- Insurance companies are in bed with hospitals to collaborate swindling money from the govt: read about kickbacks sent by the US Govt to hospitals as Disproportionate Share Hospital payments.
- Hospitals have a PR arm moving profits to defend their monopolies, including using SALT rules to create barriers to entry by geography.
- Hospitals also use govt rules against it. They were able to obtain an absolute advantage over all other players (ASCs, Independents) by getting the vaulted nonprofit status, which independents cannot get.
- Hospitals use their nonprofit status and barriers to entry to buy out competition: nimbler independent providers that are actually able to lower prices.
So, hospitals create their own rules, drive out competition, and create monopolies that leads them to hoard cash, which then they use to buy out competition and mire them in 1970s technology so we all pay more.
Then there's also PBMs, and Insurers. That's a story for another day, but plenty of blame to go around.
I post that hospital systems are so large, that at the bottom, Hanlon's razor may apply, but at the top, there's incentives one cannot ignore - and a lot of prejudice to keep the game as-is.
Make those programs go away, and CPT codes would eventually die.
It is not going to go away so unfortunately we need to learn to live life with it, and instead make it irrelevant, or niche, just like a ferrari is niche.
The best way to cope is to have an alternative to CPT coding, which means, alternative to insurance-based healthcare, which means, medicine between patients and doctors.
The only way to do that is that insurance and CPTs get so expensive that an alternative system is demanded by the market.. and people opt in (and regs allow for it). In effect, ferraris vs corolla. Corollas don't care about CPTs, Medical Billing, Eligibility, Copays, Coinsurance, or Authorizations.
The only way we can get more honda's is by having more independent doctors and less hospitals.
Hospitals create monopolies, independent doctors break monopolies with competition.
- The federal government is by far the largest health insurer - through Medicare and Medicaid it pays for 38% of healthcare in the US [1]. - The federal government directly subsidizes private health insurance through ACA [2]. - The federal tax exemption for employer-paid health insurance is by far the largest by dollars exempted [3].
All these government interventions increase reliance on health insurance, which increases the complexity of billing, which grows the medical billing industry.
[1] https://www.statista.com/statistics/237043/us-health-care-sp... [2] https://www.healthcare.gov/glossary/subsidized-coverage/ [3] https://www.npr.org/sections/health-shots/2012/12/04/1664342...
value based care is another iteration of "pray for alternative" to non FFS model, aka the APM.
This is the road of the HMO, the RVU, the QCCS...and i could go on and on. Its the road that we have traveled on since the late 80s. Its the road of the wanderer in the desert.
It doesn't lead anywhere but more profits for the road-builders.
40 years of history with 0 decreases in healthcare costs is all the evidence you need to put this one to bed.
The question might be: can we create an Uber-like business that has gives doctors the tech infrastructure to consult with patients without it feeling like a mom and pop shop?
Not in the strict uber model. Mind you. Providers will need to keep more of a share for it to work.
Courtesy of Louis Rossman, possibly stealing the quote, speaking about governments screwing up their fines and regulations.
I'm a professional patient, 99.9% of the doctors I've took treatment from(not U.S.) for major ailments are businessmen masquerading as doctors and I'm not talking about some scrappy hospitals; These are world renowned hospital chains.
What happens when you optimize for profit, instead of medical science? Wrong diagnosis and prognosis; I'm a victim of one and it has ruined my life.
On the other hand, There are doctors who risk their lives every day to serve people in need e.g. Doctors without borders, Doctors who rushed to serve during pandemic(Many of them loosing their life to it) etc.
DSH rules are gamed to extract more from the program
> Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.
It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.
Inside this richest country, the richest individuals and companies have been capturing ever-larger shares of GDP. Perhaps instead of growing private fortunes, this money could have gone towards modernising these regulated industries?
This statistic is misleading. The US is only the richest country on Earth if you consider the mean wealth. By median wealth, the US is ranked 26th. The wealth gap is enormous, and if you're in the upper echelons of the pyramid your health outcomes are vastly better than the clownshoes shitshow that the rest of the country is subjected to.
In fact, the wealth gap is but a reflection of the underlying cause of the problem: legislators corrupted to the interests of the donor class at severe cost to the actual constituents of those legislators.
