This lack of empathy extends to many other areas: Drug addiction, homelessness, rights for marginalized groups, etc. So long as there is a profit motive, these things will suffer due to the selfishness of those who don't (yet) receive a benefit.
I wonder how this study controlled for hospital selection though. In locations with multiple hospitals available, ambulances route patients on multiple factors... Perhaps there are factors leading to these hospitals receiving patients less likely to survive.
Additionally, PE often purchases distressed companies, so the likely alternative to a PE purchase of a hospital is a closed hospital. In some cases, closing the hospital would be better, but probably not all of them.
* the amount billed to individuals is often wildly different than the bill an insurance agency would negotiate with a provider. (I'm not an expert, there may be more layers of indirection there; this is simply my mildly-educated impression.)
* Depending on the sort of care you seek, a provider may have a de-facto monopoly in the area.
* There's no obligation (or indeed incentive) to be up-front about costs—we've all had the experience where we were charged for a service that wasn't even presented as a clear option, let alone one that would cost money, let alone anything approaching a reasonable charge for the service rendered.
* When you need care the most is often when you're least able or inclined to play providers against each other/shop around.
* Deductibles are so high we're essentially pitting high regular premiums against worst-case scenarios, which is deviously difficult to reason about, even for actuarial experts.
...etc etc. It's not easy to proactively think through costs in the world of American healthcare even as a cost-conscious, pessimistic actor. And on top of all this, the sheer bureaucracy necessary to manage negotiating payments and insurance coding adds a significant amount of overhead (inefficiency) to the provider's end bill and to your premiums—how on earth can you audit a provider's or insurer's efficiency? It's all opaque, and most of us don't want to think about it at all.
This seems extremely high.. Ireland with free public healthcare for example is ~6%.. I think the largest in Europe, by a lot, is Germany? ~13%.
Health providing shouldn't be a for-profit endeavor. Certainly shouldn't be in the stock market and it absolutely shouldn't be comingled with "insurance"
What keeps me from bringing my business too the competition like I do in every other market? The main constraint I see right now is that there are very few, but large hospitals and my insurance only pays for me to go to even fewer of those. However, competition already works (if the patient makes an effort) for some planned procedures like CT scans where you can safe up to 80% in my own experience.
Is this a product of inflated prices ? Or is this research funding for example ? I'm curious what the complete definition for Healthcare spending actually is.
https://fiscaldata.treasury.gov/americas-finance-guide/feder...
$965B is Medicare - healthcare for old people
$885B is Health (aka Medicaid) - healthcare for poor people
$360B Veterans Benefits and Services - at least half of this is healthcare for active and retired military (subset of federal government employees)
The healthcare for non military federal government employees is not included in the above amounts, nor is the state government and lower government level spending on healthcare for employees.
Combine the above numbers with $1.45T in Social Security (cash given to old people), and all other US federal government expenses pale in comparison to wealth transfers to old and sick people.
US public healthcare expenditures are similar to what some developed countries with fully public universal healthcare have—and the private expenditures on top are more than the public costs.
People sometimes joke about the US having gaps in healthcare because of defense or other spending, but the fact is the US effectively pays vast amounts of money to create those gaps, rather than having them because of some resource constraints.
There are still people trying to behave ethically within this framework, but it's hard when the framework itself is so corrupted by profit motives which should never have been there in the first place. Direct providers should be running the show, not financiers. They need to be aware of how to balance the books within reason and be paid properly, but beyond that it should be much more patient focused. We definitely don't need so many profit-taking leeches in all the places we have them now.
1. Doctors, nurses, and hospital admins make dramatically, *dramatically* more money in the US than anywhere except Switzerland. Every time a discussion of healthcare costs comes up, everyone tries to point their fingers at middlemen, but the middlemen extract tiny fractions of the revenue stream. Most of it goes to actual humans that are high status, and no one wants to imply they’re lobbying to lower the pay of these folks
2. The US pays for drug development for the entire world. You can call this the US “overpaying”, or the rest of the world “free-loading”, but the US is a very rich country that has decided to incentivize drug development by allowing drug companies to profit from their massive investments by setting high prices
3. Americans are fatter than the rest of the rich world (although the rest of the rich world is rapidly catching up) and chronic metabolic-disease is very expensive to treat (everywhere)
We could trade reduced innovation for lower prices, but that's a difficult ethical debate to settle given the prevalence of medical suffering from lack of effective therapies.
The solution I personally petition for is looking for ways to make drug development more affordable across the board.
Where are all the anti-taxes people on this apparent involuntary charity for the pharmaceutical industry?
It's not free, but it's shockingly less expensive, and there are cheaper countries in the EU than Austria.
https://thedailyeconomy.org/article/how-congress-created-the...
Respectfully, my perception contradicts this. My GF has been a psychologist for 25 years. For the first half of her career, funding for her work was provided exclusively by a state program (California), but about 10 years ago, the funding transitioned mostly to private health insurance. And it's been a bureaucratic nightmare every since. She had to hire a skilled/well-paid FTE just to manage the billing with the private health insurance companies. And it's still a nightmare to deal with. So yeah, to downplay the "bureaucratic overhead" of private insurance, is not universally accurate, IMHO. Maybe for big hospitals, it represents a small percentage of overheard, but not for smaller providers.
> There are no official data on their total size, but estimates extrapolated from micro-costing studies suggest that billing and insurance-related services alone comprise about 15 percent of health care spending, and total administrative costs may comprise about 30 percent.
1. https://econofact.org/how-large-a-burden-are-administrative-...?
I’d only extend that point 2 is true for many cutting-edge treatments beyond simply drug development & is tied to point 1: If you pay doctors top-flight salaries, you get a lot of smart, innovative doctors pushing (at great cost) into the future of medicine.
Similar story with admins working to make care more efficient and also humane, data science teams (yes, big research and academic hospitals have these in spades!) …
America is rich and wants to spend that on medicine. It’s not a conspiracy of oligarchs.
Insurance companies spend a maximum of 80-85% of collected premiums on healthcare, and only because this is regulated by law, otherwise it would be even less.
On the other side hospitals, clinics and private practitioners all have dedicated departments and staff whose only job is to deal with billing and negotiations with insurance providers. That also costs a hell of a lot more than a couple percent.
So just adding up these two there's 15-30% of medical expenditure that isn't going towards actual care, just overhead. Recover this cost and the US will immediately fall in line with how much the rest of the developed world spends on healthcare, even with the high doctors salaries and drug costs.
Much of this is heavily subsidized by insurance. Any drastic change in the status quo would inevitably cause pricing and coverage that people are used to be adjusted, which is why they say they want healthcare reform until it actually happens.
- health adjusted quality of life metrics and the way they are impacted by various diagnoses
- healthspan metrics
- patient satisfaction
- employee satisfaction
Ultimately, capitalism is not necessarily at odds with providing efficient high qualty healthcare. But we have to decide what matters. If death rate were the only relevant metric, medicine would be practiced much differently.
You are asserting that these excess deaths and real harms due to these takeovers are not natural and expected consequences?
What is the secret third thing that makes these otherwise compatible systems 'at odds' with human life?
What would the situation look like where revenue is better directed to shareholders than to care?
Everything else you mentioned can be manipulated in bad faith, especially by a profit-motivated organization.
Capital doesn't organize around any secondary metric but profit without being forced.
Employee satisfaction? Are you completely out of touch? Speak to any working professional in a PE owned hospital system. It's horrid, the worst, dystopian, soul diminishing.
Satisfaction only matters if there are other places you can go.
Patient satisfaction? It's already 'accept what we give you, pay what we demand, or you die' in rural areas or if you are poor/uninsured. People already avoid going to the doctor when they should because of this. What bizarre alternate world are you living in?
Um, yes it is?
First off, there is tension between "efficient" and "high quality". High quality in an environment with peaky demand requires over-resourcing during periods of lower demand, which is inefficient. The best way to resource for peaky demand curves is to run at 60-80% usage (i.e. 20-40% idle).
Health care has peaky demand curves. PE is going to optimize on efficiency therefore degrading peak demand performance, which is when quality matters the most.
Second, capitalism optimizes resources to maximize value capture. That's great when value capture is tied closely to value delivery, like you want a hamburger and you get a hamburger.
Not when value capture is diffusely tied to value delivery. You want a stable market economy with rule of law to protect your property and your contracts. While without this, nothing you own has any worth (making it the most valuable thing possible), the value of this is rarely delivered to you in discrete chunks.
Why doesn't everyone have a macbook like mine? Because society hasn't decided to subsidize them. But that doesn't mean the macbook isn't high quality.
Capitalism's incentives alone are not sufficient to provide healthcare in a way that most people think is reasonable and fair for all members of society. But that doesn't mean that it can't be useful in allocating capital in ways that are very beneficial to society.
The purpose of regulation can be to create incentives where capitalist participants profit goals align with society's notion of what is best for everyone.
The problem as usual is that some people think that researchers who create new medicines should not be motivated by profits, or that doctors are taking too much money, etc. Any dimension that we regulate will result in pressures on other parts of the system. In my view, government is often not good at creating socially optimal regulations because interest groups get involved and create regulatory capture.
Should surgeons really earn $900K and the top student in a top med school class has a 50% chance of even getting the chance to train in that subspecialty? Do the outcomes really justify such an excessive focus on quality? Should we all expect our insurance to cover 2025 pharma options when 2010 options might cost half as much?
The "optimizations" we have at this point are far from optimal, and any serious analysis needs to look at many different measures of quality or it doesn't make sense. Much medical care has virtually no impact on longevity, does that mean it is useless? I'm not advocating for private equity at all, just saying that it is the regulatory environment that creates those "market opportunities" for PE firms, not something about capitalism. As we've seen with Trump and the support his base has for his whimsical tariffs, people put way too much faith in government's ability to optimize things.
if they slash staffing and make it hard to schedule in a reasonable amount of time, patients with low-risk issues will just skip going altogether. Or, if they have the means, go to a nicer hospital.
This is about providing life-saving care, not Toys R Us.
And this whole topic is specifically about companies in the business of livegiving care. Hospital ER's.
Hospitals in those areas tend to not offer as high quality of care as most urban/suburban hospital.
When the only hospital in an area closes, it's not just a matter of going slightly farther out for care. In many cases, it's just not possible for people.
