Until I saw hospital nursing, I had never seen a company run by HR.

Every decision starts and ends with HR. From hiring, to wages, to discipline and promotion, to IT and pay-roll, to reorganization and spending priorities, there is a rule for that. Maybe that rule originally came from the CEO or the CNO, but they say things like "may" and get interpreted as "shall" (or the manager faces a bad review and/or termination) or they are interpreted beyond any rational meaning. My best explanation is that it comes from a fear of litigation and a lack of leadership at the top. The final hilarious story is the CEO negotiating a big deal with lawyers and VPs shaking hands... and then saying without joking, "but I'll have to get HR's approval". The meeting wasn't important enough for HR to show up, but they had the last say.

Your comment on lack of leadership is spot on. No one wants to be accountable. Instead HR departments put in place bureaucracy that works to deny individual fallibility in the name of a "system of human resource management". They want to treat people like a cog in a machine instead of as people.

That is American corporations in a nutshell. Outsource everything, put layers upon layers, and insulate yourself. Then when fecal matter hits the rotary you can put the blame on others and, at worst, you get fired and there's little to no worry about any sort of legal reprecussion because... well you weren't accountable for the problems in the first place!

It's a massive problem created from little cuts here and there with a few big lawsuits mixed in.

I have a lot of friends at various levels of healthcare, from nursing up through low and mid-level administrative positions.

The one thing they all seem to agree on is that patient satisfaction surveys have been terrible for healthcare.

Once the emphasis shifted to patient satisfaction, everything became more of a game of catering to what the patient thinks they want. With the spread of rampant medical misinformation on the internet and the rise of alternative-medicine podcasts/blogs/influencers masquerading as informed medical professionals they have a constant influx of patients who show up believing they have a certain condition or need a certain medication. If you disagree too much or refuse to give them the medication they want, you risk a negative review. Too many negative reviews could negatively impact your compensation or even cost you your job.

Even at offices that don't perform patient satisfaction surveys, providers are at the mercy of negative online reviews. Again, if you don't do exactly what the patient thinks they want, you risk scathing online reviews.

This is terrifyingly problematic given the trend of people to self-diagnose with anxiety or infections who show up demanding Xanax or antibiotics. Puts doctors in a situation where they don't really think prescribing those medications is a good idea, but they also feel like they can't deny too many patients or they risk their reputation/bonus/reviews.

It's also a huge problem with conditions like obesity or alcoholism or smoking, where the doctors can see obvious patient-induced health issues but the patient really doesn't want to hear the truth from their doctor.

My Wife is an ER nurse manager and while you have many self entitled idiotic patients that think they are staying in a resort versus visiting an ER, the patient satisfaction surveys is not very high in regards to the issue and why nurses are leaving.

My wife actually had a person complain that the ER did not have cow bells to call for a nurse (She claimed to be a retired nurse and they always had that for back up, lol) and they constantly complain how come they came in first for a stubbed toe, but another patient with a gunshot wound or heart attack is being seen first.

The bigger issue as why nurses are leaving the field from what she has seen and experienced is:

1. wages: The wages are beyond inadequate in certain nursing specialties and many have left to become traveling nurses or contracted nurses that get paid double the standard nurse pay.

2. Burn out: Besides covid, Hospitals Patient to nurse ratio is often exceeded and no accountability for the hospital to break those ratios. Nor any consideration for a high demand patient versus a low demand patient. Then when something goes wrong the hospital looks to pin it on the nurses. This was an issue before covid . but covid just added fuel to the fire.

3. BS. nurses get bs from ALL sides. They get bs from the patients and even more bs from upper management who set unrealistic process in place that is more concerned by hiding accountability and making things look good on paper than actual patient care. Then you had that whole BS covid movement crap calling nurses hero but besides lip service they did absolutely nothing for them. In fact they did the opposite. I know my wife had to fight the executives because they wanted to make nurses use their vacation time for sick time if they got covid. Their explanation for this that if the nurses got covid it was not likely from the hospital as the hospital takes extreme precautions to prevent it. The funny thing was that the same hospital spewing that BS also wanted nurses to not wear mask due to possible shortages at the beginning of covid. Insert the BS is to DAMN High meme here.

4. RaDonda Vaught's conviction. This is certainly not helping the case to get more nurses.

The precedent RaDonda's conviction set is far from favorable to a profession which is already very difficult and taxing. This is a BIG reason.

ER is definitely a different ballgame. Thanks for the additional perspective.

The patient satisfaction surveys apply more to domains where repeat visits are the norm: Family doctor, nurse practitioners, and so on. (Ideally, none of us becomes a frequent customer of the ER nurses!)

It's clear from your comment that the source of the problem is the increasingly sharp divide between what the credentialed medical professionals believe and what lay people believe. The satisfaction survey is simply uncovering that fact.

It would be vastly worse if patients were being treated and had no recourse when they felt their health was mismanaged. It may well be the case that the patients are wrong, but it is extremely dystopian to imagine a world where individuals are not empowered to make decisions about their own bodies.

The problems stems from people believing they are consumers of healthcare, on equal footing with the practitioner they are seeing. They're not, objectively. A 45 minute Google search doesn't equal 4 years of college (usually in something like biochem but not always), 4 years of medical school, 3-7 years of residency training and potentially another 1-4 years of fellowship training. If you're seeing anyone above a family doctor/PCP, they 100% know more about your condition than you do, whether you've been living with it for a decade or not.

That doesn't mean you don't have autonomy, or that you shouldn't question your doctor's decisions and ask for explanations, but it does mean you should err on the side of thinking the person whose spent at least a decade, but probably closer to two, educating themselves to get where they are probably knows what they're talking about.

I was with you up until this point. Part of the problem is that this cannot be true in all cases, unless either (a) your condition is commonplace (b) the doctor specializes in your condition.

Yes, doctors know more than you in almost every way about bodies about medicine, about drugs. However, people with relatively uncommon conditions have been enabled (largely by the internet) to create communities of fellow condition-sufferers, and the collections of anecdata that result represent a resource that generalist doctors do not have access to. The good specialists, in some cases, will take occasional dips in to augment their own knowledge and expertise.

Case in point: my daughter has had two major hip surgeries. While there is no way anyone in their right minds would have chosen someone who had not performed these surgeries previously (preferably, many times), and while it was completely clear that the surgeons really really really knew what they were doing, it was also the case that various online communities made up of people who have been through this procedure were able to provide lots of information that the surgeons could/would not. This was particularly true of the recovery process, where there were a number of common oddities that most people who have the procedure experience, and they're really not a problem. They are scary however, and the actual medical professionals really had nothing useful to say about them.

There's another issue with the blanket "doc knows best" rule. If you've had a GP for many years, or a specialist helping you with a condition for many years, then it's probably a great rule of thumb. On the other hand, if you've moved, or for any other reason switched doctors, and you're the kind of person who does pay attention to their body, there's a reasonable chance that you're going to know things about yourself/your body that the new doc(s) will likely not be aware of. They can (and will) learn, of course, and there's no reason to be aggressive or patronizing about it. But for example, you may understand the way you typically recover from antibiotic treatments, or the consequences of lack of sleep, or your tendency to always pull a lower back muscle given certain movements, etc. etc. in ways that your (newish) doctor may not yet be wise to.

Objectively, the patient is the only one who has 500,000 hours of experience with the unique and very complicated system we call a body, and is objectively the only one who comprehends what they're feeling. They're also the one who experiences the consequences, they're the only ones with literal skin in the game. How much is all of this worth?