These kinds of reforms would have had to begin decades ago to make much of a difference.
So... perhaps if we'd had a better goal 50 years ago - single payer or universal medicare or whatever you want to call it - we'd have decades of technical debt that propped up a fairer system, instead of an unfairer one?
Perhaps we need to change our goals today so that 20-30 years from now things will be better then?
Compliance within regulation is a noble goal? I should think it’s ethical goal.
What you refer to is actually a collection of hundreds of millions of individuals, with all sorts of interests, sentiments, ambitions, sometimes conflicting ones.
Voters are incredibly scared of change because it's so vital. The current situation isn't caused by a lack of resources but a lack of focused will
And those who generously give may not oversee how money is spent and likely squandered to a certain degree.
Takes an incredibly self sacrificing individual to risk it all, which is what this requires.
In less rich countries they use paper records, which are worse. Everything is held together with spit and twine.
Of course many countries are worse, but surely you want to look at successes of others and replicate them.
I personally think it's a very dangerous thing to believe, because it means there's no driving force to improve, and it's a part of the reason the country has stagnated so badly.
She also says that, of the half-dozen medical record systems she has used (here in the US), Epic is one of the better ones. (read: least bad)
I'm sure if you talked to medical professionals in Pakistan they would bemoan their medical record system too. It seems to be popular sport in the medical community.
Passing around financial data on SFTP drops is something that irked me. Having the total not add up from the line items is also pretty ridiculous. The systems in place are all about edge cases that have formed over decades.
Software engineers are not invited to the discussions in a lot of these companies. The area is gate kept by healthcare people, which tend to be people who don't know how to do technical writing or planning.
Our company wasn't a huge one. But the huge ones looked to me as run by accountants. If you can't establish an income stream for them, they won't even talk to you.
I see this a moderate amount in fintech, or perhaps at least older fintech?
Had a colleague tell me about a new financial info provider he was supposed to connect with for data. "Oh this one will be easy" he was told. "They use oauth". OK... well... you oauth in, then you hit an endpoint that triggers a data build which then puts your data file in to an FTP account of your configuration. But you can't even configure it via hitting the endpoint behind the oauth. You have to log in to a web app to configure the FTP account for your account.
You hit the API endpoint and get 'OK'. But... that's it. You might get a file in your FTP account 5 minutes later. Or an hour later. It's just whenever it gets processed on their end. And... if it doesn't show up - you have no indication whether something broke, or perhaps the data service "just doesn't have any data for you today - you can't expect data every single day".
It's insanely crazy how across-the-board poor so many of these mid-level data vendors are. Colleague is currently supporting 8 different integration ingests like this - some deliver FTP daily, some you have to pull down, etc.
One delivers data which is only ever a delta. You have to continually request previous daily info from them to get to the 'first record' for that account, which can sometimes go back years, but... you don't know that up front. So you have to loop and request "day before", pull down data, parse it, then check the day before, until you don't get anything for that customer, then presume the previous was "initial balance". But you also can't just do that once, because... there may not have been any data the day before because... holiday? system down? So in practice you need to go back 3-4 days at least to verify. Oh... and don't keep looping and requesting too fast... you'll exceed the low rate limit ("we don't want people abusing our API").
I can only barely imagine how systems evolve like this, because they don't really seem to serve anyone's interest fully.
And btw, that description given by your colleague brought cringy mental flashbacks on meetings I've recently attended.
I also worked with a state medicaid office. They refused to use DNS, they decided it was insecure. Which was lots of fun any time we changed datacenters (3 times over my 7 years there). They would also go down, and nothing would happen until around 9:30-10am the following work day when they would finally come around and fix it.
The most competitive/efficient markets generally need the optimal amount of regulation to keep/get them that way. Those regulations would ensure that these conditions continue to be met in order for it to be a competitive market: https://en.wikipedia.org/wiki/Perfect_competition#Idealizing...
Free markets that are completely unregulated will tend to veer towards collusion and monopolies, in which case they're no longer competitive and the customers suffer. Free markets that are overly regulated will also suffer, but more-so due to things like the regulatory burden/barriers for new entrants.