This is a big issue with the idea of socialized health care as it could happen in America. Right now we already have a two (or three) tiered healthcare system: one for the "rich" meaning urban and suburban and one for the "poor, remote, and/or rural".
When people talk about socialized health care they rarely if ever talk about how to keep such a system from getting worse.
So when a rural hospital closes down, you can expect a higher death rate in the local population. Not to mention the economic impact of losing what is probably the highest paying employer around and all the fallout that comes from that.
Source - have sold my business to PE and have advised on 900+ companies who have sold to PE firms.
Literally anywhere is better than just hand waving the parent statement away with nebulous, unverifiable claims of your own experience.
https://www.ta.com/portfolio/investments/
It's possible you're right as I'm also speaking based off vibes, but my argument remains the same. Those who sell out for a quick payout would eventually fall into the category of "the current owner is unable to continue to run the business and cannot find a successor" when they hit retirement age and their kids would prefer easier/safer/higher general market returns.
Also, see my comment below. Feel free to list out all of the companies from those portfolios that match your criteria. I'll wait patiently.
I mean so is every owner, whats your point?
This is such a weird argument...
He is going to retire sooner or later and what then?
There is a cultural paradox where it's socially unacceptable to profit too much from a necessary good or service, but you can profit as much as you want from non-necessary goods and services. In the past, this pressured small practices to keep their service standards high and prices relatively low. However, due to the accessibility of information and finance, rather than start your own medical practice, you can become similarly wealthy with half the work just by being employed as a doctor/dentist and investing your money in an ETF. Of course, people with money swoop in to "correct" the mismatch in supply and demand, which leads to worse service and higher prices.
The knee jerk reaction people have towards these situations is to "punish greed", but that doesn't change the underlying market forces. Much like rent control, it may work in the short term but makes the problem worse in the long term.
> Usually when a company sells to private equity, it is because the business is suffering from financial hardship or the current owner is unable to continue to run the business and cannot find a successor, so selling to private equity would be the least bad option.
private equity being able to offer more money for your practice when you retire than a dentist who would have continued the small practice is not financial hardship or being unable to find a successor, so please don't pretend your two comments are equivalent.
This comment is much more honest: there was room for financialization, so people did it. They were unable to find a successor who would pay more than a group of people that wanted to wring money out of their company. Gives the lie to the "selling to private equity would be the least bad option" conclusion, though.
"it is because the business is suffering from financial hardship or the current owner is unable to continue to run the business and cannot find a successor, so selling to private equity would be the least bad option."
It should be
"PE offered by far the most money and will make up for it by raising prices and reducing service"
That's exactly what happened with that dentist practice. For years I went there, got a cleaning and was told "keep doing what you are doing". After the takeover they found some problem with almost every visit and fixing it coincidentally would have cost exactly the $1500 my insurance was covering each year.
I use ASP for my pool cleaning and they referred me to their electric company (Mr Sparky). Both have been excellent services and I was able to receive a discount on Mr Sparky, because of the existing relationship with one. Seems like a win:win for everyone.
The rich don’t care about anyone but their financial advisor.
Anecdotally, here in Portland metro everyone is upset about a PE firm that's ruining several beloved local restaurant chains. They bought them up during the pandemic and now many of them are closing. The local Reddit is hating on the PE firm. I suspect these restaurants would have closed during the pandemic if it hadn't been for the acquisition. They then failed anyways because certain parts of our metro area didn't recover well. I don't have access to their books. So I'm just speculating but this seems highly likely to me.
>These “high-markup hospitals” (HMH), which comprised about 10% of the total the researchers examined, charged up to 17 times the true cost of care. By contrast, markups at other hospitals were an average of three times the cost of care.
>They also have significantly worse patient outcomes compared with lower-cost hospitals, new UCLA research finds.
NURSING HOMES: Owner Incentives and Performance in Healthcare: Private Equity in Nursing Homes ( https://www.nber.org/papers/w28474
>After instrumenting for the patient-nursing home match, we recover a local average treatment effect on mortality of 11%. Declines in measures of patient well-being, nurse staffing, and compliance with care standards help to explain the mortality effect.
Surely the hapless landscaper is substantially less responsible for any violence, death, etc, etc, he benefits from than say a lobbyist who gets paid to get the laws to favor his employer.
We don't need to figure out an exact formula in order to be able to conclude some parties leverage violence far more than others.
We all ingest some level of arsenic, and are "universally" exposed to radioactivity, but just because something is falls on a continuous spectrum, doesn't mean all levels are equal, there is a point where it becomes too much. That point will not be the same for everyone, but it exists.
> Is it some number of hops from the person who dies that makes the difference?
Not according to the Nuremberg trials.
1. https://en.m.wikipedia.org/wiki/Micromort
2. Is that what you call 10^6 micromorts?
All of this can be (is!) bad. But it's not violence in any meaningful sense of the term.
On top of that, people will give them social cover for making this decision. Because, y'know, its just capitalism/business or whatever. It's not like they murdered someone, they just told their worker bees to do something they knew would kill more people than they had to.
I have a friend who firmly believes that speed limits higher than 50MPH are violence because they lead to increased deaths. He argues that if we cared about people's lives we would impose a strict 50MPH limit on the roads and even force all cars to top out at 50MPH from the factory.
There are millions of tradeoffs in the world where we could reduce deaths, but there's never and endpoint where it's truly done. It's really easy to imagine revenge on PE firms by crushing their profits for a noble cause, but the conversation becomes a lot murkier when the impact starts hitting closer to your own paycheck or lifestyle.
Combined with a hard 50mph limit imposed on vehicles. You buy a new car, it can't go faster than 50mph, period.
The movement has roots in Ralph Nader going back to the 50s https://nader.org/1970/12/11/the-american-automobile-designe...
Now I can probably understand how one can take such radical position, when living in a place that doesn't restrict cars as much as they are restricted here. It's like being so much disillusioned with US that USSR propaganda starts to be appealing and belieaveble. I guess?
None of this is to say that PE firms squeezing vital hospitals aren't morally culpable. Just that there's a meaningful distinction between immoral decisionmaking and violence.
Life is considered valuable in integer quantities but fractional life is considered value-less.
People are free to do, endorse, concoct and peddle all sorts of things that waste people's time (life) or waste people's money on the basis that it "saves lives" because it prevents lives from being lost in whole numbers but the sum total of the little fractions ad up to more.
Consider that when speeding, you might cause an accident. Such an accident would most likely impact a small number of people other than yourself.
When a PE firm engages in extractive hospital management, it provably increases mortality rate, and it does so at scale.
The first choice carries possible risks of lower magnitude, the second choice carries guaranteed risk of higher magnitude.
“Risky behavior” vs “ruthless greed”, the latter feels much closer to violence.
Thus, I have no trouble asserting that PE firms commit intentional violence against patients.
Indirection allows you diffuse the responsibility into the anodyne 'immoral decisionmaking' while social murder remains as it ever was.
It isn't 'all the drivers' fractionally at fault (others can quibble about that), it's the people who create the moral hazard. The car industry and politicians that decided that the ungoverned car, the road, and the parking lot will be the only way to traverse Dallas or LA lo those many years ago, the ones that affirm that system with 'one more road' using tax dollars year after year, knowing that more people will die as a result. https://en.wikipedia.org/wiki/Motor_vehicle_fatality_rate_in... <- the line goes up.
They have a duty of care as representatives that they are failing to meet. Compare that to cities in Europe or the North East. When you make policies that serve the few and sacrifice the bodies of the many, that act is violence.
Likewise, with PE. When they intentionally understaff a hospital, no single doctor is responsible for killing the patient that died bleeding in the waiting room. It is the choice that we allowed that PE firm to make. Are you comfortable with a fresh MBA using excel to ensure that your local hospital should have four less doctors than strictly necessary to treat you in a timely manner? Society doesn't need to be organized this way, we can and should demand better.
Imagine the reverse, a municipality decides to privatize their water and sewage treatment, but puts no restrictions on the results as long at those wealthy enough are not inconvenienced. This is precisely how you get Flint. Or redlined cities that put the 'undesirables' in industrial waste parks. These acts are violence.
I'm sure the concept has a lot of utility philosophically, but when you try to distill it down to "PE firm owners are murderers" you wind up in pretty crazy places unless you supply a lot of motivated reasoning and special pleading.
Everything is not everything else. Scale not only matters, it's almost the only thing that matters.
I mean, is Hitler a murderer? Is your run of the mill burglary gone wrong worse than the Holocaust? Obviously not. So there has to be some kind of understanding of organized death.
The concept being - organized or institutional crimes are real, and can be much, much, MUCH more severe than murder.
If you really want to stir shit ask him what we enforce those speed limits with.
(hint:violence, but with extra steps)
You contemplate this new world... Is this... violence? It must be... manufacturing regulations are violence against businesses (people)! You relax a little. You imagine someone 'woke' being angry at your incisiveness, you are calm.
I open the hood and add a resistor across the input sensor so that it thinks I'm going 20% slower than I really am.
I start driving at 60mph.
How does society enforce the speed limit regulation against me? (Hint: the threat of, and eventually the use of, violence.)
What a wonderful argument for never trying to improve the world you also reside in.
"your own paycheck or lifestyle."
If excess mortality is required for your lifestyle, change how you live. Do you deny insurance claims for fun? Are you the human avatar of GE and Raytheon? Do you need to manufacture child-vaporizing bombs to maintain your 'lifestyle'?
Genuinely, what is wrong with you? PE firms are not people to take vengeance on. They are not necessary, if they vanished from the Earth tomorrow, the 'worst' outcome is the wealthy owners and workers would need to find new, less violent, employment.
German article: https://www.spiegel.de/auto/tempolimit-120-koennte-58-mensch...
This is a hospital. A building designed for differentiating life and death and(hopefully) attempting to steer towards the former.
This isn't a speed limit or some other market where there's no ethical consumption. One doesn't choose going to a hospital. It's a place you go when you are at metaphorical gunpoint.
Oddly enough, even homes that advertise RNs and a high number of staff still don't provide the care I'd want for me relatives. The only homes I've been to where the staff are genuinely great are nursing homes out in the boonies, in rural areas at least an hour outside of my city.
She is located in the facility she worked in as a poor laborer before becoming a resident. The facility is over an hour from the nearest metro area.
The care she receives there is pretty good. The staff are mostly locals in the rural town and are comfortable being poor and living that life.
