longerthoughts

You need to decouple care from labor as much as possible or you'll just end up trading off between cost and quality without meaningfully moving the frontier.

Healthcare in the US is mostly gated on physician labor. Physician labor is scarce. Scarce labor is expensive.

Physician labor shows negligible productivity growth over time. Wages have to increase to compete for labor against high productivity growth sectors (e.g. software). On top of that, institutionally managed bottlenecks on labor supply prop up high wages (e.g. limited residency slots artificially constrain the number of doctors entering the market). Training more doctors would supposedly compromise patient safety because it would mean lowering the bar for admissions and straining existing staff that need to train them. Even if you could admit and train them all, supplying enough doctors to meet market demand would cause a wage collapse breaking the ROI of med school expenses. So the labor is not going to get cheaper.

So care requires labor that's expensive and only getting more expensive. If you want to reduce the cost of care without reducing the cost of labor, you need to deliver more care per labor-hour (i.e. get more efficient). Provider orgs that employ doctors try to boost efficiency by squeezing every last ounce of time and energy out of their doctors and booking impossibly full schedules. They have a strong incentive to make this work, yet the doctors get only marginally more efficient (and way more burnt out).

To meaningfully move the cost/quality frontier, the majority of care cannot be handled by a human.

8VC laid out a vision [0] that I strongly recommend reading and mostly endorse. It's a long series of hard technical problems but I think the harder problem is actually winning over the institutional gatekeepers (FDA, state medical boards, CMS, AMA). I can't tell exactly what doctors are supposed to do in this envisioned future but the answer will have to be something that sways the gatekeepers even if it's not what's best for patients.

[0] https://8vc.com/resources/ai-healthcare-vision

IIRC this gets gamed by patterns like refusing to readmit patients following complications to hack low readmission rates and preserve higher reimbursement rates? Feels like so much in healthcare where you have a well-intentioned patch trying to solve deep incentive alignment issues and creating more problems.

Yeah MLRs removed an incentive for payers to fight long run rate increases as long as they can model the risk effectively and pass on the cost to members via premiums, but they still tend to fight rapid increases because they break their models and retroactively misprice existing plans. Otherwise we wouldn't see contentious contracted rate negotiations between commercial insurers and providers, but we do.

Absolutely not here to praise US health insurance companies, but they're not the ones using regional leverage to negotiate higher rates - that's the providers.

Yeah absolutely re regulated profit margins (indirectly through MLRs - their actual margins are way below the cap due to expenses) but that only reinforces my point that providers are having more success growing their margins (on a relative basis, anyway).

Great point on bigger pie increasing both shares. I didn't mean to imply it's zero sum.

Oh the irony of MLRs encouraging insurers to provide terrible service (opex recovery boosts profits) and let providers push fees ever upward (bigger pie, bigger premiums, bigger net profit on constrained margin).

Yeah capitated reimbursement moves the risk but doesn't seem to effectively encourage innovation on care delivery when it's relatively easy to just cut costs at patients' expense because they have no agency and meaningful recourse.

Your criteria for when a market is (not) a good solution seem reasonable. My biggest concern is there's a fundamental problem with scaling labor-driven services that's exacerbated by entrenched interests constraining the labor supply to support wage growth. Care delivery needs to change if you want to fix both cost and quality, and I have a hard time imagining monumental changes to care delivery from a government service. Care will be expensive as long as it's constrained by scarce labor. That means either costs will balloon at the taxpayers' expense, service quality will decline to cut costs, or more likely both.

The way you fix that is either a) dramatically increasing the supply of qualified clinicians, or b) automation. Clinicians don't want more clinicians because it lowers their wages, so it will be fought at every level in the name of patient safety. But they also don't want automation to decouple care from their labor, so automation, too, will be fought at every level in the name of patient safety.

Most of this is opaque to voters who are largely under the impression that it's all health insurance executive greed, so there's not much of a political incentive to impose meaningful changes.