What we have in the US healthcare system is a demented hybrid where some parts are free market but under-regulated, while other parts are free market but over-regulated. It's the worst of free market and state-run combined.
But in reality, good regulation is good, and bad regulation is bad.
It sounds silly written out because it's a tautology, but if more people internalized it we could have much more productive conversations. Instead of going back and forth on whether regulation is good or bad, we should try to figure out which regulations are good and which are bad, and then try to get rid of the bad ones and pass more of the good ones.
No one brick in the road to hell is bad. But you can definitely pave a road to hell with the accumulation of "positive" changes. People tend to define positive over too short a timeline or too narrowly.
They're just rules we make for ourselves. There's nothing special about them. Opinions like that are why we can't fix messes like this.
Perhaps its just low pay attracting low talent
The goal of the regulation is to increase prices (profit) while preventing other parties from competing on prices
Suppose I want to sell my product, and find a company willing to buy, a middle manager signs the contract. When the company recieved my product, it refuses to pay, says this person was not authorised to sign the contract on behalf of the company.
Must the company prove the purchase was unauthorised, or must I prove the employee was authorised? Suppose employee was unauthorised, is it my or the company's problem if this guy 'took initiative', who eats the loss?
What if they already used my product and only realised after the bill came due? What if the deal was overpriced like 10x from market average? What if the guy's title says 'Head of procurement' but the company swears their bylaws don't allow him to authorise purchases?
And I think you're talking about contract law, not regulations.
(Source: was doing medtech development for a while in the early 2010s).
I don’t know how it works in the US but at least in France, most hospitals are part of universities so they are also doing a lot of research.
It's precisely the opposite. Its a racket but its not for profit. If you made a health care service that didn't have any of this cruft and just provided great care, it would not be used, because it would not be compliant with insurance, and employees would not get the tax benefit of using it.
If it were for profit, it would work better.
https://www.cigna.com/employers-brokers/insights/informed-on...
(Germany has private insurance and France as well in parallel, but the main system is "sozialised")
The healthcare systems in Canada, the UK, France, Germany and Switzerland are all distinctive (they’re main commonality I suppose is that they somehow deliver quality healthcare at a fraction of the US cost.). But to hear Americans say we should “do it the way it’s done in Europe” is to understand that the person likely don’t know how the healthcare systems operate in different countries.
The other frustration in talking about this is the tendency to “It’s just” the problems. If this were a simple problem with an obvious solution it likely would have been solved. We are where we are because of a century of organic, and often idiosyncratic, growth. Well intentioned policies of decades ago have come back to bite us with unintended consequences as likely are our best ideas today.
I don’t say we should throw up our hands and give up, but when anyone says there is an easy solution - we just need the political will to let them do what they want - I do see snake oil.
"Some of you may not be in compliance. We start you off at a fine of $1. For every month this continues, the fine doubles."
All you need for a sensible regulatory environment is a complete overhaul of how your society works, starting with a campaign finance & congressional staffing system that isn't built on implicit corruption.
Fine these people out of existence and let someone competent (if such a person exists) pick up the pieces and start anew.
Eh, I'd rather listen to duffpkg, with his extensive, real world experience in health tech, than a random comment.
FWIW, a former coworker of mine spent a few years at a health technology company (also worked with MUMPS), and legal compliance was the number one hurdle to modernizing. It was expensive, and created a huge drag.
I'd never heard of it -- until I was at an afterparty at last year's AWS ReInvent and started talking to an older couple near us over some drinks.
The guy was well to do and had been in technology a long time. We had a great discussion where he told me about things like MUMPS and other tech I'd never heard of.
When they left, his wife gave me his name. Looked him up, it turns out he was C-Suite at a company nearly everyone has heard of (but is not known for being a tech company).
Makes me wonder how many billions of dollars are being pumped into tech I wouldn't recognize the name of.
From what I read, MUMPS is actually very performant. Although other companies use it, Epic is the giant. Epic was considered a decent company to work at - good reviews, good work/life balance. The downside is mastering technologies that no one else would value. Or so everyone thought. The reality was that if you become well versed in MUMPS and the Epic stack, a lot of hospitals would pay good amounts of money to you - a lot more than what Epic paid.[1] The only catch was that Epic had a 1 year non-compete clause.