We considered moving her into the city to be close to family who have to drive almost 3 hours to see her but the care is so bad in the city it isn’t worth it.
We have had family members in city nursing homes and they’re abysmal. Which to some level I get. The people there like you stated are underpaid and overworked. They live in bad neighborhoods because of systemic poverty. They bring all the stress of being poor in a metro city with them to work. Quality of care plummets but there’s nothing that can be done because no one is going to pay more than bare minimum to reach mandatory staff minimums.
> all the stress of being poor in a metro city
Is it generally accepted that people in similar economic circumstances have improved life satisfaction in rural areas? It is counterintuitive to me given any city typically has better low cost amenities like museums, libraries, and parks than rural areas that I have observed.
It’s really suburbs that end up the most expensive. You combine higher housing and labor costs vs rural areas without any of the cost savings of cities.
Indeed, one can also add availability of theaters, operas, music festivals, multi-cuisine restaurants and sport complexes too.
Honestly, the article literally made me want to vomit. I'm not religious but our society has sacrificed everything human in the worship of mammon.
Healthcare, insurance, banking, education, and so on should be not-for-profits or nonprofits (depending on the case).
Nobody want's the state involved because they think they'll do a better job, they want the state involved because it's the last option available with incentives remotely aligned with the benefit of the polity.
We can have nonprofit education, say, and people will still be left out.
Less education is bad for you, it's bad for me, and it's bad for the whole country. Therefore it must be public or we must suffer.
HN discussion about a similar company exposing private information: https://news.ycombinator.com/item?id=43349115
The apps are ESHYFT, ShiftKey, ShiftMed, and CareRev. CareRev is a YC company (https://www.ycombinator.com/companies/carerev), so maybe the founders are around to explain the technical details of their desperation algorithm or why they allow employers to cancel shifts with 2 hours of notice.
Yes sure, technically that's no different than Uber hiking up your price at 3am because really, what other choices do you have.
But I do hope you spend a minute to wonder what is it doing to our society as a whole, and how the relentless pursuit of profit means we treat people whose job is literally to look after others like disposable trash that can be priced the same way a taxi ride is.
Sure, it's "just a scary way to describe it" - and I hope it's really scary.
Do those staffing firms for nurses also pull information on your credit card debt and offer nurses less money if they have a lot of debt?
As a paramedic who delivered probably thousands of patients to (and picked up patients from) nursing homes, I'd unfortunately absolutely agree. Not always to the point of filing complaints, but not great.
> Oddly enough, even homes that advertise RNs and a high number of staff still don't provide the care I'd want for me relatives.
As that same paramedic, absolutely, you know why?
Many of those homes have ONE RN as the supervisor for a bunch of LPNs and CNAs. And they have policies/insurance/whatever that say "anything larger than a bandaid, call 911 and have them deal with it", which leads to ridiculous situations where you have two nurses standing around while my partner and I bandage a straightforward laceration.
Those are usually the ones advertising out front "Round the clock nursing care" (and absolutely charging for it).
I personally know of several people who ended up having to leave acute nursing because they just couldn't continue with the schedules while trying to have any kind of sane family life. It seems to me hospitals need to change up schedules to have better options for work.
But I'm a lay person tech bro looking at an industry I only have a small window in. What are the other arguments for and against these kind of long schedules?
Worked to death, but well paid. Don't actually have to care anything more than the bare minimum because at the end of the day, there's an end of the day (contract).
Thing is, I loved those nurses. I watched them walk in with the look I remember from my restaurant days when you knew you'd be in the weeds all shift - call it a hundred-yard stare, if you like. They were all completely burnt out, and openly and cheerfully cynical and contemptuous towards the owners and administrators, but for the sake of the patients they just got on with it, as best they could. I don't think I ever saw the head nurse sit down.
There weren't enough supplies, because the laundry service was late, so I went back to my dad's house and brought him an extra blanket. The next day I got another for his neighbor.
There weren't really any rules, because nobody had time for that. The blanket thing? Shouldn't have been allowed, especially giving one to someone else. I asked about visiting hours, and just got a raised eyebrow, and "just put 8pm on the signout sheet". I said "well, then, I'll come back with a six-pack and stay until midnight!" She laughed at me, because I was (half) joking, but I'm pretty sure that would have been fine.
More substantively, when my dad needed the heavy-duty painkillers - prescribed by his doctor, mind - the administration (reached by phone) wouldn't allow them to be dispensed - supposedly because of the liability of having that kind of controlled substance on site; we sorted it out, but it took a couple of of days - when that happened, I said I'd bring in the bottle he had at home and give them to him myself. The nurse said pretty much "we can't do that - but if I didn't see it, it didn't happen," so I did. Then she made sure to give him his other medications herself, so she could check on how much I'd given him, and that it wouldn't cause a problem with the other pain-killers he was on.
I'm sure all of those things were wildly "wrong", from someone's point of view - ethically, or legally, or fiscally, or something. But I viewed the whole situation as so morally appalling - people live there for months, waiting to die - that I can't view those nurses' ethical commitment to whatever it takes to make their patients' lives more tolerable as anything but admirable.
Thing is, we're eating our societal seed-corn. The more awful those jobs are made, the more quickly people burn out of them, and the worse the care provided will become. Those folks were dying on their feet, and there was no help coming, and I don't know how much longer that facility - let alone the whole medical system - can stay afloat on those admirable people's dwindling store of compassion.
But hey, some folks got a little richer by owning that place. All the rest of it's a small price to pay for living in such a land of glorious opportunity, right?
We have to move the argument to “this is an illegal business”. The Right is an amalgamation of extreme Libertarianism and race-centric Nationalism currently, and making a persuasive argument to them requires breaking everything they think they know about what is “good” in the world.
I say this with respect to actually politically reshaping the discourse dynamic (it has to start at debate).
The Right is the obstacle to solving this, not the Left. This is not a universal issue, it’s only a universal issue for people to politely agree and get along, but all actionable items are against the ideology of the Right. To put it simply, to get to where we need to get, we have to chisel and whither away their narratives and mindshare in debate, they skate freely on this topic. Their stance and narrative actually have no place in a problem-solving environment (we can’t solve it if the underlying ideology holds free markets paramount, over humanity).
Check out Certificates of Need. You need one to open a new hospital in an area.
The other existing hospitals in the area get to comment on how it would affect their business and if it would cause them to reduce their investment.
This is all framed as "ensuring communities are appropriately served with healthcare capacity," but CoNs were an idea that was conceived by and lobbied for by ... hospital owners.
But the alternate problem exists too: hospitals with too many vacant beds, and hospitals shutting down because lack of utilization makes it impossible to pencil out keeping them up and running. That's happening where I am right now.
I don’t hear anyone (well some, but very few and usually not taken seriously) suggest police and fire departments should be for profit, so clearly it’s understood that some services should not be profit driven.
But apparently it’s a huge leap to extend that to healthcare.
And as I'm sure you know, the answer to why it's a huge leap for healthcare is the obscene profits that healthcare companies make off of the healthy, the sick, and the dying.
Now let's recognize that we live in a system that fully supports this trading of health and lives for money.
Getting the patrol aspect of policing privatized would cut down a lot of the worst of the stuff cops get caught doing.
You don't see rent-a-cops going off and killing people.
The inspection and compliance related clerical work that a lot of municipal fire departments do could probably be privatized but I don't see an argument for it like I do with cops since they're less abusive. Nobody ever wrote a song called fuck the fire department.
Haha, I just saw a video the other day of a couple of “bounty hunters” (bailbondsmen) pulling up with tactical gear and rifles and kidnapping some kid because he had the same name/ethnicity.
Naturally (and thankfully) these idiots are being charged, but one of the kidnappers sat in an interview whining about how his job was too hard because he lacked qualified immunity.
Are you referring to something like the current private security patrol or an actual police? If it's the former it already is there, if it's the latter I'm not sure how that'd cut down on the amount of bad things police do today.
Is this according to something like Gallup polling? Or according to what the talking heads on cable news say? Americans can be very progressive according to polling data, despite all the best efforts of the propaganda machine.
Likewise, if a hospital hands you a bill for 30k and you need help, are you really going to be able to negotiate and find a better price?
Healthcare is fundamentally an in-elastic good.
Is the list of such places public? Sounds like very important information for people who need medical care. (Which is... everyone?)
(For comparison, Medicare/Medicaid has something like a 95% MLR, because it has low administrative overhead and isn't returning a profit to shareholders.)
17x upcharges, if they were extracted at the insurance level instead of the hospital level, would be the equivalent of a MLR of around 6%.
When it's private healthcare given to those who can afford it: Efficiency
Public healthcare is the only way to go. This has been proven multiple times in so many countries.
As opposed to the 12 years of democratic presidents in the past 2 decades?
1) Congress will come together to impeach and remove a rogue president, even if he is from their party. This is not true anymore, the impeachment clause is inoperable due to party polarization.
2) The President is liable for any crimes committed in office after he leaves. Merrick Garland proved this wrong after he failed to prosecute Trump for the crime of fomenting insurrection, and then SCOTUS gave Trump and all future presidents an almost impossible shield for future prosecutors to overcome in the form of "presidential immunity".
So unless something changes, the next and all future presidents will have carte blanche to wield the DOJ and FBI to attack his personal political rivals. He can impound and reallocate any Congressionally allocated funds toward implementing his ideological goals, and he can defund any programs he doesn't personally like. He can withhold funding and clearances for companies, lawfirms, and universities unless they implement his agenda. He can send the US army into US states to enforce his agenda. He can withhold disaster relief from areas he deems not politically loyal enough. He can take huge equity stakes of companies he deems nationally critical.
These are all powers POTUS has now, and they will remain powers POTUS until he's prevented from using them.
The Democratic party as you knew it is dead; it died in 2024, just as the Republican party as your knew it died in 2020. The Republican party has been reformed into the MAGA party, which bears no resemblance to the neocon Republicans of the 2000s. Just the same, the Democratic party will reform but they will not resemble the party of Clinton/Obama/Biden/Pelosi/Schumer. They are done as a political force.
Moreover, why wouldn't a future POTUS start off by arresting the current conservative SCOTUS judges? Decide on the arrest, make up a pretext, if US attorneys don't comply just fire them until you find one that does, like what they're doing to Comey right now. Make some vacancies and then appoint his own court. Or, just ignore them entirely, there are no consequences for not following their orders.
