someone having a heart attack will need treatment, or let's say they are out of the market. It's not like they can shop around either. I could go through and compare / contrast with food, but here's the main point:
Unlike food, that doctor visit doesn't really have a cap on risk. 5 figure? 6 figure? 7 figure? All can and does happen.
And things people require? When people have to participate in the market, they pay the most and get the least value for the dollar. See insulin prices in the US?
Now, for a nation that has it's priorities in order and those priorities are not making money first and foremost, that price is a small fraction of what gets charged here in the US.
This is a shitty market. People are forced to buy, their choice is often limited, risks are crazy variant, costs not transparent, and on and on it goes.
At a minimum, most nations break these out making sure people who find themselves sick or hurt have baseline options that are not life changing, and market type options for those health care related things that make better sense.
Boil all that down, and what do we get?
Making money IS NOT THE TOP PRIORITY. Fixing sick people is.
When we examine all this in detail, we will find those shining examples of for profit health care actually working out are very well regulated, and that means they are forced to fix sick people first and foremost.
If they were not, then people would be tipping over for lack of ability to participate in the market, which isn't really even a market in a need scenario. It can be a market in the want scenario.
All of which is precisely why I frame it in those terms.
Which is it then?
Currently the US has chosen to make money first and foremost and look at the carnage!
Wants for food absolutely cannot be ignored. Without food, you starve and die. Along with healthcare, food is the quintessential example of a good/service with price inelastic demand.
Now, you’re absolutely correct that in most food markets, there is a variety of options; that’s exactly what’s needed for a market to function. Unfortunately you haven’t demonstrated that private health insurance markets are inherently devoid of such options by nature of their being private. Medicare Advantage is an extremely healthy market, as is the individual market in Switzerland.
> Unlike food, that doctor visit doesn't really have a cap on risk. 5 figure? 6 figure? 7 figure? All can and does happen.
You’re just talking about catastrophic risk here, and as I’ve already mentioned, there’s nothing inherent to the private insurance model that makes this unworkable. This isn’t based on guesses and conjecture, it’s based in empirical outcomes: see Medicare Advantage, Netherlands, and Switzerland. Also keep in mind that nobody here is arguing against subsidies for poor or unhealthy people; we’re just talking about whether that money is used to purchase plans are created by actuaries that work for the government, or for private sector organizations, and the merits of each.
> And things people require? When people have to participate in the market, they pay the most and get the least value for the dollar.
That’s true in the US. That’s not true in Switzerland. Both have private healthcare markets. Therefore, it’s impossible to conclude just based on US outcomes that private-ness is the root cause. It’s clearly something else.
> See insulin prices in the US?
The unfortunate reality here is that government-enforced patents allow insulin prices to remain bloated. Again the root cause isn’t the profit motive, that’s just a side effect.
> This is a shitty market.
Absolutely no disagreements there. The US healthcare market is indeed shitty (outside of Medicare Advantage at least), unlike Switzerland.
> People are forced to buy, their choice is often limited, risks are crazy variant, costs not transparent, and on and on it goes.
Agreed. Again, nothing to do with private-ness.
> When we examine all this in detail, we will find those shining examples of for profit health care actually working out are very well regulated, and that means they are forced to fix sick people first and foremost.
This is also true of the US. Health insurance is by far the most regulated industry in the country. Profit margins are capped by ACA, plans are regulated by ERISA, health insurance has minimum standards thanks to the ACA, insurers cannot deny access based on pre-existing conditions, and employers are mandated to provide health insurance — all thanks to the ACA. From a regulatory standpoint, the US is virtually identical to Switzerland, except for one notable difference: employer sponsored care.
That's just utterly naive or politically biased. The profit motive is what causes those regulations in the first place! It has always been like that, especially in the states.
Don't try and create some sort of a fairy tale place where the profit motive won't try to rig regulations in their favor, they will always try to, this is what the incentive to make more and more profit creates.
Actually, that's not true. The regulations were created as a result of a series of well-intentioned but catastrophic policy decisions, starting in World War 2. FDR instituted a wage cap to discourage private sector employment, which resulted in employers using non-wage benefits to participate in a competitive labor market. After a decade or so, it became an expected benefit (sort of like company cars, at the time). Eventually around the '70s, the Federal government decided it was time to incentivize remaining employers to provide health insurance by making premiums tax deductible; again a well-intentioned attempt to expand access. It finally all culminated in ACA which _mandated_ that employers provide health insurance. None of this can be attributed to lobbying, almost all of it attributed to well-intentioned regulations gone awry, not the profit motive.