At the time I considered them, they were starting to develop stuff with Visual C++ and .NET, so there was a chance you'd learn more transferable skills.
Fun story: The first time I encountered them at a career fair, I knew nothing about them. I was a grad student. At the booth, they asked me my SAT and GRE scores and were crazy impressed, and immediately booked me for their "entrance exam". At the time (perhaps even now), all candidates had to do a written exam - they'd arrange for the university to conduct it. The exam was mostly assessing logical skills, etc. No advanced material.
I didn't know anything about Epic at the time, and was extremely turned off by anyone being so easily impressed by things like SAT scores. I didn't bother to go through with it. I was studying an advanced degree, and wanted to work for a place that was not so superficial.
Fast forward a semester later when I really needed a job. I researched Epic and it actually didn't feel so bad. I felt I would easily ace their logic exam. So I applied to them. This time, though, they made me do an online behavioral screen first. The type where they ask questions like "Are you more of a X or Y?" where you feel you're neither X nor Y. Apparently I flunked that test and they didn't invite me to take the logic test. Bummer.
[1] Not FAANG level money, but still a lot more than industry average, and a relatively cushy job with you being treated as "the expert".
heard this is no longer the case with the pandemic. Apparently the CEO had some questionable perspectives on COVID for someone who managed health tech. None of my friends who had jobs there made it through covid without quitting or watching their team quit.
Anecdotally, their recruiting is a mess and the IQ test type interviewing is very common for them instead of FAANG style interviews. I reached out to them at a career fair and they laughed at me and told me I was unqualified because by resume said "medical engineering with a focus on software" and said they only wanted software engineering. That day I re-wrote my resume to say "CS with a focus on medical tech" (I was formally un-declared as a student at the time) and the same person who threw out my resume offered to interview me - I declined.
* I also would later graduate with a degree in computers not medicine, in large part due to that interaction, despite forming a very negative perception of that recruiters behavior.
From my brief time working there, it seems their recruitment pipeline is wonky for the devs while the support staff are open to applicants of any and all backgrounds (provided they can pass the IQ tests)
At the end of the day, Hanlon’s Razor is just something some dude came up with to explain what is the most likely but not even necessarily correct assessment of a given situation. It is often unjustifiably treated as some immutable law when it is really just a flourish of rhetoric.
Regulation is one piece but ultimately dysfunction stems from huge differences between what different constituents want from a healthcare system and what they want it to be (and not be). People hold extremely different views about it. Depending on your circle and where you live you may not realize just how far apart your thinking is from people in other circles and places. Creating palatable compromises between those groups has proved almost impossible and so a lot of what we have in lieu of a compromise occurs by default and accident.
Isn't this the desired outcome, that such organizations go broke? And let their assets, employees and customers go to some other organization that isn't saddled with technical debt?
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I mean, I can see why reimplementing could be scary even with org churn.
In healthcare especially incompetence opens the door for bad actors to exploit weaknesses in the system which amount to huge amounts of money being wasted. Medical fraud, for example, is one of the most sophisticated organized criminal activities in the United States. Mafias setup hijack doctors offices and pharmacies (or setup fake ones) and they know exactly how long it will take until they get caught. In the meantime they can extract tens of millions of dollars from insurance companies in fake claims.
And the fraud pales in comparison to the blatant waste. Doctors office's who order unnecessary CT scans when they or their affiliates happen to own a CT scanner. Pharmaceutical companies who market brand name pills that are no more effective than generics. Insulin manufacturers who manage to charge $1,000 a month for a product that's over a hundred years old.
In the case of pharma specifically, there are a lot of pricing inefficiencies that are deliberately not corrected due to political corruption so that they can be exploited.
Humalog insulin was patented in the 90s, and IIRC, is what Walmart sells for $25/vial. Novo Nordisk (among others) continually improves the product. Those improved products are where you see the $1k/month prices.