It's a difficult thing. The answer is some mix of giving the doctor and patient power.

The patient may be comprehending how they feel but that absolutely doesn't mean that they understand the complex interactions within their body, which the physician does know.

But in the real world, if someone is receiving bad care they don't continue making followup appointments with that doctor. Nobody continues going back to the same bad doctor over and over again and writing negative reviews. It's really easy to calculate churn rate for individual providers.

The hot topic now is tracking outcomes: The idea is that with enough data collection and crunching, we can eventually start tracking which providers have better outcomes among their patients. This is one of those things that sounds great on paper but has a lot of challenges in the real world. It's also prone to gaming, as we've seen from surgeons who have learned to avoid difficult cases so they can avoid the risk of another patient death statistic.

I don't think that's necessarily incongruent with the OPs point. If the metrics are being gamed or the metrics are being used to inaccurately gauge provider care, those are systemic issues. Or it could be the case of well-intentioned, but poorly chosen metrics.

10/10 plan to get sick again.

It's honestly surprising that more haven't taken the jump and is really shocking that hospitals aren't doing more to retain critical staff.

But on the hiring side, experience is one of the most widely accepted signals of value.

Help me understand this. Make it make sense...

1. Hospitals pay their nurses $X, which is way too low

2. Nurses quit because they're underpaid and overworked

3. Hospitals have a nurse staffing crisis and so pay travel nurses 2 * $X (or more!)

4. Hospitals are in a panic over the cost of travel nurses, yet instead of paying their nurses more to keep them around and eliminate the need for travel nurses, they ask the government to cap the cost of travel nurses

My mind is exploding over the ridiculousness of it.

Apropos of nothing but why is the knee jerk reaction "we need executive action to fix this staffing problem?"

IF the tradeoff is bad at 200k/yr, it wont be better at 225k/yr or 250k/yr

Instead of $250k, halve the work load somehow and make it two $125k.

If there is no number, then society cannot afford it.

But this is nursing, not trying to find ways around the 2nd law of thermodynamics. If nurses received $300k/year income, then there probably would not be a shortage since the barrier to entry is not that high.

If we really want to get down to the nitty gritty of it, most people cannot afford quality nurse care (or doctors or hospitals). So the question really comes down to how much wealth is society willing to redistribute to those who need it in the form of healthcare?

“Nurses” can be used to mean many things (CNAs, LVNs/LPNs, RNs) but this is specifically RNs, who, make much more than that, generally (median $77.6k/yr) https://www.bls.gov/ooh/healthcare/mobile/registered-nurses....

Given the amount of school a nurse must have, that’s low.

Not even close if you are talking about the USA (and actual nurses, not CNA's or MAs) - starting pay for 2 year RN degrees near me are about 55-65K, and you easily go over 100K in a few years.

He did consider that a career change, I think in the same sort of way that a computer programmer like (presumably) most of us would consider quitting Google to work on an indie app or videogame development would be a career change.

The larger point is, medical professionals are bailing from the hospital system, which looks pretty busted.

The demand for nurses is increasing as people are leaving and there are more from the boomer generation hitting an age where they need more care.

The supply has stayed the same. Schools local to me have not increased output for various reasons (lack of instructors, lack of space in local hospitals where nurses train, etc). The supply is too low.

So, we have a supply and demand problem. Travel nurses get paid a lot more because of this.

The solution is to produce more nurses. Something few are talking about.

One of the local schools, to me, turned away half of applicants because the program isn't increasing capacity.

Obviously higher pay would increase their abuse tolerance, but I think it is only part of the problem and a short term solution since no amount of pay will offset stress problems.

County level nurses seem to have much better work conditions than hospital nurses.

Nurses are generally payed very well. This is a supply problem driven by increasing restrictions on nursing degrees and insurance.

Not enough nurses and high cost leaves hospitals understaffed and nurses overworked, leading to a feedback cycle.

But, before COVID there was already a supply problem. The supply problem has been slowly getting worse for years and then COVID accelerated it. If every nurse came back to working as a nurse who wanted to work there would still be a supply problem.

Supply has not been growing to meet the demand growth for years.

I suppose you could just pay people more money to make it worth it but the long hours take a toll in other ways as well and contribute to burnout no matter how much you get paid.

You just summarized the decline of Western civilization in one phrase.

This has happened almost everywhere and efforts to push back have proven extremely difficult. I personally place a lot of the blame on the educational system for overproducing administrative skill sets and underproducing practical skill sets. There is some role for those things of course but we have far too many people for the administrative roles we really need and far too few for many other professions. This combined with the tendency of people to recruit people like themselves has oversaturated the market with administrators looking for reasons to exist.

The rot is to the point that we have the spectacle of Elon Musk looking like superman. Why does he look like superman? Because he actually does things instead of having meetings to discuss the meeting schedule. He's just a reasonably competent engineer and business founder with huge resources who... does things... and this makes him look superhuman by comparison to the hordes of administrators that only discuss doing things and commission studies about hypothetically doing things.

The sad thing is that this is so very obvious, and yet such an intractable problem to solve. The entrenched systems at every level of society will fight you at every turn when you try to improve things.

Preventing the Collapse of Civilization. https://www.youtube.com/watch?v=ZSRHeXYDLko

See also (2): Monty Python’s bicycle repairman sketch.

They have been very clear and upfront about the goal. They want to "solve" racial discrepancies in graduation rates so they've taken the classes often failed and are removing them.

For a while now it feels like the left and the right are attempting to one-down each other on how stupid they can get. That proposal seems like an example of the left trying to out-stupid Trump and the alt-right. Don't worry I'm sure the right is working on things even dumber than this, and then those will have to be topped, and so on. In 2024 we will have Dr. Oz and Marjorie Taylor Greene running against Oprah Winfrey and Kamala Harris.

I'm not sure how this downward spiral ties into the administrative position over saturation problem, but I have the intuition that it does somehow. Maybe what we have are a whole ton of people who don't really know how to do things who vote. Voting is ultimately a hiring decision, so what we get is a voting process that hires a whole bunch of either administrators who themselves don't know how to do things or crackpots because people without practical knowledge can't spot a crackpot.

Since they got by without any practical skills, they don't value such things. Now, they want to eliminate them entirely from the educational system.

The managers are at war with the individual contributors, and they don't understand that someone has to actually do work, or the system will collapse.

> Burnham’s claim was that capitalism was dead, but that it was being replaced not by socialism, but a new economic system he called “managerialism”; rule by managers.

In 1941.

a) Forsyth County, GA in 1987

b) Michelle Obama’s senior thesis at Princeton

Influence can propagate so easily through mass media, meaning that it is now possible to generate enough business interest just through "hyping" (it's difficult to achieve this when messages have limited reach) --- combined with the fact that it is often cheaper and less risky to "talk" than to actually "do", we end up with a culture where hyping is preferred whenever possible.

I would bet it's caused by:

- stifling bureaucracy

- hostile legal climate

- massive start up costs

The only winning move is not to play. Let the system fall apart and join on the later upswing. The unfortunate part is all the needless suffering people will endure during this process.

My mother switched to an administrative role internally, 10 years before she got retired and my sister went from nurse to anesthetist and now in the progress of moving to IT as a domain expert for medical software so she can work from home.

This should terrify everyone. Large segments of our society are failing us despite being stuffed to the gills with administrative staff that don't contribute much to productivity but rob professions of their independence. We're managing ourselves to death.