You could start by passing legislation and excluding it from judicial review under Article III. After all, as you say, the SCOTUS would otherwise vote along their own ideological lines against everything you want to do. Sure, SCOTUS and others will undoubtedly howl that Marbury gives the court the right to judicial review, but you would not be the first president to ask the court "with what army?"
We are at a crossroads. Will the Democratic Party see itself as responsible for conserving the republic and push the government back towards something boring and sane? Can such a party actually get elected today? I have this suspicion that a lot of people think so, especially MAGA -- they [mostly] cannot conceive that the opposition can turn the tables and use identical tactics on them, so they feel like the current situation is a temporary but crucial win only for them, which will move the Overton window to the right. But what if there is really a sea of anger boiling below the surface right now just waiting to be tapped by a Democratic demagogue?
Could get exciting.
IMO the GP is touching on removing regulatory burdens (more traditionally republican/conservative ideas) and adding in funding/care via medicare for all etc (democrat position). the combination of reducing/improving/simplifying regulatory burdens while increasing government spending seems to be a combination of ideas that hasn't been winning enough support. afaik, Ezra Klein in his book Abundance is one of the only voices trying to push this balance.
One popular approach to saving money is to replace physicians with nurse practitioners and physician assistants, who have less education and training. The article does not discuss this element, and I'd be interested to see if that is a factor in patient outcomes. There's less data on this than you might expect.
ETA: From my post lower down, adding for visibility:
[The training gap is] quite a lot more than a year - in primary care, it's more like four additional years of training for physicians, and 15000 supervised clinical hours for physicians (vs 500 to 1500 hours for NPs). The gap can be wider in other physician specialties, because many have longer residencies than the primary care programs. For example, child psychiatry training is four to five years (depending on the route you take), making it longer than the three years of family practice residency.
Here's a chart looking at training for MDs vs NPs in primary care. It is from a physician organization. https://www.tafp.org/media/advocacy/scope-education.pdf
I get it they're probably overworked too and their time is valuable but it's not quite as reassuring not actually interacting with doctors very much. The few times I have it was literally for my actual surgeries and surgery pre-appointment. Practically everything else is some assistant.
Right now, there are not enough residency spots for every US med school graduate.
Here's a chart looking at training for MDs vs NPs in primary care. It is from a physician organization. https://www.tafp.org/media/advocacy/scope-education.pdf
Last year I went to an interview where they flat out admitted to me that the private equity that bought them fired the entire previous team because they "believed" it could be done with far less people (4 vs 25). I asked them who has been maintaining things since that happened and they told me they have been hiring contractors to get through the period but "they haven't really been doing the job". I guess at least they were honest with me so I could nope out of there ASAP.
The PE firm is a great representation of why monopolies eradicate the positive incentives in capitalism.
And this only happens after a long time and companies have had a chance to centralize vast amounts of money and power. Since there is no point that’s “good enough,” these massive companies are forced to continue growing by cutting costs (worse services, lower salary, fewer employees, closing locations) or doing absurd tricks like stock buy-backs to make their shareholders and executives very wealthy.
It’s literally impossible to avoid this situation without strong consumer protection and anti-trust regulation because the incentives for massive companies are so deeply unaligned with human well-being and society’s best interests.
We can either take strong action against massive companies or accept that this trend will inevitably get worse. It’s called late stage capitalism for a good reason
The institutions supporting three things, Health Care (Life), Prisons and Justice (Liberty), and Education (Pursuit of Happiness), should never be run for a profit if a society wants to be equitable and prosperous.
Capitalism and profit motive are great for some things in a society, but are also counterproductive at many others. Use the right tool or system for the right job.
Profit motives don't care about humans, it cares about profit. If it has to care about humans because of it, then so be it.
We've never been individualists. We need infrastructure, thus some form of collective action. Without roads, no freedom to comfortably drive a car, without the internet no freedom to comfortably search for information, without healthcare no freedom to comfortably stay healthy when a medical emergency occurs.
Could you imagine if all roads were a for profit road? Could you imagine if TCP/IP was for profit? Well, I think some of you could, as some of you know failed attempts of protocols for money at that deep of a level. I'm curious about the stories.
In any case, that's what's happening here with medical institutions that should have an infrastructure role.
[1] Well, to be fair, there are many caveats, but let's not go into oligopolies, cartel-like formations, etc.
Everything they touch, turns to shit.
However, they squeeze a lot of money from the coprolites, and that’s enough to buy regulatory capture, I guess.
In other words, an increase of 0.00055 deaths per visit.
>Limitation: >Potential unmeasured confounding; lack of generalizability to other acquisitions or patient populations.
But I suspect that won't happen.
I'll never forget with my first kid they tried to scare us into genetic testing - I mean, they had a pamphlet and video they were required to show us that were meant to scare us into it, but I could tell from the doctors face that she wasn't into it and felt like she was apologizing when she said she had to play this video and leave the room. We switched to a different hospital almost immediately.
The only thing missing in all the good talk about healthcare is what to do about health insurance, which is the middleman that drives up prices. I propose making all forms of price discrimination illegal in healthcare, i.e. uninsured and HSA patients cannot be charged more than health insurance companies.
I also propose standardizing healthcare into 5 different health plan contracts, then requiring all health insurance companies to make all of their health plans fit into one of those contracts with zero modification to the terms and conditions. This will make litigation faster and easier, and it will avoid fraud disguised as "fine print".
Then, finally I propose requiring all health insurance companies to pay for the services up front and then sue the patient to get the money back, reversing the existing pattern where the burden of proof falls on the patient and the patient has to wait until the insurance provider relents. Think of it like a patient suing an insurance company and getting an injunction to pay out the claim while the legal ruling is pending, but faster.
As long as it's left generic so it goes both ways. Currently it's usually the uninsured patients who are charged less (since they're paying the whole thing out of pocket instead of having insurance cover most or all of it), not the insured patients.
Hospitals and clinics offer a preferential rate to insurance companies as a sort of volume discount because insurance companies with thousands of patients have a lot more negotiating power than any individual patient who is uninsured or using an HSA.
It got even worse once health insurance companies started negotiating contracts with favored nations clauses requiring hospitals to bill then ~10-30% less than patients paying out of pocket. It's an oligopoly, but on the demand side: an oligopsony.
That being said, in my view, one of the fundamental problems with healthcare is that outside of truly elective procedures like cosmetic plastic surgery and lasik, it's nearly impossible to have free market economics function.
- There are HUGE information asymmetries between doctors and patients - Judging performance of doctors is very challenge. Reviews are terribly inaccurate, data can be better but has big problems, and even other doctors aren't good judges of doctors outside their specialty. - Right now at least, price discovery is nonexistent so you can't price shop and compete on price vs quality - Insurance means that consumers of healthcare are not actually footing the bill so they have no incentive to price shop. And most healthcare procedures are completely unaffordable so there's no way we can do without insurance - and finally it's really hard to make an economic decision that is literally life and death. Am I going to forgo a $100k surgery if it means I'll die? There's no choice there
All of these things lead me to the conclusion that healthcare is fundamentally incompatible with classic free market economics, and some form of single payer is the only solution to avoid us bankrupting our country spending on healthcare
I was thinking I could buy an hour or so of time in my day cutting this all out, surely then I’d be shredding music practice way more… so hard to get down to it after work and kids.
That said... How much is a day, a month, or a year of a human life worth? Since it's clearly not infinite, there must be some line where saving a life is too expensive. What is that line?
Of course I have no answer here, but I think this ethical dilemma is what it boils down to. Still terrible. :(
[]
Ideally, the control would be a set of hospitals that PE firms otherwise wanted to acquire but were blocked for reasons unrelated to financials & performance of that hospital, e.g. regulatory. Granted, I expect that might be quite rare.
To be clear, I think private equity firms have had quantifiable negative impacts in many other aspects of healthcare. For example, acquiring helicopter-rescue/air-ambulance companies and sending them out for non-emergency situations.
http://michaeldnahas.com/blog/numbers_that_matter/2019-9-15_...
https://www.opensecrets.org/industries/indus?cycle=2024&ind=...
derbOac•4mo ago
I'm not surprised by this finding, although I find in economics and healthcare forums the results tend to be misused (at least in my opinion), because it gets used to argue against any deregulation or cost cutting, instead of cost cutting of the type that tends to happen for the benefit of investors and shareholders, rather than cost cutting of the type that increases healthcare options and access.
palmotea•4mo ago
Don't hand-wave your claim of overregulation, be specific and name the regulations you think should go away.
pfdietz•4mo ago
Regulations that prevent construction of new hospitals without some sort of "demonstration of need".
myrmidon•4mo ago
Isn't that just more infrastructure, administration overhead and staffing that victims have to pay for, in the end?
wat10000•4mo ago
ceejayoz•4mo ago
wat10000•4mo ago
ceejayoz•4mo ago
Tell that to the waves of cupcake shops, craft breweries, and now cannabis dispensaries in my area.
wat10000•4mo ago
ceejayoz•4mo ago
wat10000•4mo ago
ceejayoz•4mo ago
Yes? That's the idea. I won't say it always works, but it's the idea; preventing the existing facilities from closing.
> They aren't devastating in an oversaturated market.
It certainly can be, if the oversaturation puts all of them on shaky financial grounds.
goodpoint•4mo ago
palmotea•4mo ago
I'm not defending the "Certificate of Need" regulations, but your thinking is sloppy: healthcare is not a product like bananas. That analogy will mislead more than it will inform.
If every person has to buy 10 bananas a day or they will die, the town with 5 stores may have more expensive bananas, because they can just raise prices to cover the excess capacity and people will pay.
wat10000•4mo ago
There are two things that set healthcare apart here. One is that sometimes people need unusual treatments to stay alive that are extremely expensive, and our desire not to let people die is at odds with the normal market mechanism where products that cost too much just don't get purchased. The other is that sometimes people have emergencies so urgent they can't really choose their provider.
But the vast majority of healthcare doesn't fall into those categories, and normal market mechanisms work fine for those. Competition would lower prices for most healthcare just like it does for food and everything else.
ajmurmann•4mo ago
The same works for non-emergency surgery as well. Take a look at https://surgerycenterok.com/ it's such a breath of fresh air to see the full price for each procedure right there. People travel there from all over the country to get needed procedures. So competition clearly works but the system doesn't really enable it. For example insurers don't want to work with the linked center because they won't give them rebates but charge everyone the same price. More details: https://www.econtalk.org/keith-smith-on-free-market-health-c...
lux-lux-lux•4mo ago
That’s still 4-6x what it would cost at a private clinic in Canada.
palmotea•4mo ago
Not necessarily. They're all under the same pressure. If they all provide similar services with little differentiation, the price will probably settle at a higher level to cover the fixed costs of 5 stores instead of 1.