Where's the way out?

>I don't quite get the difference, patients pay a fixed amount for insurance, hospitals charge "fee for service" to the insurance. Both systems coexist, it's not one or the other.

I think their reference to "per capita" here is referring to a capitated payment structure where a provider organization is given a fixed amount per patient up front instead of billing for every service they provide. The software analog would be something like a flat subscription fee vs usage-based billing. While it's not the default in the US, it theoretically encourages providers to provide cost-effective care rather than just racking up bills on unhealthy patients.

The mechanism here is who bears the financial risk. The model you're familiar with is one where the payer (commercial insurance or medicare/medicaid) is the risk-bearing entity. They want more cost-effective care so they can protect their margins while the provider is incentivized to push a high volume of expensive care so they can boost their margins. Don't have it handy but the data on this shows providers are winning this battle with healthier, growing margins vs insurance companies whose margins generally aren't great.

>Observation: Most health insurance policies today, whether they are government or private corporation, national or regional, are based on the idea of paying for medical/health problems AFTER the onset of the health problem...

There's a lot wrong with health insurance in the US but this problem is largely on providers, not payers.

Insurance claims submitted by providers are effectively itemized using standardized Current Procedural Terminology (CPT) codes. Those codes are written by the American Medical Association (AMA), the lobbying group for physicians. Doctors make more money when services are expensive and require a doctor to be involved. As a result, reimbursable services tend to be reactive (i.e. more lucrative), rates have a tendency to go up, and CPT codes tend to favor reimbursing for physician time rather than patient outcomes.

In fact, there's a whole category of preventive health companies (e.g. Virta) that sell to insurers because the insurance companies bear the financial risk and benefit from a healthier member base. Insurers will pay for these programs on their members' behalf and try to get them to enroll so they don't have more expensive problems later. Providers make a lot less money when prevention works.

I don't think it's some grand conspiracy by evil doctors, just incentives gradually reinforcing bad patterns at scale.

>Safety regulations are written in blood. They exist because people died because the industries could not and cannot be trusted to regulate themselves.

This sort of absolutist rhetoric is why people waste so much time arguing against maximal regulation and zero regulation in the abstract, neither of which is actually popular or sane.

Many regulations are good, necessary, and effective. Many of them are short sighted, over-specified, or written by lobbyists against citizens' interests (shouting that rent-seeking and safety regs are mutually exclusive doesn't make it so).

>It categorically does not. It would be foolish to do so.

Foolish hardly implies categorically false. It's a well-documented incentive for other risk-bearing entities (see insurance claim denials). Why are providers under capitated contracts categorically immune to refusing treatment to protect margins?

Completely agree with your characterization of the current system but why does making healthcare a government service necessarily lead to better outcomes vs current state or a more sensibly constrained market?

Seems obviously right in terms of total cost to the median patient (less obvious for individuals in higher tax brackets), so I'm not disputing that. More curious about incentives to improve care delivery for better long-term outcomes.

>There's a paradigm shift needed in how health insurance works: optimize for total cost of care.

You're criticizing health insurance but payers are far more incentive-aligned with patients on lowering total cost of care than the providers. They carry the risk and have to pay out claims. Providers, on the other hand, have an incentive to provide lots of expensive reactive care that's bound to expensive labor.

I agree with the sentiment of your "only for emergencies" point and wish direct care was more affordable. The problem is providers charge insanely high rates for services because a) they can get payers to cover it, and b) they're covering the cost of labor that's getting increasingly expensive with no commensurate increase in productivity [0].

For prices to come down substantially in the US, we'd need a much greater supply of doctors or more automated care. The former is against the financial interests of current doctors and the latter is an uphill battle against FDA regs, state medical boards, and billing codes from CMS to make it reimbursable.