My mom was a long-retired medical director of a hospital and even she was shocked at poor quality of care, compassion and competence. Even in the ER of a recognized trauma center, things were pretty meh. Some specialist floors and ICU were good, but when an infection caused by poor hospital hygiene struck, he was relegated to the “medical” floor, where he was not fed, medicated, turned or treated with respect. Ultimately we maintained a 24x7 staffing of family volunteers for over 6 weeks.

Many of the staff frankly sucked. But it was easy to see why - the staffing levels were so poor pre-COVID, that any RN risks license every day by virtue of being there. The smart ones GTFO. You can’t care for 15 patients.

I’m pretty sure both of these will implode under the bureaucratic weight at some point — the financial and social costs of the excessive administrators is not justified by their (often minimal or negative) value added.

In my experience, the administrators are often doctors at hospitals and people all the way to the top have to have strong medical backgrounds. That's not to say there aren't do-nothing administrators, but those do-nothing administrators are often doctors. They tend to adhere to the way things are and always were as an orthodoxy, like 1st year residency is the worst and at these points quality of life improve, but it's almost like a fraternity hazing justifying the insane hours, complete loss of work life balance just because this is how it is. Candidly, there does seem to be a guilty pleasure there.

There is little to no real discussion on how to improve not only the work conditions but also the user experience of medical care. In my view, it starts at the top; organizationally, they are lacking an entire skillset to make any improvements what-so-ever.

Everything is controlled by insurance companies. You can’t do anything unless it’s exactly how insurance wants and only for what insurance will pay.

It limits everything, including how every profession can be compensated simply because you can’t easily hire somebody for more than what insurance will pay for their services. You can, but the funds have to come from somewhere.

* I strongly believe that only physicians should be running hospitals. Certainly not administrators whose only education is an MHA and only experience is working for for-profit health companies. Medical decisions need to be made outside of cost considerations. The only factors should be medical science, quality of life, and patient wishes (in that order).

** In stark contrast to asking questions and trying to understand. But I have family members who are the "look everything up and then try to tell my doctor how they're going to treat me" ilk and it's crazy.

*** I don't think the above points are unique to US healthcare other than cost considerations, but that's all I have experience with.*

- an attitude of "most patients are just trying to wring medications out of you" - an ego-hit of "if I didn't make the diagnosis, I don't want to help" (this applies to both patients coming in with a suspicion of what they have, or getting a diagnosis from another doctor) - burn-out/overworking, where doctors have a hard time managing all the different cases coming at them without dropping the ball here and there

It's not a simple, single-cause problem at all, but just want to provide an alternative point of view about patients who look things up or come in asking about a specific condition or diagnosis.

When I got my ADHD diagnosis after a quarter-century, I went in specifically asking about ADHD because I had seen some flags that made me think I might have ADHD. Contrast that with the people doctors screen out who are trying to get a stimulant prescription despite not needing it, and you have a situation where it's hard for doctors to tell who does or doesn't need meds, and where patients with actual conditions have to fight hard for those to be diagnosed.

Even in cases like POTS, which has no medication involved in treatment, just lifestyle changes, and yet people close to me who have POTS all had an uphill battle getting it recognized by anyone, especially doctors who could diagnose (disclaimer: sample size = 3).

I told my doctor I had already been diagnosed with ADHD because I had a strong suspicion I had it and wanted to see for myself if the medication helped (it helped massively). I think medicine should be accessible for patients who need it but I don't know how to avoid large amounts of patients then taking medications for the wrong thing, which would probably happen if it was a free-for-all. It kinda comes down to the question of having the personal freedom to hurt yourself doing something stupid, which is a balance (a little of that freedom is good, too much probably bad). All-in-all I lean toward the current system of using on experts to make the final decision. Still, I would be really pissed if a doctor prevented me from getting stimulants for something I believe I need, so I am not 100% satisfied with the current system either.

[0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638275/

[1] https://www.medicalnewstoday.com/articles/gender-bias-in-hea...

Edit: It originally appears to be getting heavily downvoted.

https://www.health.harvard.edu/blog/women-and-pain-dispariti...

> a 2000 study[0] published in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack.

0: http://www.nejm.org/doi/full/10.1056/NEJM200008243430809

https://www.independent.co.uk/life-style/health-and-families...

> women with chronic pain conditions are more likely to be wrongly diagnosed with mental health conditions than men and prescribed psychotropic drugs, as doctors dismiss their symptoms as hysterics [1].

1: https://psycnet.apa.org/record/1990-98104-000

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/

> racial bias in pain perception is associated with racial bias in pain treatment recommendations... Black Americans are systematically undertreated for pain relative to white Americans.

I agree that they do exists and am aware of the research showing it. I work in healthcare.

I didn’t make the grandparent comment that got downvoted but was interested to know why it was happening.

Thanks for mentioning POTS, btw. Despite how many people have it, it's still fairly poorly known about even within the medical community.

I just can't understand this argument. Women already live 5 years longer than men on average. You mean to tell me if the system didn't discriminate so strongly against their best interest they'd live even longer than men?

Women have a hard time getting symptoms, esp around pain, taken seriously. Oftentimes these symptoms are downplayed or ignored, regardless of the sex/gender of the medical professional.

It's like you completely disregarded my comment and decided instead to just proselytize.

I don't understand your argument. Just because women live longer on average, they're supposed to live in pain without treatment?

In reality they get about 7 times the allocated health expenditure that males get.

I have found it helpful to approach it in more of a teamwork-like mentality. Don't just read WebMD and try to diagnose yourself - journal your symptoms, observe the trends, record data. If it seems like it points to a specific condition hop on Google Scholar and look for some legitimate new research the average doctor may not have heard about. Print that out and then when you go in show them and ask questions without attempting to specifically diagnose yourself.

You could be totally wrong but with some background info your doctor is much more likely to accurately diagnose and take you seriously.

In my experience, I have had:

1. Doctors that know nothing about a really basic ailment and not have any meaningful guidance or treatment to suggest

2. Doctors that Google something literally in front of me, things that I have already Googled myself, and draw the wrong conclusion because they're looking at results at a glance - when I had searched myself earlier and dug deeper though, it was clear to me the result he was looking at was just plain wrong

3. Doctors that provide very little to no guidance about a wide selection of medications available to treat a problem, leaving me to essentially guess which option of a dozen or more I should go with

4. Doctors that force me to advocate for myself and my condition before they agree to help treat it - so much so that I had to visit 4 different doctors to find one that would, wasting nearly a thousand dollars of office visits with nothing to show for it.

It's no wonder people do their own research and dare to advocate for themselves. Most doctors are fucking worthless.

Keep in mind they also have to do a stupid amount of paperwork these days for every patient and the place they work for may be overscheduling the crap out of them - generally (unfortunately) I always consider my first appointment to be sort of a wash due to this and assume I am not going to really get anywhere until the second time I see them.

However, I think acknowledging when one doesn't know something is a skill many could benefit from improving...

Doctors are not like other proffeshions, they cannot put things right if the opportunity for treatment is missed

Doctors that blatantly lie to your face because they want to push some procedure.

I still think it’s better than the other extreme of just showing up and trusting the professionals. That should work in theory, but my experience for myself and those around me is it’s incredibly ineffective. If what you’re dealing with requires the least bit of thought, odds are you’re getting brushed off to the extent you allow.