> In my local market we literally got a scan for 2k where the hospital we'd usually go to wanted 10k.
You kind of get at it below, but I wonder if that's an effect of insurance negotiations (e.g. the hospital you usually "usually go" gave in to insurance discount demands in one area, but pushed back on scans pricing to get the revenue they need to operate).
I do think the totally fictitious nature of posted healthcare prices is a serious problem.
zdp7•4mo ago
h2zizzle•4mo ago
cogman10•4mo ago
The labor to produce, ship, and shelve the banana determine it's cost along with whatever margin the store that sells the banana is willing to take. Walmart, for example, could be perfectly willing to sell a banana at a loss if they think that will get you in to buy a TV.
This is why dollar stores exist and often kill off local grocers. They can sell a lot of non-perishable goods at a loss and win back by understaffing the location and overcharging on non-perishable goods.
I live in a city with probably around 50 different clinics, but they are all associated with 3 major medical groups. It isn't a lack of buildings that's preventing competition.
anubistheta•4mo ago
myrmidon•4mo ago
Unlike grocery stores, hospital ERs don't get frequent repeat customer interaction, so that makes the competition aspect basically completely inapplicable.
As typical ER visitor,
- You wont know what "quality" of care you are going to get beforehand
- You will have very limited capability of selecting the hospital
- You will be unable to compare prices beforehand
So why would any of those 5 hypothetical hospitals decrease prices?
More competitors won't do shit if the market is uncompetitive by design.
esafak•4mo ago
We do need price transparency though.
myrmidon•4mo ago
No. Preventing rapid unplanned end of life is the main purpose of hospitals in my view.
Enough time to make a choice of hospitals (or even to collect information on specific hospitals) is a luxury that I would not expect patients to have.
esafak•4mo ago
wat10000•4mo ago
Yes, there are some kinds of care that aren't very amenable to competitive market forces, but the vast majority is.
cogman10•4mo ago
If you go in because of a killer stomach ache you could end up needing a CT and emergency surgery. Or you could end up getting some pepto-bismol.
And if you are taken there by an ambulance (which you also have no ability to compare any price to). You'll be sent to the hospital the paramedics decides to drop you off at.
There is an inherent complete lack of information when going in for a medical situation that can't be fixed by the free market. You need (or believe you need) treatment now. There's no way for you to know what that treatment will be.
Even going in for an annual physical can be the exact same. Some dicey numbers on your blood work and you might be looking at some huge unplanned bills that are completely unavoidable.
myrmidon•4mo ago
Number of competitors is only one of the inputs for how competitive a market is, and price intransparency + lack of information on treatment quality make it moot for the healthcare sector in my view.
I don't think higher hospital density would hurt, but we would have to pay for this and I don't see it help drive down prices.
shawn_w•4mo ago
Oh yes they do. I can think of any number of patients I'm familiar with who end up in the ER multiple times a week. Practically daily for some people. And a few who are known for getting discharged from one hospital and immediately heading to another nearby one.
myrmidon•4mo ago
I have a bunch of people with serious conditions in my "bubble" (spontaneus penumothorax, diabetes, ...) and none of those needed the ER more than ~1/lifeyear.
If weekly hospital visits were typical, competitive free market hospitals would be more feasible IMO but I don't think we're close to that (and I don't want to be, either).
philipkglass•4mo ago
This happened with a friend's mother during her last year of life. She had dementia, cardiac problems, infections, breathing problems, a whole litany of symptoms of slow death. But she didn't have any one clearly terminal condition (like late stage cancer) that would justify a switch to hospice, so she lived in an assisted nursing facility and also had to go to the ER more than 70 times in that last year. It was horrifying for everyone and the costs were astronomical. The state is now trying to seize her daughter's house to partially offset the accumulated expenses.
shawn_w•4mo ago
Medically fragile elderly people trying to live on their own when they shouldn't be. Frequent falls with injuries, etc.
A friend of my mothers was in and out of the ER and med/surg floors for months with mysterious cardiac symptoms that ended up being a new reaction to a medication she'd been taking for years.
People who are just psychologically, hmm, needy and looking for attention. When I worked on an ambulance there was a lady who'd call weekly because she said her blood pressure was high (it never was) and we couldn't refuse to transport her.
And more...
jasonlotito•4mo ago
2. One offers bananas to walk in visitors, but the others have a minimum wait time of 1 month to a year.
3. One is a mile away. One is an hour away. Still in the same county.
4. None of them offer an easy to understand menu. You can't just order a banana. You ahve to order Banana Services and meet with Banana specialists. You can't take the banana home.
5. You wake up in a banana shop and you didn't get a chance to shop around before being presented with a bill. They don't take your payment of choice, so it's 10 times as expensive.
6. Some won't let you buy a banana. Instead, you have to buy a banana service. Per banana pricing is the lowest here, but the total cost is higher if you just want a banana.
Which banana store do you buy from? A, B, C, D, or E?
I'll take the first choice you make and let you know if you picked correctly. Anything other than the correct choice is a failure.
taeric•4mo ago
Which is all to say, my gut is it is far more complicated than that allows for. Not a useless model, but also not a very actionable one.
pfdietz•4mo ago
myrmidon•4mo ago
If you are arguing that the customer is not paying for inefficient providers, then I strongly disagree.
Customers always end up paying for inefficient supply chains. If you end up with an inefficient allocation of hospitals/doctors (local overprovisioning), it's always gonna be the patients that are gonna pick up the bill for this in the end through higher average prices.
Inefficiencies are doubly bad because you potentially don't just pay the pure cost for the inefficiency (middlemen, waste etc.) you even pay for margins on top.
I think the assumption that such inefficiencies could lead to actual savings for customers (by magically making the providers decrease their profit margins) is highly overoptimistic.
pfdietz•4mo ago
Obviously not. There is nothing that compels a customer to do business with an inferior competitor, if there is an alternative. The end result of having a sufficiently inefficient supply chain can be that the company involved goes out of business, as it cannot operate at a profit.
vlovich123•4mo ago
A “need” certificate is similar to the cap that med schools have - it’s effectively a pricing cartel to keep salaries/revenue high
milesskorpen•4mo ago
Overall we have a crisis of hospitals shutting down, not a crisis of oversupply.
jplrssn•4mo ago
I don't see how this could be true for emergency visits. Would an ambulance drive you to the cheapest hospital within some fixed radius?
hamdingers•4mo ago
theptip•4mo ago
opo•4mo ago
https://ij.org/report/striving-for-better-care/overwhelming-...
h2zizzle•4mo ago
The problem is not restrictions on medical facility construction, it's inefficient use of what we already have.
In general, America has an issue with defaulting to "building new", as if we have an everlasting greenfield, rather than careful provisioning of the already overbuilt infrastructure base. Capitalists love being freed of prior obligations, with no regard for how they contribute to an even more unwieldy set of obligations in the future. Enough. You can't just do as you like. Help solve the actual problem.
pfdietz•4mo ago
https://www.health.ny.gov/facilities/cons/
alostpuppy•4mo ago
pfdietz•4mo ago
Any other goal lines you want to redraw? Let's get that out of the way now instead of going back and forth.
(To answer: in my personal experience Illinois also has such a regulation.)
ch4s3•4mo ago
kotaKat•4mo ago
h2zizzle•4mo ago
h2zizzle•4mo ago
jasonlotito•4mo ago
Regardless, you have to explain how removing CON solves the PE issue mentioned when states without CON had the same issues.
RHSeeger•4mo ago
- There is a specific list of regulations that cause the problem
- Each regulation in that list is present everywhere the problem exists
Neither one of those are true. Instead, there are many regulations and, combined, they add up to causing the problems. The specific regulations can and do vary by location; but the result is the same.
20after4•4mo ago
jasonlotito•4mo ago
No. You are 100% wrong.
The context of this discussion is PE. So comments discussing this involve PE. So while you are correct in general, you are wrong specifically.
In light of that, I stand by what I said: you have to explain how removing CON solves the PE issue mentioned when states without CON had the same issues.
Maybe this isn't possible, but then we accept that this is not an answer to PE, which again, topic of conversation.
viscountchocula•4mo ago
https://en.wikipedia.org/wiki/Certificate_of_need
bilbo0s•4mo ago
Do you have a hypothesis as to why CON requirements are driving inferior outcomes and increased cost metrics at PE owned hospitals? (A hypothesis that accounts for the fact that PE owned hospitals underperform even in the absence of CON requirements.)
Serious question. I'm trying to get my head around this.
SkyBelow•4mo ago
PEs seek to make profit, and are looking for places where they can either raise prices or lower costs (which will quickly correlate with worse outcomes) while not losing customers (yes, you could call them patients, but PE will view them as customers), or at least losing so few that the overall numbers result in more profit. One way of doing this is looking for barriers to competition/moats. CON is just one type of moat, and so is one factor PEs evaluate, but the presence or absence of other moats can still override the presence or absence of this one moat. One could try to work this out from data with some sort of regression, but with so many possible moats and a relatively limited number of data points, it would be easy to overfit the data.
In comparison, non-PE hospitals might have some profit motive (or keeping to budgets, not going bankrupt, ect.), but will be less driven by this mentality and thus their relationships to moats will be more complex, and so something like a CON requirement won't be as fully exploited to raise prices or lower costs.
This also fails to account for other ways that PE can seek to make money, which involves more complex parts of law and financing that I'm not well versed on (I've ready some things about real estate, but don't know enough to fairly analyze the claims).
dodobirdlord•4mo ago
You respond questioning how that could explain why PE operated hospitals have worse outcomes. I agree, this doesn’t seem to have an explanatory power for why PE operated hospitals have worse outcomes, but how does that relate?
bilbo0s•4mo ago
Which "finding", presumably, being that PE owned hospitals have substandard metrics.