The 3 main reasons cited by pharmaceutical companies for the high cost of new prescription drugs do not apply to insulin. First, the “high cost of development” is not relevant for a drug that is more than 100 years old; even the latest and most commonly used analog insulin products are all over 20 years old.8 Second, the pricing is not the product of a free market economy. Free market forces are clearly not operational; there is limited competition on price, the person who needs the product is not in a position to negotiate the price, and there is no relationship of price increases over time compared with overall market inflation. The price of insulin has risen inexplicably over the past 20 years at a rate far higher than the rate of inflation.9 One vial of Humalog (insulin lispro), which used to cost $21 in 1999, costs $332 in 2019, reflecting a price increase of more than 1000%.10, 11, 12 In contrast, insulin prices in other developed countries, including neighboring Canada, have stayed the same. Insulin pricing in the United States is the consequence of the exact opposite of a free market: extended monopoly on a lifesaving product in which prices can be increased at will, taking advantage of regulatory and legal restrictions on market entry and importation. Third, the arguments that high costs are needed for continued innovation and that attempts to lower or regulate the prices will hamper innovation are not a valid excuse.13 There is limited innovation when it comes to insulin; the more pressing need is affordability.
https://www.mayoclinicproceedings.org/article/S0025-6196(19)...
You are mischaracterizing MUMPS which is now called M and has been updated many, many times since its invention and has a robust standard library of functions from M vendors.
https://en.wikipedia.org/wiki/United_States_v._Microsoft_Cor.... https://en.wikipedia.org/wiki/Epic_Systems
1. There is absolutely nothing special you need to do when handling values out of the database compared to in-memory values 2. The nested data structure—it's like a nested Python dict, except each level can contain a value and children.
Can you share your insight as to why it is not something that smaller companies or starts up have tried to fix? You can also email me (email is my HN username at Gmail dot com). I'm interested in learning more about this on a technical/"behind the scenes" level.
US healthcare billing certainly could benefit from a massive simplification, and the reason of the success of neobanks/fintech is the same: they always started from green fields and didn't have to fight internal politics battles to change a data entry mask.
I feel this is why efforts like FHIR are very important, though certainly scratching the surface.
I'm going to ballpark migrating from Epic to OpenEHR without losing data would probably cost you something around $500/patient. So consider a medium-sized hospital that has 250k patient records. $12.5m project. That takes 2 years. (I'm considering all the places that Epic has custom integrations with other systems, with your insurer, etc, in that $500/patient, which is probably low, but gotta start somewhere). Add in the cost of re-training staff to use the new EMR, finding out after implementation the 'shadow IT' systems like someone exporting data to an excel spreadsheet and then doing a huge workflow on that that no one outside the department really knows about but is absolutely vital to the pharmacy's ability to operate...
OpenEHR can help address some things for one part of the system. But that is like saying fixing OpenSSL bugs will make all the internet secure.
It is very good there is are the transparency regulations. It is worth briefly explaining some of the reasons why many facitilities are having a hard time complying. There are some bad actors, absolutely true. However "Hanlons Razor" -- never attribute to malice that which is adequately explained by stupidity -- definitely applies.
Many health systems are a lot more like "medical malls" than they are single monolithic enterprises. Lots of health systems use really, really old technology and also a lot of it from a company called "Epic". Epic does what it wants, when it wants and there is basically nothing anyone can do about it. There is rarely one central consistent mechanism and source of truth for pricing data because it gets generated from a complex web of different entities, systems, and processes. Herding all those cats is why it can take a health system a long time to comply. And also why a fine of even a million dollars can be small potatos vs the cost of actually complying in a timely manner.
Just one facet, MUMPS is a widely used technology which you probably haven't heard of and which very few technologists understand. Lots of people are struggling to create new code to meet the new regulations using 1970s era technology including MUMPS.
Another, a lot of health systems have been around a really long time. The insurers they work with also, (since the 1960s at least). They have Electronic Data Interchange EDI relationships built on the standard called 837. Business logic that surrounds pricing and billing is often buried in 50 years of tech debt. Everyone is deathly afraid of making too many changes too fast because when those systems break the money stops flowing and a health system will literally go insolvent. People still have hard physical lines connected to Medicare mainframes.
This is a similar situation to other regulated industries like banking, airlines, etc. Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.
Disclaimer: I have been involved with the development of some of the fee schedules and health systems mentioned/criticized.