The real model of US healthcare is essentially apprentice/master, with the patient as apprentice. Apprentice does a lot of the work, not all, some needs to be approved by the master and the apprentice better know how to learn from the master, when to push back, and how to make it seem like it was their idea all along. You can imagine how this falls apart for mental health.

The skills need to run a hospital are quite different than those required to be a doctor. I'm not saying hospitals aren't unique - I believe they are and their adminstration is highly specialized. Doctors should inform the administration at every level but it would be a waste of their training and a bad idea for doctors to run everything.

> Medical decisions need to be made outside of cost considerations. The only factors should be medical science, quality of life, and patient wishes (in that order).

Would you be as quick to say "Doctors should work without pay." ?

It's possible to meet the sole criteria of science, quality, and patient wishes with exploding costs. I think the OP's point was that money has to come from somewhere.

One might ask why that is; while some is surely due to natural decline in later years, one could likely also posit that the cost-fears leading up through that period (decades), and the general inability to get people to do preventative care throughout adulthood contribute to that significantly.

Indeed.

It is one consequence of a highly atomized culture. I suspect it happens because individuals are expected to take responsibility for their care (basically, this is the human side of cost-shifting and corporate planning around the care gradient available to someone at a given wealth level).

To someone at the end of their life, money is usually less interesting to them than a few more days of breathing. So the market provides.

To be clear, I'm talking about the absolute twilight of one's life that's reached regardless of levels of preventative care. I think there's potentially an opposite point that could be made: taking care of one's self can prolong this period and make it cost more. Someone who drops dead of a heart attack one afternoon won't have the same end-of-life costs as someone who gradually becomes enfeebled with age.

We’re “fixing” this by flooding the market with less trained nurse practitioners and PE. Doctors are being gobbled up by regional medical cartels and put where they can maximize billing.

In reality though, the overwhelming majority of cases that walk into a doctors office on any given day do not require an actual MD - NP and PA's are more than capable of handling many, many things that a typical patient needs.

Everybody tends to think they need a 'real doctor', they usually don't. Its good they are there when they are really needed, but do you really need an MD to diagnose a sore throat, adjust your BP meds or many other routine things that are people are seen for everyday?

And still, in many countries, including highly industrialized ones, hospitals are run by doctors. So either US administrators are making their hospitals run a lot better (which does not seem to be the case), or the core incentives each group optimizes for are different.

Why do you think law firms and accountancies are partnerships? Because the best proffesional for managing lawyers/accountants/develipers is such a proffeshional with loads of experience. Thats why we have progression, you gain management skill as you bevome more senior but you still know how the industry works and the people you manage

This is how it is for other professional industries. As an attorney, you can lose your license for sharing any profits with someone who isn't a lawyer. I believe states typically require accounting and engineering firms to either be wholly or two-thirds owned by such professionals as well.

There are plenty of things that could be done better now by non-lawyers with the help of lawyers (look at Rocket law).

While I know HN is probably SV and software biased, saying "only" $120k comes across as out-of-touch for the way most people live. For comparison, the median SF lawyer makes $191k according to BLS data. I could not quickly find 90 percentile data for the area.

And your number is correct according to Census data.

https://dqydj.com/average-median-top-individual-income-perce...

The average person does not develop software and does not live in a major city. If somebody is making double the median wage and 2.5x the average wage and complaining about keeping a roof over their head, they can probably expect some sideways glances. It's like when people complain about the difficulty of making ends meet once they make their Lexus payment and pay their kids private tuition bill. The subjective struggle may be legitimate but it's still out of touch with the experience of most people.

What states are these, Canadian states?

In the US, many many many SaaS shops are wholly owned by businessmen / bean counters. It's like, weird, to be an engineer who runs a software company.

> SaaS shop

Now, I get we like to refer to ourselves as Software Engineers, but surely you understand he means actual certified engineering firms, not groups of code monkeys, right? Software is virtually never engineering, you'd have to get to a situation like flight control software before you're doing anything legit

[1] https://www.harborcompliance.com/information/engineering-fir...

That's not always the case. The reason I stopped writing mobile applications long ago was because the mobile carriers were doing exactly this, and not even providing enough paperwork for you to argue with them about it.

People like to lambast the Apple App Store for being greedy, but the fact of the matter is that people netted 3x as much off Apple that they did from the carriers. They are asking too much money now but their rates were absolutely defensible at the time. It's not a coincidence that we had a gold rush that started almost exactly when the App Store became a viable target.

One might ask what would happen if we joined the rest of the 1st World in providing medical care and marginalized private health insurance. Would it be a similar watershed moment?

The issue is if you have someone with a scientific background doing politics, what you have at the end is still a politician. Same thing here. An MD doing hospital administration is an administrator.

Which is not to devalue specialist expertise in these roles. I definitely think you want people with these backgrounds in those roles as well. Just not necessarily exclusively. A career administrator has different skills than a physician, you want people with both, and other, roles working to run a hospital.

The real problem as I see it is probably the incentives, constraints, and pressures they work under, or towards. A physician forced to run a for-profit hospital maximizing returns is going to make a lot of the same decisions as someone with a business background in the same situation. The thing is to change the situation, not put different people into that role and expect them to do it dramatically better.

I think the practical issue is those fields that have similar restrictions basically predate a major societal shift. We now consider the only valid limits on profit and ambition to be market forces. I'm not sure restricting hospitals in this way is less radical than just nationalizing them, in terms of practical politics.

Anyway, again, sure. I'm not informed enough on this subject to know what model would actually work best. I think the problem is the raw exclusive profit motive rather than who specifically is running them, but there are a lot of ways to eliminate that.

Indeed! Whereas a doctor might say yes, give that patient with cancer the treatment they need, the MBA is going to say no, it costs to much, let them die. If the goal is to maximize profit, the MBA is doing a better job. If the goal is to maximize the health of your patients, the doctor is. We must realize that these two goals are fundamentally in conflict with one another.

The question isn't whether a doctor or an MBA should be running a for profit hospital, it's whether we should even have for profit hospitals. If we care about people more than profits, then clearly we should not.

It sucks and no one likes it, but what is the alternative?

Each human life is worth infinity? So we should bankrupt the entire country, spending 10 trillion dollars on a surgery that has a 1% chance to save a 98 year olds life?

Obviously that is an extreme example.. but the point is sound. We only have so many resources, how do they get divided up? Should be spend millions to give 80 year olds 1 more year of life? Do we value life on the reverse of age, so a baby we value at 10 million dollars, but a 90 year old we value at $20,000? What if that 90 year old is your Grandpa?

This is a pretty wild straw man fallacy, but I'd like to give a good faith response nonetheless.

You may not know, but the US spends more per capita on healthcare than any other country in the world, by a longshot. Many other countries provide unimpeded treatment for all of their patients. If a doctor in Japan wants chemo, the patient gets chemo, and treatment starts immediately. So how does it make sense that we spend more on our patients but doctors are still told no, the patient can't have that treatment? It's because a larger share of our biggest-in-the-world healthcare spending goes to for profit companies, like insurance companies, than anywhere in the world.

So when an insurance company says no to a treatment, it's not because we don't collectively spend enough for that treatment, we do! It's just that the insurance company wants that spending for themselves.

https://www.econtalk.org/christy-ford-chapin-on-the-evolutio...