My question is natural given the context of a discussion that's literally titled:
"Death rates rose in hospital ERs after private equity firms took over"
It's literally the entire subject of the discussion. Why would anyone think it's irrelevant?
dodobirdlord•4mo ago
bilbo0s•4mo ago
landl0rd•4mo ago
bilbo0s•4mo ago
betaby•4mo ago
Source: https://thedailyeconomy.org/article/how-congress-created-the... and many others
miltonlost•4mo ago
"The increased deaths in emergency departments at private equity-owned hospitals are most likely the result of reduced staffing levels after the acquisitions, which the study also measured, said Dr. Zirui Song, a co-author and associate professor of health care policy and medicine at Harvard Medical School."
The issue with American healthcare is the profit-seeking capitalists.
jwilber•4mo ago
leoc•4mo ago
khimaros•4mo ago
banannaise•4mo ago
mothballed•4mo ago
You could hire a whole army of doctors and they'd still be there, word gets around. If the doctors are cheap enough to cover whatever you can get from debt collection agencies to sell off the debt they'll never pay, then you could hire a lot.
rileymat2•4mo ago
mothballed•4mo ago
Cutting doctors means only the most prioritized triage cases makes it to doctors, which skews towards people that are employed or on medicare and the money can be recouped, and thus improves profitability.
It's an end-run against the requirement they take in the hordes of people with no insurance who show up to the ER for low-income cases and no way to pay it.
If doctors were so cheap as to be covered by the sales to debt collectors, the whole thing gets flipped, as it would be profitable to just hire armies of them to cover the hordes who come in with non-emergent cases.
rileymat2•4mo ago
mothballed•4mo ago
matheusmoreira•4mo ago
This thread is talking about ERs so let's focus on that. Pay for a 12 hour shift has fallen by over 50% and that's without accounting for inflation. As a result, only heavily indebted and inexperienced doctors are manning the ERs now. These are critical life saving jobs that ought to attract the most experienced doctors but they turned into reassigned-to-Antartica tier jobs that only new or failed doctors put up with. Now factor in the substandard education provided by the hundreds of newly created medical schools which don't even have a hospital for students to practice in. The result is of course stupid and incompetent doctors manning ERs. I remember one guy who sent home a patient with textbook myocardial infarction symptoms without even ordering a routine EKG, obviously leading to the patient's death. Imagine being that dude's lawyer.
Depressing the wages of healthcare workers has fatal consequences. There's no reason at all to spend the best decade of one's life busting ass in medical school and residency if one is not gonna get rich off of it. You want your doctor to be the smartest, most studious, most hard working, most debt-free person you'll ever meet. You don't want to put your life and well-being in the hands of a stupid indebted doctor who graduated from a diploma mill.
myrmidon•4mo ago
Profit seeking capitalists would be fine if healthcare was a competitive market, like grocery sale.
But it isn't, and I honestly don't see how to make it one. Full price transparency would help, but I don't believe classical free market selfregulation can work out for the healthcare sector, by design.
You need good ability of healthcare customers to judge quality of treatment/medication, to know prices beforehand and to have sufficient choice for market dynamics to work, and every single one of those points is somewhere between really difficult and impossible.
rtkwe•4mo ago
TheOtherHobbes•4mo ago
Labelling markets "rational" is pure rhetoric. There's nothing even remotely rational about a market system, because the moral basis of calling markets "rational" is... greed.
Just greed. Nothing else.
All of the failed outcomes, deaths, pollution, lost opportunities, distortions of democracy, and other damages are a direct consequence of this moral system which claims that greed is rational - when in fact unfettered greed is clearly and objectively sociopathic, with predictable sociopathic outcomes.
20after4•4mo ago
nickpp•4mo ago
Greed and desire push us to spend our energy, otherwise we'd simply conserve it.
It's normal, it's natural and it works. It's human (and animal) nature.
Altruism works fine in individuals and small organizations. But large systems based on altruism uniformly failed to provide the most basic necessities (like food) for their citizens. Can't work against human nature.
nosianu•4mo ago
We are?
For example, I never file taxes. I'm certain I could get quite a bit back. I am far from rich, I earn medium pay in Germany - medium overall, not medium in IT. (Because I deliberately took a more rewarding and relaxing job, but that's besides the point.)
I will not fill my mind with "money" stuff. Even if that costs me some of that money.
I am sure, given that the terms used are as fuzzy as can be, you can twist and shake the words until you can claim that I am "greedy", the problem with this rationality discussions is how extremely flexible the words used are, making it quite impossible to win or lose an argument. All one has to do is insist on one's own definitions... but taking a relaxed view, I don't see good way to make not-at-all-rare positions such as mine as a form of "greed", without severely twisting the commonly understood meaning(s).
I think a lot of that world view is self-fulfilling.
When I was a kid I LOVED working like the adults. That includes taking one to four week stints in factories, as a teenager in school. That was common in East Germany and encouraged, early acquaintance with work life. I did the same helping out my craftsman grandfather and my shop-owing grandmother.
Work was FUN!
But now, the reason I don't just go - which I would LOVE to do! - and work a few hours low-level jobs here and there, is because it's all been heavily commercialized. You just don't do that! Work has to be pain, and you get paid. Only an idiot would work for free!
During university, during a semester break, I took a job in a chocolate factory. I did not actually need the money! My parents paid (divorced, but both paid). I actually had a lot over at the end of university (cheap dorm housing and no fees for the university itself sure helped). I took the job because I wanted to work in a factory again. It is FUN!.
Until that middle manager a..ole appüeared. I had just optimized my in-between assignment of taking care of some machine chocolate thing, some mixing, I forgot the details. I had set everything up perfectly and now had to just wait a few minutes for the machine to finish.
In comes that.... manager guy. Immediately, seeing me sitting there he yelled at me why I'm not working. FU manager guy. That was the day I realized work now is WORK, not fun. You are not supposed to have fun. You now need middle manager person to keep your lazy ass in check! By yourself, without continuous pressure, you would not move a hand! Right?
At least for the "lower" jobs, which are the majority.
> It's normal, it's natural and it works. It's human (and animal) nature.
You are definitely not speaking for a lot of people, and what you see is NOT the one natural outcome. Expectations and behavior towards people determine theirs (behavior).
The culture I describe existed all around me in East Germany. Yes we were waaayyy backwards with everything, but work culture was really good. I learned a technical profession in a large chemical factory before studying. Everybody worked, useful stuff too, all day. The ancient machinery in the crumbling buildings needed a lot of attention to keep them running. There was hardly any slacking off anywhere I looked. Sure, it was relaxed, but it was work, work, work. I've seen waayyy more slacking off in the offices of large American IT companies.
What you describe as "natural" is natural only in the context the current society has created.
nickpp•4mo ago
Yes we are. When discussing a salary offer, do you negotiate it down? When buying products and services, do you just pay the minimum amount asked or do you offer more from the goodness of your heart? When getting your paycheck do you immediately donate most of it to the less fortunate in Africa, keeping only enough to cover the bare necessities for yourself? If not, welcome to the club: you too are greedy.
> When I was a kid I LOVED working like the adults.
My kids loved helping with yard when they were little. Their reward was spending time with me and learning. It was enough then. Now, as teens, not so much. I have to pay to motivate them.
> Work was FUN!
Work is still fun, for me at least. But a paycheck makes it even better. I don't know anybody cleaning sewage for pure fun though.
> East Germany
I too grew up in communist Eastern Europe. I clearly remember the never ending lines for food and any basic items like soap or toilet paper. With the profit motivation made illegal, nobody did any work and we were all starving.
samat•4mo ago
Idea of people caring about money above all else and money being sole measure of things and 'more money is always better' is a huge delusion of our modern societies.
I think we are taking this idea to an extreme and we are already bearing consequences. I am afraid there will be more to come until the bell swings back. I hope it does not break the civilization as we know on it's way forward.
somenameforme•4mo ago
Same for my own stuff. The first time one of my children got sick it was terrifying, so I naturally took him to the most premium pediatric healthcare institution. And what did they do? Basic tests to rule out anything particularly nasty, and fever management. The exact same thing the cheapest hospital does, except I got the privilege of paying 10x more for it and feeling like a complete sucker. From that point on - 'oh he's sick? shall we go to the university hospital, or the religious nonprofit?'
owenthejumper•4mo ago
somenameforme•4mo ago
The second [2] is for all sorts of cancers, but is a large observational study without much effort to control for biases. It found an overall increase in five year survival rates of 3.6% (64.3% in NCI centers, vs 60.7% in non-NCI). That's certainly something, but it's fairly certain that biases would bring that down a healthy chunk.
However there were significantly better outcomes in more rare/lethal cancers. For instance in hepatobiliary cancers, the NCI survival rate was 33.8% vs 18.7% for non-NCI centers. And that is largely the point I'm making. For the overwhelming majority of things, care is mostly commoditized and you will be fine wherever you go. The value of high end institutions is mostly only realized in the case of rare/serious issues, for which transfer is always an option anyhow.
---
Though I'd also add here that these examples, cancer, are on the fringe extremes of what my point was. That there is a strong argument to be made that even cancer falls within it, just further emphasizes the point. If your local hospital can competently treat cancer, they can certainly treat the overwhelming majority of reasons people go to the hospital, which are relatively far more commoditized.
[1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8462568/
[2] - https://pmc.ncbi.nlm.nih.gov/articles/PMC4892698/
epcoa•4mo ago
No this claim, just because, is not weight-bearing. Extraordinary claims require extraordinary evidence. And I don't understand the motivation to make such a tenuous link when at a bare minimum one can look up direct data like joint commision and MPSMS safety data and related publications. There is tremendous variability in serious hospital safety events inter-institution for bread and butter admissions. One can further just examine CMS and NHS data for mortality and readmission for "mundane" MI, HF, sepsis, pneumonia, respiratory failure. OB/GYN outcomes are their own thing.
The flaw in reasoning here is that quality of care and outcomes is strongly related to the simplicity of diagnosis. A further flaw is the belief that care is "commoditized". Treatment protocols vary widely across institutions and health systems, often times based on cost factors. Certain basic things can not be done at night, or even the day for fully accredited hospitals. There's a big difference somewhere with 24 hour anesthesia airway and in-house surgery and not just an intensivist "on call" 600 miles away and staff that can't even do RSI. Transfer is not always an option, there's a reason critically ill people die more frequently in the sticks. If one is admitted to a regional hospital, they are unlikely to be accepted for transfer to a safer hospital unless they truly need an intervention that absolutely cannot be provided where they are, not simply because there is better backup provider support and a higher standard of safety. They will still remain at that higher risk for sepsis, or outdated care because the community physician group doesn't keep up with guidelines, or that hospital only offers the inferior treatment (or a limited formulary) for cost-cutting reasons.