[0] https://en.wikipedia.org/wiki/Baumol_effect#Healthcare

Meh, I think it's fine for blog posts to assume familiarity like this if it reflects their niche. They're writing for the type of person who already knows what Duet is. It's not the NYT where there's a massive general audience.

In fact, the choice not to explain things tells me a lot about the shared knowledge of a niche when I'm looking in from the outside. I don't mind the extra digging to decode it and the implied familiarity gives me information about its importance.

>Sometimes the time it takes for an order to land on your doorstep is longer than it would have taken for you to drive to the store and pick it up yourself.

This misses the point. One is you devoting your own time and attention to doing the task, the other is delegating it so you can use your time for other things. Some people are going to burn the extra time scrolling (not great), others are going to help their kids with homework or get a workout in.

I'm all for people getting time back even with the downside that not everybody will choose to use it well. If people are choosing brainrot over living well, there's a bigger issue than delivery services.

This can all be true yet people fighting for their lives often feel like they're getting ignored, dismissed, or treated like livestock by their doctors. It's hard to see your doctor as the victim when it's you or somebody you love bearing the cost of their shortcomings.

To your point, it's hard to imagine any human dealing with the conditions a lot of doctors face then showing up the way we want them to all day, every day. But how much suffering are patients supposed to absorb to subsidize the stress budget of their doctors?

I wouldn't go as far as drawing an analogy here, but it reminds me of debates surrounding police violence in high stress situations. Is there a higher standard when you're accountable for other peoples' lives? Are you off the hook or is it on you, and not the people you serve, to fight systemic and situational problems that make it hard for you to do your job well?

The legal and political hurdles here are worse than the technical ones (at least in the US).

Not as familiar with dentistry for but for "AI doctor", FDA needs to either create new categories or approve AI care under medical device and software as a medical device (SaMD) standards, state medical boards need to relax the licensure grip on scope of care, and CMS needs to create new CPT codes (which are largely dictated by the AMA i.e. lobbying group for physicians) so there's a way to bill insurance for AI-provided care.

Unfortunately we have a much better system for maximizing physician wages than minimizing patient cost of care. Doctor demand is guaranteed by frequently tying legal, reimbursable care to physician labor, and doctor supply is limited by the number of available residency slots. Ironically it makes doctors miserable because they're ridiculously overworked due to the excess demand and constrained supply.

Found the dentist /s

>What I do think is evil is using your wealth and power to corrupt the bounds of the law to enrich yourself.

I think a lot of people (myself included) would agree on this and fail to agree on what qualifies. For example, if somebody earnestly believes they can do more good with the money than the US government, even if they're wrong, is it evil for them to try to legally influence lawmakers? I'm not sure that's evil, but I don't need that individual to be evil to believe you should reform the laws that let them do it.

It seems way easier and more productive to demonstrate that a law is failing to achieve its intended effect than it is to demonstrate that a group of people are evil so we can all be mean to them on the internet and hope it makes them stop.

>I guess amoral sociopathic behavior is permitted behind the corporate veil and there is nothing that can or should be done about it.

This is such a weak characterization of the argument. What are you proposing we do to sufficiently punish people who have broken no laws? You can't effectively police individuals or corporations according to unwritten rules, so write good rules and fix them when they fail. That's what can and should be done about it!

I agree with your first point. On the morality question I generally don't take moral issue with legal tax avoidance, but "it's legal" and "you would do it too" hardly imply "it's right".

Either way the morality debate seems irresolvable, which is why I wish people would debate tax policy and focus on the system instead of calling people evil and hoping they consistently act against obvious incentives.

I'm never sure what to make of this point.

OP's point implies that it's a predictable byproduct of the system design because people consistently work to minimize their tax burden and the effort scales with their means. Wielding money to influence lawmakers seems bad, but is also a certainty in a system where your lawmakers are willing and able to legally accept it.

If you want to hold people morally responsible, why hold entities designed to maximize profits to a higher standard than lawmakers who are there to represent the interests of the people?