Spoiler alert -- the author being interviewed doesn't have a solution, quick, easy or otherwise. But the history is fascinating -- in the end there are a lot fewer villians than you might imagine. A lot of good faith decisions seemingly made in the public interest over the past 150 years have led us into a weird local minimum that seems inescapable. Where we are was not inevitable, and as they say if something is unsustainable it has to end eventually, but before suggesting sweeping solutions I'd recommend hearing a detailed history.

I know for example, my grandmother who lived in europe many years ago, had failing kidneys. While today it's likely she could have subsisted for more years on dialysis, perhaps that money didn't need to be spent.

Life is finite, and racking up bills at EOL is a waste. People need to learn how let others die with grace, instead of giving chest compressions to a 85 year old 80lb grandmother.

Your interlocutor was actually using "reductio ad absurdum", which is a valid style of argumentation. https://en.wikipedia.org/wiki/Reductio_ad_absurdum

You didn't address the scenario as presented, or demonstrate how it violated a principle you had described. Instead, you shifted to excoriating the insurers for greed and waste.

Should the insurance company bankrupt itself on the first client? If not, how should they decide how much to spend on each? I should note that non-profit hospitals have similar results as for-profit hospitals (in the USA), so there's little evidence of shareholder greed playing a significant role (though there are many other stakeholders including employees).

Of course resources are finite, nobody ever argues that they're infinite. But we treat healthcare as if there's a constant scarcity of medicine with how much is charged because there's a constant urge to squeeze even more profits out of patients who probably have only 2 choices- pay for the medicine or die.

In the end, labor hours of professionals are finite. Even if you don't need to pay doctors, you only have so many, they can only work so many hours, you will need to prioritize who to help in what way, which procedures to do. Same with all the other personnel, the consumable stuff, the devices/scanners/equipment, etc. So someone is going to have to prioritize. It can be just "how much quality of life can we save using the resources we have", regardless of the patient's ability to pay/insurance/citizenship, but some prioritization will need to happen. The policy of the death panels can be changed, but their existence is inevitable.

This is why it makes no sense to have doctors and nurses waste time battling insurance companies over treatments, and hospitals over staffing. Their time is indeed too valuable.

Let's stop trying to come up with "simple" solutions to the healthcare catastrophe in the US because the reality is more complex.

Every time someone makes an argument like this, it's always to say that somehow, medical treatment in the USA is special compared to other countries. We couldn't possibly have universal healthcare work here. Please.

"For every problem, there is a solution that is simple, neat, and wrong."

Don't kid yourself into thinking a complex system that makes up 20% of GDP is going to have a simple solution. Just a couple examples you'd have to contend with:

1) Insurance companies get a say too, according to the Constitution. That means they get to lobby in their own interests. That political problem itself is a boondoggle.

2) The US funds a disproportionate amount of medical R&D. Some of that fat is going to be cut from research. You need to have a plan on how that will effect long term quality of care and innovation.

3) Physician licensures are limited by the AMA. If you expand coverage, you will need to expand supply because any time something becomes "free", people will consume more of it. That's not a necessarily bad thing in healthcare, but needs to be addressed. The AMA also gets to defend their political interests.

There's lots and lots of other issues. I'm not claiming the US healthcare system is great. But pretending it has a simple fix is naïve.

It's like when people point out how much the US spends on the military compared to other Western industrialized nations. Part of that discrepancy is due to the fact that the US disproportionately funds organizations like NATO. Other countries reap the benefit without footing the bill. There was a lot of outrage in Europe when the US tried to enforce the NATO GDP spend that other countries already agreed to.

The US can do better, but I would argue we can't unless we fully understand the complexities of the system. That means not getting enamored by the idea that there are simple fixes. The first step IMO is getting the political will to do so (and to understand the tradeoffs within a complex system), because many of the potentially solutions are stymied at Congress.

A common attitude which may cause:

Health care is extremely costly in the United States. Although the rate of growth in spending has attenuated in recent years, per capita spending on health care is estimated to be 50 to 200 percent greater in the United States than in other economically developed countries. Despite leading the world in costs, however, the United States ranks twenty-sixth in the world for life expectancy and ranks poorly on other indicators of quality.

https://journalofethics.ama-assn.org/article/complex-relatio...

On the other hand, imagine the world where Coca-Cola makes billions on healthy drinks, people are slim and fit until they die, and half of the money spent on treatment of chronic diseases of excess can be used for something else.

This is not unique to the US. Can't really say "but we only have 25% obesity here" and call that any kind of win. Maybe the US leads in this regards (though it varies by region, some areas have European-level obesity rates), but obesity is a worldwide problem.

It's really jarring to read an otherwise reasonable comment that drops a whopper like this. Nothing exists outside of cost considerations. The NSA has cost considerations. The Space Shuttle had cost considerations (obviously, not great ones!). The design of nuclear submarines involves cost considerations, however unsettling that may seem. You're telling me that my broken hand needs to be judged outside of cost considerations? Give me a break.

The problem is that there is a lack of "trustworthy" parties to evaluate cost expectations in medicine. The patient often doesn't understand their condition or its treatments, the doctor has a clear perverse incentive to inflate costs, and the insurance company may actually be better off if the patient dies. At least that's the conventional picture. Leftist pundits often complain that the American economy is based on "greed", but a more precise criticism is that there has recently been a trend away from expecting benevolence and for-its-own-sake honesty from anyone under any circumstances, or equivalently an increasing cynicism about human motivations. It remains to be seen whether a medical system can function when nobody expects to trust anyone.

It absolutely did, and great ones too. The program was too costly and never lived up to the original expectations of fast and easy access to orbit.

Falcon 9 + Dragon is the first American human-rated launcher and ship that can be labeled as somewhat cost effective.

I think this is exacerbated by doctors a lot of the time. I'm in Canada so it's obviously a very different system, but visits to a GP often have strict time limits and "one issue only" rules. When you can only talk about one symptom, and you only have 5 minutes to explain it, it's natural to try and do homework first to see what you're going to use your limited time on.

Strong disagree. This same attitude pervades the military ("only pilots should run the air force") and really all it does is that lower representation of the interests of the other non-pilot 90% of your organization and put a pilot bias on every decision being made.

Anecdotally, this has been true in my experience on complex engineering projects. When the project manager is a mechanical engineer, guess which systems get the most time, money, and priority? Mechanical. And when it's an electrical engineer, the electrical system gets the priority. When it's a software engineer, the software etc. They all recognize the other systems, but availability bias skews their worldview and priorities to the neglect of others.

More than that - hands on healthcare should not be a for profit industry. The need to make profit is fundamentally opposed to providing the best care. As the push for profit increases, more people get sick and die. This goes for long term care as well, which is facing a similar staffing crisis for similar reasons.

Can you elaborate on your rationale? I ask because I've worked in hospitals run by a cadre of physicians and it was not run well. Anecdotal, obviously, so I'm curious on your thoughts on what they provide.

My worry is that it can lead to an unbalanced technocracy. It's like saying a politician needs to come from [industry x] to govern [industry x]. Technical competence is a necessary, but insufficient criteria when managing a multifaceted problem. The risk is that the front-line physician priorities would always become the organization's top priority. In reality, a hospital administrator has to manage competing priorities across many different domains.

This actually isn't necessarily true when you learn how billing codes work. Most insurance companies pay out at a fixed rate per billing code based on your plan. That doesn't change. What does change is that hospitals can retroactively apply new additional billing codes.

This happened to us once for an ER visit where we got 3 additional surprise bills over 6 months because the hospital retroactively applied new billing codes to our visit.