Breast cancer and most cancers are not even typical inpatient encounters. Breast cancer is generally not managed on an inpatient basis, in fact one may never even have to visit an inpatient hospital campus for breast cancer. Upgrades for cancer are usually different than acute inpatient care. Breast cancer does not usually involve abdominal, intrathoracic or orthopedic surgery. Breast cancer does not usually involve advanced interventions like endarterectomy, ECMO. Cancer is a special case. Regardless of complexity, extrapolating cancer treatment to even the most "mundane" acute inpatient or surgical care really is beyond ridiculous.
This is a complex subject and this is a silly hot take.
somenameforme•4mo ago
---
"One third of sepsis survivors were readmitted and wide variation exists between hospitals. Several demographic and structural factors are associated with this variation. Measures of higher quality in-hospital care were correlated with higher readmission rates. Several potential explanations are possible including poor risk standardization, more research is needed."
---
As they're implying, this is likely due to biasing and not a causal observation. One possible explanation is that higher quality hospitals may be able to keep people knocking on deaths door a bit longer than lower quality hospitals, but it's not like night and day - they're still knocking on that door, just a bit longer. And so it makes sense that they'd actually have worse outcomes on discharge, including higher overall readmission rates. But once again the picture between the quality of hospitals is not this tremendous dichotomy that many try to frame it as.
Billionaires, in general, seek out the highest quality care money can buy, and have no limitations on the meta-factors that also improve longevity including activity, relationships, healthy food, exercise, etc. Yet their life expectancy (~85) is comparable to the life expectancy of Hispanics in America. The "Hispanic Paradox" [2] again emphasizes that longevity isn't about premium healthcare and money.
[1] - https://journals.lww.com/ccmjournal/abstract/2017/07000/seps...
[2] - https://en.wikipedia.org/wiki/Hispanic_paradox
epcoa•4mo ago
MI, HF, sepsis, pneumonia, respiratory failure are among the most common reasons for inpatient admission, not fringe.
Equating acute decompensation of chronic illnesses requiring inpatient admission to "knocking on death's door" is a bit simplistic.
No data has been provided showing how the relevance of outcomes based on institution of first presentation (not definitive management) for breast cancer, that is usually managed outpatient on an elective basis, has anything to do with outcomes for the "overwhelming majority of things people to go to the hospital for".
Even pre-pandemic the life expectancy of Hispanics was not as high as billionaires. Speaking of "deaths door" perhaps at least QALY, or something else is a more appropriate metric.
somenameforme•4mo ago
Let me first describe what I meant by fringe though. Take a random adult going to the hospital, not elderly, with no other major health conditions. When he walks in the door, what are the distributions of issues that he might end up having? Sepsis is going to have a probability of near 0. By contrast the typical patient that might present with sepsis - elderly, other major health conditions, well into senescence - he is generally indeed 'knocking on deaths door.' He might not answer this time (though there's a decent chance he will!), but he will imminently.
Your study compared hospitals based on a number of factors. The most significant was high volume, but in that case the difference between the highest volume hospitals and lowest was a 13.3% rate of readmission vs a 11.2% rate of readmission for hip replacement, and 12.4% vs 11% for knee replacement. Again I think this is another example of when you look at the actual data, outcomes fall quite close.
Beware their method of taking a sampling and breaking it into buckets and comparing those buckets. If even hospitals/patients were identical (which I'm certainly not claiming) and so the results were literally just random noise on a distribution, you'd see a major difference between the top and bottom buckets due to the nature of random distributions - 68-95-99.7 and all that. Their results show a signal beyond that, but it's generally a very misleading way of presenting data because of this issue.
Pre-pandemic hispanics had a life expectancy of about 82, which I described as comparable to the 85 of billionaires. I'd certainly expect billionaires to be higher for the endless reasons outlined in the already linked Hispanic paradox. The fact that it's only 3 years, less than 4% longer, is the point.
yibg•4mo ago
epcoa•4mo ago
Two registry cohort papers on breast cancer outcomes, one only in Los Angeles county "provide extensive evidence for my claim"
The claim: For the overwhelming majority of things people to go to the hospital for, where you go doesn't really matter.
Ok, whatever.
somenameforme•4mo ago
They covered an extensive number of variables across hospitals and patients (including NCI/ACS status). They found no correlation with improved survival rates for any variable except for black women receiving their initial treatment at an ACS hospital. While that is technically an affirmation of your claims, I think it is clearly suggestive of some form of bias rather than being a clear causal association.
[1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8462568/
epcoa•4mo ago
somenameforme•4mo ago
Incidentally, it's also the same story for colorectal cancer, the 2nd most common type of cancer. Here's another study on the topic. [1] They have a survival rate of 88.6 vs 85.9 for breast cancer, but it's a large observational study that's not normalized, so the confounders/biases there probably explain the reduction in survival rate at non-NIC hospitals. Colorectal cancer is even smaller - 0.2%.
NIC hospitals only showed a significant effect on cancers with low survival rates, and especially on rarer cancers. For instance with pancreatic cancer 93.8% of people who went to a non-NIC hospital were dead in 5 years, by contrast 'only' 87.5% of NIC hospital patients were. Feel free to look up the data yourself. I'm not searching for cherry picked studies, there are none - as there seem to be oddly few studies on this question, and they all say the same thing. What benefit there is is quite small, and heavily driven by extremely rare things.
[1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC4892698/
epcoa•4mo ago
somenameforme•4mo ago
epcoa•4mo ago
The claim: For the overwhelming majority of things people to go to the hospital for, where you go doesn't really matter.
You win, as always.
https://news.ycombinator.com/item?id=45199654
somenameforme•4mo ago
If your local hospital can treat e.g. colorectal or breast cancer to the same degree as a specialized institution, then they can certainly competently treat the overwhelming majority of other issues that people show up to the hospital with, which are generally going to be substantially more mundane with rather more 'commoditized' treatment available.
DangitBobby•4mo ago
rtkwe•4mo ago
ModernMech•4mo ago
1. patients need to be able to actually choose where to go. If they are incapacitated they have no choice in where they are taken.
2. we have to endure an unknown number of deaths for an undetermined period of time while we wait for the market to reach equilibrium.
So it's pretty clear free market dynamics are not the way to go when it comes to the healthcare marketplace.
coredog64•4mo ago
That would come as news to the French.
The TL;DR of the French system is that you pay for your outpatient care at the point of service. Later, your insurance company will reimburse you for 80% of the "reasonable and customary" charges for the service. It's up to you to pick the provider that matches your budget.
Emergency care is understood as not amenable to the free market, and that doesn't have the same payment flow. Having said that, I could tell you some stories about folks who wound up worse off because the care was still rationed, just by the state instead of an insurance company.
I'll preempt the common next argument, and that is that emergency care is ~ 10% of US medical spending, so it's probably not Pareto efficient to start with that case when designing how this all works.
kelseyfrog•4mo ago
I wish this would stop being used like it's a credible argument. The truth is that we can find these cases in any healthcare system. The only valid evidence when weighing system versus system is aggregate numbers.
myrmidon•4mo ago
I would literally expect overpriced snake-oil from actual free market healthcare, and there is significant empirical evidence that this would happen from my point of view.
tptacek•4mo ago
myrmidon•4mo ago
Compare grocery shopping:
You have frequent/repeated interactions; if you always get ripped of by one shop, you can go to another. Before you go grocery shopping, you will have a decent mental model for: prices levels at each shop, quality of produce and accessibility/distance. You also have the full choice in where to go, basically every time.
Hospital interactions (especially ER) is the polar opposite:
You will have few interactions with it over your lifetime (hopefully), costs are basically impossible to know beforehand (and difficult to compare, too), quality of treatment is extremely difficult to judge as patient (because every case is somewhat unique, and outcomes can easily come down to luck/individual doctor). Especially in the ER case, you often don't even have a real choice of hospital and even in cases where you could (and had all the info) there might be throughput limitations on "desirable" hospitals that prevent you from switching (=> having to wait for 5 months).
Another factor I think is that hospitals gain less from being "good": As a "good" grocer, you get to steal market share from your competition at low cost and risk to yourself; for the hospital, scaling up is more difficult and risky, thus "good" competitors are also less threatening comparatively (thus less of a motivation to improve things).
tptacek•4mo ago
thisislife2•4mo ago
The "mixed economy" model - introduce government run hospitals to create competition.
Indian healthcare industry is experimenting with such a model. There are free to cheap government hospitals (along with medical colleges that provide cheap labour in the form of student interns) and smaller public health clinics, that work somewhat like the UK NHS model. But as they tend to be over crowded, or have high wait times to see experts, people with money (and / or insurance) tend to prefer good private hospitals. Private hospitals do charge a lot, but where there are good government hospitals, they have to be mindful that they do not charge too much. Affordable insurance (along with socialised government insurance) and medicines also make access to quality healthcare possible.
smj-edison•4mo ago
I advocated against universal healthcare for a long time, since I was worried that it would cause stagnation in health innovation, but now I see a need for universal healthcare for the 80-90% most common procedures (and leave private clinics to innovate). The only downside I can think of is less dependence on insurance, which has the potential to drive up premiums. But, if that means taking care of the poor for the most common ailments, then it's a worthwhile tradeoff.
naasking•4mo ago
It could because a larger supply of doctors means salaries would be lower, and thus the incentive to cut staff is lower.
GoatInGrey•4mo ago
Your complaint against for-profit hospitals would apply just as quickly to a nonprofit hospital in a socialist regime. The fundamental problem is monopoly. Because most people don't behave nicely unless they are forced to by market pressures. Whether those markets are economic or social in nature.