And if you want things to change, why fixate on moral judgements about legal behavior instead of systemic changes that yield better outcomes within the constraints of humanity's natural tendencies?

I can't be the only one who read this in that old-timey radio voice

Yep you’re describing an RSL - it’s a line that should deploy the reserve as the main gets cut away (although good practice to pull the reserve handle anyway as a precaution).

In my hypothetical failure case you referenced it wouldn’t help because the instructor didn’t cut away the main - they went straight to their dedicated reserve handle.

Cutting away should automatically deploy the reserve, but deploying the reserve from the reserve handle doesn’t automatically cut away the main.

ah true, openings would still be harder - bigger canopy only saves you on landings

>Not that watching the safety video would have helped in this case, as the instructor was not properly trained and vetted in the first place.

The article is a little vague about the failure but I'm a skydiver and this might not be the instructor's fault. I know that sounds insane but hear me out.

The article says "main and reserve parachutes had tangled, preventing either from opening". This could mean a few things:

1. Neither chute was ever deployed - "total malfunction" on main and reserve where they're both stuck in the container (backpack thing holding the parachute).

An instructor following perfect protocol with a poorly packed reserve would have died here, and they likely did not pack the reserve themselves. Reserve chutes are packed by a master rigger who's required to apply a seal and update a little paper record on each rig indicating when it was packed and by whom. These are meant to be checked before you're allowed to get on a plane. Reserves are (thankfully) rarely opened until they're due to be repacked based on time. There's overlap between master riggers and instructors who handle tandem jumps, but the reserve was most likely not packed by that instructor.

2. Main deployed but has a "partial malfunction" (out but not fully open), reserve then deployed and tangles with the main.

This would be the instructors fault - in this case they should cut away the main before deploying the reserve.

3. Main has a "total malfunction" where it doesn't come out at all, instructor deploys reserve, then main deploys late and tangles with the reserve.

This one is inconclusive but probably not the instructor's fault. Protocol here is don't waste time cutting your main because you're falling fast with no drag from a partially deployed chute and the main is unlikely to ever open. The reason it could still be the instructors fault is if they had a chance to cut away the main after it came out and failed to do so before they tangled.

Lodi is a notoriously unsafe drop zone (I'm an experienced skydiver in the bay area). I don't know if it's a cold-hearted greed thing so much as it's an anti-rules, anti-establishment thing where they like to scoff at safety and protocol. I wouldn't jump there or even do a group dive with anybody who regularly jumps there.

Not sure when the people you know were jumping but I've heard a few older (non-military) guys at drop zones complain about shoulder, back and hip issues from harder openings with the rigs they used in the '90s and early '00s.

Parachutes are typically sized according to weight to manage rate of descent, so the extra weight shouldn't be an issue. Given the context I wonder if the military just calibrates around faster rate of descent because it's risky to stay in the air too long.

I'm an experienced skydiver - one death per year is an insanely low bar for any drop zone. Lodi is notorious for incidents and I would never jump there.

Skydiving seems insanely risky because it's scary but it's statistically not particularly risky [0], especially for conscientious skydivers at well-run drop zones. The calculation on "calculated risk" changes dramatically once you start blowing off safety protocol, which are what keep the sport relatively safe.

[0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9859333/

it’s possible to think extreme wealth disparity is a bad thing without needing every single action taken by its beneficiaries to be a bad thing.

yeah, i got it. and the point i’m making is i’m not getting outraged over it because it is a charitable contribution and he has an incentive to report it. does it feel a little gross and is this whole thing probably a PR stunt? sure. but i’ll settle for letting billionaires be charitable for the wrong reasons if it means they’re being charitable. i trust people to see this for what it is. i’m not sure why anybody feels obligated to leap into threads like this and strain to reframe neutral-to-positive events as profoundly negative. you don’t need to save us from possibly thinking a brief positive thought about a thing a billionaire did. we’re fine.