The doctors and specialists gave me every treatment under the son to no avail.

Then I did my own research and read I should try OTC psuedophredrine. It worked like a charm. Now every time I catch a cold (and when I got Covid), I pop psuedophredrine for a few days and I am good.

Yes, psuedophredrine is suggested to treat Covid if you have virus induced asthma.

Second anecdote: I have relatively mild cerebral palsy. As I’ve gotten older, my affected foot tightens up especially in the winter. My neurologist said it was physical and not neurological. I went on vacation and was drinking more alcohol than I usual do. I noticed I was walking without pain. I did my research when I got home and found a prescription muscle relaxant with the fewest side effects and ask my doctor about it. He prescribed it to me.

He didn’t bother telling me that I should get blood work done to check for liver problems. I had to bring it up to him.

I can now walk without pain and run when properly conditioned.

If you look up possible treatments /side effects and your personal history you will be in a better position to engage and weight options. If you blindly accept everything you will end up on the most profitable treatment plan plan insurance allowed.

(Disclaimer: I have been on the design team for several hospitals, including El Camino and San Francisco General, in the bay area - and I have a family of doctors and nurses in my family - my brother was head of the Veteran Administration for the state of Alaska, and is currently CMO for a large health provider (he is a doctor)

---

That said, the "running" of a hospital isa hell of a lot more than medicine (when we are specifically talking to the running of -- but this comment was made in relation to costs/efficiencies as far as outcomes, patient treatment, insurance etc...)

Hospitals are really complex ecosystems and should be thought of more like an aircraft carrier than an other form of business.

The costs within the realm of a hospital are ridiculous - as are the methods and manner in which hospitals raise money.

Insurance is cancer to be sure, but there are so many other factors that go into the operational costs of a hospital - and I don't just mean ngoing care and operations - systems and technology and medicine evolve. People are people and regardless have the same hierachy of needs in any environment.

You have every single actor as an enemy of the hospital bottom line:

New tech, $$

Older nursing pop $$

Current nursing/doctor market salaries $$

Maintenance for existing systems $$

Insurance billing code lock-in $$

Competing hospitals for doctors and nursing staff $$

California $$

Corruption $$

Utilities and related redundant infra to ensure life systems

The ridiculous cost to upgrade

The list goes on and on...

(The cheapest hospital project I worked on was hundreds of millions of dollars)

etc...

Hospitals are really expensive to run, and it requires a hell of a lot more skills than simply being a "doctor" to run one.

This is precisely why I think we will never be able to effectively treat healthcare as a "free market" with tools like HSAs, posted price sheet, etc. The end user can never know the true cost of their procedure until it's long over (sometimes years later) and often don't get to choose at all.

There was a time when hospitals could have helped the nurses with the stress and workload, but the admins bungled it at every possible turn, and now it seems they missed their window.

This is in the US, and I can't figure out why the Department of Labor hasn't cracked down on the medical industry yet. It's really horrific, especially because these are the people we're supposed to be relying on to keep us healthy and safe.

How hard is it to enforce 8 hour days 5 days a week? Every other industry has figured it out.

My gf did both and while she was tired after 12 hours, overall I think she preferred it.

It's already happened with low-wage fast food jobs. Health care is next. Nurses and doctors will be replaced by poorly-trained third-world counterparts.

Yes that's basically what Quebec (and probably other provinces) is doing.

> Do twice as much work for half as much money

I might get tomatoes thrown at me for this, but anecdotally "third-world" nurses are usually not as good due to having experience on different equipment, drugs and often languages. It's better than having no one to cover the shift, but it can be seriously dangerous due to lack of training on specific protocols.

They get paid the exact same amount of money and are in the same union, so they absolutely don't do "twice as much work for half as much money".

Regarding the pay structure for nurses, over time the unions will be filled with mostly third-world ones, so I predict their bargaining position will be weakened and they will accept worse conditions.

For every story of 'X leaves to do Y', there are a thousand people claiming they'll leave, that never do.

A lot of it has to do with size and the complexity that goes along with it. So, as hospitals get bigger, do more, and increase in size and complexity these issues become worse.

The economics math even mirrors factories... a factory that can build 100 things compared to one that just produces one thing.

The book was enlightening, even though many of the time frames called out in the book were wrong. Disrupting medicine is a lot harder than something like technology.

https://www.businessinsider.com/inside-indias-no-frills-hosp...

So like a 2000 bed hospital just for heart surgeries. Like you're saying, the more a heart surgeon specializes, the better they are at it and the cheaper they can do it. Better Outcomes for less money.

> Like you're saying, the more a heart surgeon specializes, the better they are at it and the cheaper they can do it. Better Outcomes for less money.

Not necessarily.

1. A heart surgeon is going to be doing heart surgery at more or less the same frequency regardless of whether the hospital they're at handles only heart patients or not. Wouldn't they?

2. I doubt if anybody here considers them cheap. Yes it's probably cheaper than in the US, but still it's rather expensive. But then again, since life is priceless, ...

https://www.reuters.com/article/us-healthcare-quality-surger...

Maybe cheap is the wrong term, but less expensive? I mean $800 may be expensive but certainly it's better than more?

About the cheapness aspect, what I've seen in India is that if a hospital specializes in a specific type of treatment, there's a good chance it is going to be expensive. Unless it's run by the government or something. But a lot of super-speciality hospitals near me are private hospitals.

It’s is like that in other professions too if it’s only the tech that gets compensated well. There is a shortage of skilled labour.

There’s near-infinite demand for healthcare and a constrained (mostly artificially) supply.

Insurance, people and government can’t solve the problem of the supply and demand by throwing money on it.

You either expand supply or remove demand. Given removing demand is... not desirable. The only alternative to fix the issue is remove regulation and expand supply. That’s it.

Insurance makes the issue worse by increasing demand and in a way limiting supply through requirements and procedures.

Government limits supply through regulation AND expands demand by paying for procedures.

An approach is to deregulate, such as removing government licensing, remove Medicare, etc.

Imo Prices would drop >95% within a 2-5 years (to India or Mexico levels).

I worked in medical billing for a few years and the issues are beyond obvious.

In my opinion, healthcare has reached the state where the people who receive the benefit are too far removed from the people who pay for it and given there is no "victim" of price gauging, the prices will just keep going up up and way.

I defer to those wiser than me for the solution. I don't like complaining without being constructive so here is my ignorant pass at it. This will require a few key steps: 1) Yes, we need more supply (by deregulating the profession) 2) I personally think a more effective solution would be to gradually eliminate insurance except for catastrophic risk (like emergency medical care from a car accident). #2 will shift responsibility to the individual and the system will be capped at what they can charge based on the average person's ability to pay for it (which is how it works in many parts of the world).

I agree with you and the quote above is because of insurance. Medicare will pay 10% of that total and your father would be charged 2-5%. If he has private insurance you’ll see something different, maybe 15% and your father would be charged 3-6%. If he’s going out of network could be 100%. Hospitals / practices charge insane bills because people pay just a small fraction typically. It really impacts those without insurance or private insurance the worst. It is insane.

This is why I have suggested deregulation, particularly around licensing. It drives down the cost. Insurance may cover doctor X, but if nurse Y can do it for 5% the price... well use the nurse. All doctors would have to reduce prices and insurance would have to raise the coverage amount to compete. It’s what is done elsewhere in the world.

So it looks like software development? Are you comfortable for your life to be in the hands of a rando who just finished a 6-months bootcamp?