In fact, the best shot we have right now of decoupling health insurance from employment is the ICHRA (https://ichra.com/), which allows employers to fulfill their healthcare obligations by providing tax-advantaged cash to employees that can be used to cover health insurance premiums on the individual market; and I imagine that came about due to lobbying.
Again, the easiest way to falsify a causal line between the profit motive and the current outcome is by finding instances of markets wherein there is a profit motive, but with differing outcomes. That's exactly what we see in Medicare Advantage, Switzerland, and the Netherlands.
> Don't try and create some sort of a fairy tale place where the profit motive won't try to rig regulations in their favor, they will always try to, this is what the incentive to make more and more profit creates.
No disagreements that industries will try to rig regulations in their favor. This is true everywhere in the world, and yet we see wildly differing outcomes. Notably, I'm yet to see an argument explaining away the Medicare Part A/B vs Part C outcomes in the US.
What ends up happening is that anyone left over has to participate in risky markets with higher premiums in general, resulting in the mostly broken state of the US individual market.
In contrast, you have countries like Switzerland where pretty much all health insurance is purchased on the individual market, and risk is pooled across larger and more diverse populations.
However, this is beginning to change. The Centers for Medicare and Medicaid Services has begun to allow private Medicare Part C insurers expand into long term care. Notably, to this day the public Medicare still doesn’t cover long term care, whereas M.Adv plans are beginning to.
If you’re talking about SNFs, Medicare Advantage is basically at parity with OM. I’ve seen Advantage plans by big payers like Humana with SNF benefit periods of 100 days. The 39% savings figure is on average, but if you require long term SNF stay, you’ll probably cost roughly the same to a private insurer as you do to Original Medicare. None of that stops private insurers from offering the benefit, since the actuarial math works out to the kind of savings that we’re mentioned above, across a whole benefit population.
> in exchange for subpar vision/dental
I’m not sure what data you’re looking at, but from where I sit, Medicare Advantage almost always includes vision/dental, whereas Original Medicare does not (which is why some seniors go for Medigap).
For example, I'm distantly involved in a project with non-US-radiologists about ML support for automating radiology note dictation (which is a much simpler and much "politically cleaner" issue than actual radiology automation), and IMHO they and their organization would be happy to integrate some image analyis ML tools in their workflow to automate part of their work. However, the current methods really aren't ready, and the local market isn't sufficiently large to make the jump and make a startup to make them ready, that would have to wait until further improvements, most likely done by someone trying to get the US radiologists' money.
This isn't necessarily a bad thing - I for one happen to think it's great that our expensive medical system is financing all kinds of wonderful new technologies that benefit the world overall. However, the major problem here is that things that would be useful for other places simply don't have the market to support it, so most medical innovation exists in the context of the US medical system and it's problems - some of which are widespread, some of which are not. I do wish there were some other testbed healthcare systems out there for companies to try to disrupt, but I don't think it is (by itself) a call for medical reform.
My preferred medical reform is to "legalize insurance markets" (ie: repeal laws that state that insurance companies operating in state Y cannot sell insurance to people in state X because state Y policies are not legally compatible) and try to break the monopoly that doctors and nurses enjoy....somehow. Telehealth? Maybe?
To note, a big issue in public innovation is that rich western countries, led by the US, HATE governments competing against the private sector. So if a government comes up with an innovative solution, they are generally disallowed from selling it, which hurts everyone except private companies.
This happened in my city a few years ago, which had a very early innovation in bike sharing, much before any VC funded bike sharing company, and other cities had expressed interest in paying my city for implementing this service locally.
But because of laws banning public endeavors from engaging in commercial activities, this was struck down, hurting all the taxpayers in my city, citizens of my city that would have benefited from better service from the experience, and millions of citizens from interested cities which would have received better service and who would have saved money.
Or another case in my province was the invention by the electricity utility of the electric hub motor - which is now over 40 years later in widespread use due to its efficiency and low cost - but instead of exploiting that patent and selling those things, it had to partner with a private company which got exclusivity and mostly squandered it. Again, hurting almost everyone which might have benefited from lower cost electric transportation as well as the taxpayer here.
This is actually part of why China is eating everyone's lunch, they used their size and never really agreed to these rules, leaving themselves the opportunity to profitably invent at the state level, leading into more efficient state owned enterprises that can often profitably outcompete the private sector.
Does it factoring in situation of people unable to pay medical bills?
But yes, medical reform is definitely something that might be helpful - technological solutions almost always aren't the best way for solving social/political problems.