1 - what does the 'non-premium', i.e. bottomn of the barrel service look like, is that incompetent people offering rock bottom prices (resulting in death?).

2 - are you sure you can identify a life threatening situation correctly? Because my father did not.

3 - how do you know the 'premium' provider in question results in better outcomes, rather than being the same rubbish well presented in fancy packaging?

I think markets are efficient here and there are plenty of services we operate in now with similar spectrums of quality (food, airlines, general contracting, dental work, etc).

The gap between my position and yours i believe fundamentally is that I believe people can and ultimately should be accountable for their decisions. I suspect you believe they need to be protected by a system of accreditation. I guess I don’t put too much weight into that.

When you own the outcome, you are far more likely to do research, ask questions, compare etc.

2- I’m very sorry to hear that. I believe most people can most of the time. The more people are tasked with doing this, the more likely they will be to invest the time and effort to understand their health choices, seek counsel of others and potentially lead healthier lives.

I too am a bit scarred by the medical system. My sister was diagnosed with colon cancer at 33 and it was discovered “just in time” because she kept rejecting the quick diagnoses multiple doctors in Boston gave her. Had she not self advocated she’d likely be dead. I made a similar mistake when my son was born during Covid. We went into an nyc hospital foolishly thinking that if you are nice, quiet and well mannered you will be treated with respect. My wife went into labor alone in a waiting room where she was abandoned for hours despite us telling them how long she was already in labor and her ringing the help button numerous times. I wasn’t allowed until she went into the delivery room but she never made it there.

The lesson for me was clear 1- do your research 2- be prepared to self advocate 3- doctors are humans. Humans make mistake, they have limited and often flawed memories but unlike software development professionals, they do not have the benefit of being able to deploy state of the art systems, technologies and libraries

Happy to take this offline if you care to. My email is in the profile.

The problem is a large swath of the population that believe in all earnestly that squeezing profit is some magical tool for a functioning economy.

Too bad US is so good at PR, this mind virus is wreaking havoc all over the world.

In france your public insurance allows you to walk in a private clinic or hospital too, as a relative did and they cover her post-cancer treatment better than in the public hospital (by her account at least).

So yeah, "free market deregulation" may be an oversimplification but you have a problem in the US that's also far more than just being for-profit. We have for-profit over here and it works.

And that includes private & public institution doing medical R&D and selling their products to the national health services and private clinics, like quite a bunch of spanish companies do, for example. I say this becase it weirdly pops as an argument when it's totally unrelated, and it may be only a tiny fraction of the total cost.

Most healthcare in the west is subsidized by the US. The US market is far more lucrative, so companies do R&D and make capital from the US. The US also subsidizes in terms of both military and energy almost every western country. Even then, Europe has a higher tax rate and on average is far poorer.

I’m well educated on this subject and worked in this area in the US and spent time in other countries. You have no idea what you’re taking about.

These claims are outrageous and totally unsubstantiated. How does US subsidise energy of France or Japan?

"Most healthcare in the west is subsidized by the US." "The US market is far more lucrative, so companies do R&D and make capital from the US. "

You are subsidising the companies, not my healthcare. And they pay out this money in dividends to shareholders. I am sure they are very gratefull, maybe you should ask them for a rebate.

Stop subsidising them and overpaying - do you think healthcare costs in Europe will rise? If you do, I've got a wager.

The US is broken because we somehow believe that a highly regulated market is "free" as long as the government isn't paying for it. We literally have the worst of both worlds.

This worked so well for Rosemary Kennedy when she could be prescribed an ice pick lobotomy. And so well for Eben Byers when his doctor prescribed him radioactive water, and he drank so much his jaw rotted off. It works brilliantly for this woman[1] and her cheap Turkish dentist work leaving her in pain. And for, well all of this junk: https://en.wikipedia.org/wiki/List_of_unproven_and_disproven...

Deregulation is what we had when things were terrible. Regulation and licensing is what we use to block the most obvious junk 'treatments' and the worst con artists.

> "Given removing demand is... not desirable."

Removing demand is enormously desirable. Regulate the shit out of CocaCola, Marlboro, and all the other health destroying parasites and their advertising, tax them, rework town and city planning to remove driving as the primary transport in life and all the associated exhaust fumes, rework public schooling and rebuild trust in the government and medics so people aren't anti-health-advice on principle, rework employment so that employees have some rights and aren't stressed out all the time with no sick breaks. Rework medical access so people can see medical professionals, and sickness can be caught and treated early, which reduces demand on seeing much sicker people later.

> "Insurance makes the issue worse by increasing demand and in a way limiting supply through requirements and procedures."

Insurance makes the issue worse by driving up costs to patients and at the same time driving down pay to medical staff, by insurance taking as much as possible. Without insurance, supply and demand could remain the same, medical staff earn more, patients pay less, and services be more efficient with less time wasted fighting insurance companies and filling in insurance paperwork.

[1] https://old.reddit.com/r/northernireland/comments/ua9me9/eas...

Unfortunately the American public hasn't figured out what the real issue is yet. They reason why they haven't is mostly because the Democrat party , Republican party, entertainment industry , the Main Stream Media, tech industry, and the the Commission on Presidential Debates (CPD) has them occupied with the symptoms of the REAL issue in order to keep them chasing their tails.

The REAL ISSUE why healthcare isn't getting fixed is because of Conflict of interest.The American public hasn't figured out that going to congress who is riddled with conflict of interest and who designed the existing system that we have in place and is benefiting from it, might not be the best idea to fix healthcare.

In fact the best thing to fix healthcare (and the other 99 problems)is to STFU about it and focus ONLY On reducing conflict of interest in congress. Until we reduce conflict of interest in congress nothing will be fixed.

The Democrat party ,republican party, CPD and MSM want you focused on everything but reducing conflict of interest in congress. In order to fix healthcare and any of the other issues we must FIRST try to minimize conflict of interest by implementing the following as a start:

1. Term limits

2. Closing or reducing revolving doors between private and public sector.

3. No private campaigning contributions. Use tech to overcome the need of money.

4. Reform lobbying by doing away with the money aspect of it and utilizing technology to get your voice heard.

5. Pay congress members more and better benefits, but in return demand complete transparency from financial information to limitations in investments , NCA , and make pay and benefits tied to the general overall approval of congress by the American tax payers.

6.etc

Both party and the MSM solution to fix healthcare is the equivalent of going to the MOB and asking them to fix crime in your neighborhood which the MOB is benefiting from and is promoting. It just makes no sense to talk solutions with people riddled with conflict of interest.

You want to fix healthcare stop talking about healthcare and get the individual republicans and individual democrats to put their political ideology on hold and join forces to demand that their party ONLY focuses on reducing conflict of interest in congress.

Hospitals are legally enforced local monopolies (look up Certificates of Need). Meanwhile, you might have a dozen choices of insurance companies, but they all suck because they have to take what the hospital billing departments give them and take the blame or risk being dumped by the hospital.

This is the part that makes the whole experience so sadly ridiculous. Nobody could ever tell patients what something might cost and let them make choices, it was (and is) "Sign here to acknowledge you'll ultimately be responsible for all charges, no matter what they turn out to be." But the insurance company doesn't operate like that, they say "Want to be part of our network? Guess what, you have to ask us for permission or we just won't pay you."

We need to rip off the bandaid, as it were, and reboot the damn system. Pick one of any number of good examples from other modern industrialized nations that have functioning healthcare, and copy it. Yes, everything will be a zoo for a while. We'll survive, and maybe even come out the other side with a better system. And maybe some bankrupt insurance companies, let me find my handkerchief.

Healthcare can be either care or industry.

Applying corporate values to a healthcare system leads to maximum wealth extraction from both providers and patients.

In this context innovation focuses not on the care part but on the extraction. The care is secondary.

How can anyone who cares be a proponent or coexist with a healthcare industry?

Apart from administrators and insurers, I think a large problem is that the job has become substantially more difficult and technology intense, while support and pay hasn't kept pace. At the same time, liability is more serious these days, which I don't think is a bad thing, but certainly sucks for the workers who have to constantly justify themselves and can get crucified for mistakes.

It blows my mind that super long shifts are the norm for a job that's generally more exerting/stressful than your average 9-5. But it's a viscious cycle now because of the shortages of qualified staff.

Here in BC we have a full on crisis where family doctors are retiring at an alarming rate and not being replaced.

Framed that way, this sounds terrible. But... the truth is actual health care outcomes for insured patients in the USA are extremely good. This holds in comparison to other nations, when corrected for GDP and patient income, etc...

"Insurance companies" are, at least in the narrow sense, doing what we pay them to do really well.

They may or may not be making things easier for nurses, which is a different metric. But nurses aren't their customers, we are. And we're getting a fairly good[1] product.

[1] Albeit extremely expensive relative to other nations.

I had not done an eye appointment in years and years because my vision is generally very good - I went in expecting to offer cash, negotiate, and generally play a bit of hardball. I was amazed when the front desk person IMMEDIATELY perked up, looked super happy, and started offering massive discounts before I even threw numbers out. The eye doctors as well were very enthusiastic.

Unsurprisingly, this means many normal people can't afford a therapist and they're getting harder to find.

https://www.verywellhealth.com/health-insurance-companies-un....

In theory, this sounds like a great way to make sure insurance companies aren't just taking unreasonable profits, and that they are spending money on medical care, not administration, keeping the business lean.

In _practice_, what it means is that profits are constrained by medical costs, so the insurance companies are literally incentivized to pay _more_ for medical services. Originally, insurance companies were supposed to be an intelligent negotiator on behalf of their customers. After all, their experts should know much more than a layperson every will.

But with the poisoned incentive to raise costs, customers are basically held hostage by a bag faith negotiator. Not bad faith as in malicious, but in terms of having an enormous conflict of interest.

In the very early nineties, insurance companies lured doctors in with promises of referral if they would just accept certain terms. Originally, this was to the benefit of the doctor -- more referrals. But only originally: once lock-in occurred, the insurance companies began to set their own terms. They couldn't have accomplished this without some greed on the part of many doctors early on.

This seems like the root of the problem, and insurance seems like what "fixes" that but causes tons of downstream unwanted side-effects.

Our options are either to mandate publicly available price lists that are adhered to and hope the market pushes things downwards, mandate prices, or socialize insurance (so that the sole representative of everyone can negotiate the price downwards using the leverage of the provider risking losing most if not all their clients). Or, you know, keep doing what we're doing which is working so well (/sarcasm).

They just sent me a bunch of small bills in the mail one at a time and had a text field online where I could blindly pay them without indicating whether or not I had completed my payments.

Of note, my vet insurance doesn't negotiate on my behalf; they just pay X% afterwards. The price the provider quotes for a given service is the price everyone gets (probably; some of the smaller vets might modify it if someone is low income and in need).

She's looking to switch jobs now and her first offer expected her to travel to locations deep in queens, manhattan and brooklyn, seeing on average 50 patients a day. She currently works at one of the largest hospital chains in NY and is now negotiating an offer from the other largest chain, initially she was told to not worry about salary and that they'd be able to match her previous offer, then HR called her and told her she had 1 and not 2 years of experience so the best offer they can offer her is lower than expected, she said she wouldn't be able to do it so the HR people went to check again to see what they can do and it turns out they called up the hospital that my SO works at now and checked their pay tiers and said they can only match the number that they were told. The new position was close to where we live so she considered taking it anyways but they just called her again and asked her if she'd be willing to travel to other locations multiple times a week to help fill in gaps (but weren't even able to tell her which locations before accepting the offer).

TLDR: don't let your friends and family go into healthcare

Turned a "trusted professional" advisory role into a keyboard role.

Same thing with professors.

One of their neighbors used to work for a home healthcare company in the area.

Is it?

The financialization of every aspect of life, in this case with for-profit hospitals through multiple layers of insurance middle-men, the exodus you describe would seem one of the natural byproducts from miles away.

The profit model of the U.S. healthcare industry might have something to do with it. The fact that hospitals are run like businesses and have shareholders is insane to me. I know other countries' healthcare systems got hit hard by the pandemic too, but it seems like the uniquely capitalist nature of healthcare in the U.S. sets it up to mistreat workers and cut corners for the benefit of administrators and executives.

Having said that we also need to look at patients taking more accountability for their health and consequences for wasting medical professional times.

My 6 month old son was put on topical steroids for a small rash on his back and the doctors solution when this turned into a progressive issue was more and stronger topical steroids.

Eventually I learned about topical steroid withdrawal, and after a hellish withdrawal period, my son has no real skin conditions.

https://www.youtube.com/watch?v=PpW4VV2bsD8&t=28s

And yes, my son at ~1 year old was red and bleeding like that head to toe.

When I brought up steroid withdrawal I was rudely dismissed by multiple doctors including dermatologists.

Doctors currently have willful blinders on at a minimum, and some may be a true embodiment of evil. I hope the whole for profit medical system crashes and burns.

There's just a large range in quality amongst doctors. What you're calling "willful blinders" or "true embodiment of evil" is more likely just a failure to adapt out of a simple paradigm: {Inflammation}->{Treatment = steroids}. And a failure to recognize when that was causing a loop. Maybe they forgot about steroid withdrawal. In fact, as someone with quite an interest in pharmacology and some background as a paramedic, this is the first I've ever heard of it, and I love obscure medication issues.

As I mentioned in my comment I mentioned steroid withdrawal to many doctors when my son was literally only sleeping an hour or so a night from itching and I was dismissed out of hand.

If its not kickbacks, then its such a terrible arrogance as to be evil.

How can a dermatologist not know of my son's condition? Particularly seeing as steroids have been around for a while as you've mentioned. Even when I brought the idea to the dermatologist, after a bit of head nodding his solution was another two weeks of a yet stronger steroid to `calm it down`, and then to taper.

There's a nonprofit trying to get doctors to properly acknowledge the condition.

https://www.itsan.org/

There's as I linked above about a million videos of people recovering from TSW as well.

There's even a study out of Autstralia that followed 10 children with what was called bad eczema, but after a withdrawal period every child at max had pruritis on elbows or knees.

https://www.medicaljournals.se/acta/content_files/files/pdf/...

If my job were skin, and topical steroids was one of the main things I used as a tool, how could I not know about these issues? You'd have to be such a hack that nobody would consider you a professional, yet the same dermatologist that offered yet another round of steroids had his office on the penthouse suite of a downtown building with a showcase displaying awards.

It may seem hyperbolic to you, but you didn't live through this like I did. You didn't see your young child in complete misery due to medical authorities you thought you could trust misguiding you. It's evil of some form.

The correct diagnosis was: That sounds like chronic inflammation. Hit the gym and lose 20 lbs, fattie.