That's not what the article says.
"Two-thirds of people who file for bankruptcy cite medical issues as a key contributor to their financial downfall."
Those issues can absolutely include direct costs, but they also include things like not being able to work, needing a lot of day to day help, and other things that increase costs and reduce income even if the actual medical costs were largely covered.
There is an essentially an unrestricted demand for healthcare across the world.. they will use the time to either talk to their patients more (or start to if they don't already).. or they will move into other medical fields.. or increase the volume of screening.. (may be harmful, but that's another matter). They probably don't want to do it as it won't really save them much time. OR it will save them time and they have been burnt before. For example, early voice recognition was very poor and over promised. Stopped me using it for ages after it became fairly good. It's still not actually better than typing, but it is closer now. Let's all focus on voice recognition that works before moving on to grander plans....
If you could collect reliable diagnostic data locally, you could serve this globally and for free.
It would also be a treasure trove of data about how we respond to various treatments.
No, you can't.
> If you could collect reliable diagnostic data
And there's the reason. You can't do that either. There is a reason why GPs go through medical school.
Any sound reason, or are you either a) a defeatist, or b) a GP?
>There is a reason why GPs go through medical school
The input data would be basic things like:
- blood pressure
- weight
- images of the ear canals and throat
- blood, urine, saliva samples, perhaps analyzed in a regional centre
You don't need a ton of training to get the above from a patient and into a computer, and to ship the samples.
The job of a GP is actually probably one of the top hardest to automate, because the GP's main (and often only) job is to extract information. And that _does not_ consist in performing plenty of tests, but in speaking to and most importantly listening to the patient.
> You don't need a ton of training to get the above from a patient and into a computer, and to ship the samples.
Great! And you know what good that would do to improve diagnostic accuracy? Zilch. Zero. There's a saying that '90% of diagnoses are done on history'. Now tell me why that would be different for an algorithm given identical information? If there was a simple answer to that, we'd already be running statistical models over patient labs all day long, which we're not.
> are you either a) a defeatist, or b) a GP?
I'm an epidemiologist and also a practicing anesthesiologist, which is why the statistical theories of people who have never set foot in the clinics to see what's the job really about make me want to jump off a bridge.
- Doctor says "Say ahhh" and looks in my throat with the thingy
- Doctor looks in my ear canals with another thingy
- On other occasions, my other vitals are taken, maybe some vials of blood, etc. Again, a student can do this.
I'm asked a few general questions, with some follow-up questions based on my answers.
Then the doctor puts this information - along with my patient history - into the decision tree in their head and comes up with a result. If the doctor is stumped, I'm sent to a specialist.
The above can be automated, plain and simple. It would also be an improvement over my experience of the health system - in Canada. I have never seen my GP pull up a multi-year graph of my blood pressure, weight, or whatever. What I am describing is a system for creating regular data points of the kind currently used in diagnosis. What I fail to understand is how you cannot see that there must necessarily be predictive value in such a database.
Even if only 80% of the job can be automated, public health would improve immensely if the global population can do regular checkups like the above cheaply.
I can see allright. But you cannot see that your hypothetical database is lacking most of the info because your doc actually mostly evaluates you by looking at your general composure and relying on X years of experience and a bit of knowledge shoves that into the really complex decision tree in his head: "Hmmmm... this guy looks mostly fine."
Now, you feed your database to the latest deep-learning shiny thingy that tells you: "this guy has X% chance of having a horrible cancer, but I can't explain why". So you enjoy many months of costly investigation because you don't want to miss something, right? And after the fact, it is discovered that the lack of standardization in measurements caused the algorithm to decide that the light hue in the office was a sign of cancer.
All that to say that yes, someday what you are imagining may well be possible, but we are really very far from having the technology to do that now.
"It turns out that deep learning is a very good match for some of the most time consuming (and therefore costly) parts of medicine: the perceptual tasks.
We also saw that many decisions simply fall out of the perceptual process; once you have identified what you are seeing or hearing, there is no more “thinking” work to do."
[1]: https://lukeoakdenrayner.wordpress.com/2017/05/03/the-end-of...
The taxi system, until Uber and Lyft kicked their ant hill.
"They dont understand the business" is a great excuse for maintaining status quo. I'm an Engineer, a quant, and a computer scientist by training and I refuse to accept defeat w/o sound reason. I will if I'm given a good reason, but "go away you guys, you dont understand our business" is defeatist. If we all accepted such answers society would never progress. I'm sure horse carriages said the same thing when people tried to invent motor vehicles.