Even if you ignore present-day socialist economies, you can look to NIMBYism in the developed world as a flagrant example of what happens when "normal people" gain collective control over a resource without any competitors. They immediately weaponize it to the harm of greater society. If not for financial purposes, then ideological ones.
pure_ambition•4mo ago
Admin bloat is a far larger problem, and so are the pharmaceutical companies which get to charge the government whatever they want to develop new drugs that often are only marginally effective.
mothballed•4mo ago
1980phipsi•4mo ago
https://www.noahpinion.blog/p/insurance-companies-arent-the-...
https://www.noahpinion.blog/p/service-costs-arent-exploding-...
stackskipton•4mo ago
However, at the core, US insurance system is the problem because it gets compounded by government trying to regulate such a system, so people do not die needlessly, but not destroy these profit seeking enterprises. So, what you end up with is a massive mess that leaves everybody cranky.
dantillberg•4mo ago
But this "semi-monopolistic trade union" not only inflates their wages (which maybe that's a good thing), but it also harms the lives of the population they purport to serve. Many (most imo) people in the US simply cannot afford the monopoly's prices, and the monopoly has little incentive to innovate. This cartel of doctors actively prevents lower-cost, more efficient alternatives from coming to market.
tptacek•4mo ago
insane_dreamer•4mo ago
topkai22•4mo ago
nick__m•4mo ago
insane_dreamer•4mo ago
tptacek•4mo ago
insane_dreamer•4mo ago
tptacek•4mo ago
insane_dreamer•4mo ago
there is no regulatory cap on the number of new residencies
there is a cap on _federal funding_ for new residency slots; yes that impacts hospitals' willingness to add new positions, but it's _not_ the same as a regulatory cap
waiquoo•4mo ago
emchammer•4mo ago
stult•4mo ago
nobodyandproud•4mo ago
The nursing orgs are naturally lobbying hard (MD and RN orgs have an icy relationship).
The quality and capabilities of these noctors—calling themselves residents and even doctors and performing surgeries and general anesthesia—is a growing problem.
mothballed•4mo ago
nobodyandproud•4mo ago
Incompetent treatment is worse than not being treated at all.
It’s not to say that noctors can’t be competent within a narrow domain; it’s that they’re being taught to increase their scope of treatment beyond their training.
If it becomes common, then it’d be safer and more cost-effective to pay out of pocket and get treatment in another Westernized nation.
mothballed•4mo ago
Just treat them as totally incompetent and nudge them where they need to go. No need to assume or rely on competence that may not exist.
nobodyandproud•4mo ago
mothballed•4mo ago
nobodyandproud•4mo ago
It seems like a useless metric.
derbOac•4mo ago
It's a bit weird and disingenuous to me — if you took a bunch of MDs right out of medical school with no residency training and asked them to function as a senior staff physician in a given specialty, there would be complaints about them as well. It's no different from hiring an inexperienced computer science BA graduate to handle a complex high-stakes network security position.
johnisgood•4mo ago
palmotea•4mo ago
What, specifically? Just abolish them all, and return to the pre-1938 status quo (e.g. marketing radium water to cure what ails ya)? Or specific reforms to make the drug approval processes more effective?
https://en.wikipedia.org/wiki/Radithor
jamil7•4mo ago
Sounds like something the current US health secretary might actually like.
cogman10•4mo ago
Turn it into a pure R&D effort and not one driven by profit.
ajmurmann•4mo ago
cogman10•4mo ago
Same way the NHS previously funded medical research. Grants and grant review. You can expand that department and effort.
> What's their skin in the game and their feedback mechanism?
Believe it or not, some people just want to research and look into cures for diseases. Shocking I know. Feedback can be reviews of their work and blackballing bad actors that consistently kick out bad research.
> Why will they do a better job picking what to research than current pharmaceutical companies?
Because they already are. Pharmaceuticals aren't doing the majority of research, they are taking NHS funded research and running it through FDA approval.
Ozempic, for example, didn't come from pharmaceutical research, it came from grant research into lizard spit.
ajmurmann•4mo ago
I don't think we should cut all public funding for research, but we also need private research. While semaglutides were discovered in Gila Monsters a long time ago it was Novo Nordisk that put in many years of leg work to actually turn it into something useful for humans. The more interesting argument might be that Novo is controlled by a non-profit org.
palmotea•4mo ago
Pharma companies are pretty terrible (e.g. pricing a cure for a kind of hepatitis just under a liver transplant, not because it costs that much, but because they can make the most money that way even though access is severely restricted). Getting rid of that market-driven terribleness may be a enough gain to justify the reform.
Personally, I'm so sick of the business-all-the-things approach and its well-known failure modes that I think society needs to put some effort into making other models work. Either straight up nationalization (with perhaps internal competition between research centers), or stricter oversight (e.g. putting government officials, patients, etc. on pharma company boards with enough power that the shareholders have to take a back seat).
ajmurmann•4mo ago
potato3732842•4mo ago
Each and every one of these regulations can in abstract, be justified by some useful idiot looking at only the first and second order inputs and outputs and not looking at the totality of the effects.
Nobody with a brain would defend shitting in the river, but here you are asking for individual turds so that they may be justified on the basis that the individual dropping them was relieved and their individual impact on water quality was minor.
scott_w•4mo ago
potato3732842•4mo ago
It beats anything open air by miles. Sure, an outhouse would be better but river > street.
>Trying to "just count" the regulations to determine quality completely discards this critical dimension and betrays an almost childlike view of the world.
You're grasping at straws here. I am under no obligation to give such an infantile opinion (the one I initially replied to) a response at length. This is not the venue for such minutia.
scott_w•4mo ago
Responding with “I know you are but what am I?” is just proving my point.
pfdietz•4mo ago
Elsewhere, quality of a good or service is traded against cost. But in medicine, there's a cost ratchet as ever more expensive and marginally more performant treatments are introduced.
bilbo0s•4mo ago
There may be such a reason, but you haven't outlined it in your post.
mimikatz•4mo ago
landl0rd•4mo ago
- The majority of states still maintain "certificate of need" laws for new hospitals, ambulance providers, etc.
- The AMA holds a state-enforced monopoly over physicians.
- Many states still limit NPs/PAs, requiring physician supervision for things for which those people were trained.
- Lack of interstate reciprocity in licensing means mobility is constrained and supply can't follow demand.
- Costly medical equipment usually requires first-party repairs; mfgs claim a third-party modification (repair) constitutes remanufacturing under FDA regs.
- Stark law makes e.g. physician/hospital value-based care arrangements very hard. It's quite strict and everyone has to tiptoe around it a bit.
There's also the huge problem of malpractice insurance costs due to insane tort settlements. Awards need to be capped yesterday because it's too easy to talk a jury into bankrupting people over things that legitimately just sometimes happen.
I'm guessing others could give you an even better list. Some of those are a bigger deal than others but it's a huge issue. Insurance net margins just aren't high enough to blame it and drug costs aren't enough of our total healthcare spend to be at fault.
It comes down to humans being too expensive. There remain many areas of care where we can't cut man-hours down without sacrificing safety and quality. As such, we should reduce the insane byzantine co-ordination and compliance overhead.
dimal•4mo ago
Oh, and patient value isn’t considered for these units. They are explicitly defined as input driven, so a procedure that is less costly to perform but has higher value to the patient will be billed at a lower value. Hospitals are incentivized to choose procedures that they can bill at a higher rate, and so because of these perverse incentives, they necessarily will ignore cheaper more effective treatments and choose the more expensive ones.
I’m a lefty, but the older I get the less I believe in the old New Deal style leftism I’ve been sold my whole life. As systems get more complex, they simply become a way to obfuscate oligarchic control.
maxerickson•4mo ago
Should also probably drop requiring an ER for Medicare certification and just directly subsidize ERs.
derbOac•4mo ago
I also generally think there's a lot of choice that could be encouraged in terms of drug access. I generally think people should be able to buy medications and drugs without a prescription, or at least under the monitoring of a pharmacist or something, or at least in most cases. I can think of medications that there have literally been papers written saying that they are safe to give without a prescription decades ago and they still require a prescription; there's also medications that people take for years safely, and it seems kinda absurd to require them to get a prescription for them. My thoughts about the FDA itself are complex and could probably an essay in itself.
I'm very in favor of public healthcare, and public healthcare institutions but I also feel a lot should be deregulated or reregulated toward greater openness, choice, and competition. There's probably a lot of areas where there should be more regulation too I suppose — I think antitrust principles should be applied to insurance and hospital consolidation more often.
baq•4mo ago
giancarlostoro•4mo ago
It all goes back to your healthcare costs being subsidized by those who are left with the crappy end of the stick. I think transparency in hospital billing is drastically necessary. If not for every single surgery out there at least for all the really standard things that arent so complicated.
I am not a doctor. I think healthcare can be fixed without throwing more government money at it, but we need people to understand it better and work out how to bring costs down.
If you are not aware yet, if you think you need to go to the ER think about what you NEED, is your arm broken? This sounds crazy but find a lab that will xray your arm. It will cost way less, and sometimes the insurance will pay the full cost of labs for you since you saved them a fortune. It sounds dumb, but it could save you so much financially. If you are in more urgent needs dont waste any time go get the care you need.
joe_the_user•4mo ago
Health Care is a natural monopoly like an electrical system. Basically, a large portion of health care the creation of infrastructure that everyone benefits from. An MRI machine or whatever is benefit to everyone since everyone might need it even if only some people actually use it, etc.
For that reason, the cost of procedures, infrastructure, etc, etc. are infinitely debatable and there is no true way to way to assign costs. And sure, the actual assignments are irrational but framing this "things are subsidized" has things exactly backwards.
Here's scenario - suppose electrical companies weren't responsible for maintaining their own grids and homeowners had to individually maintain insurance in the event of a pylon going down. Suppose if you didn't have insurance and could be tagged as the last user of a substation, you could in-hoc for the entire cost of repairing a pylon or whatever. This would only approach the irrationality of private medicine but I think it illustrates the situation. (and the finance system might manage to put that in place too if we're not careful).
joe_the_user•4mo ago
Just noticed this comment. Wow, free ideology seems to turn people into monsters. "No you" (in kids voice). You diagnose your own heart-attack/kidney-failure/etc. I'll take a professional.
giancarlostoro•4mo ago
joe_the_user•4mo ago
Not even medical doctors can sure of a diagnosis, where of themselves or others. And the average person lacks the knowledge of a doctor.
dev_l1x_be•4mo ago
Somehow people have this notion that healthcare should be treated differently than other service industries.
I would argue that the least amount of government control yields to the best result. There is only the size limitations (antitrust) that had potentially good outcomes. We could simply ban m&a above a certain size and make the externalities have an impact on revenue and that would be probably enough.
DarkNova6•4mo ago
Everywhere else in the civilized world, you pay less and have better service. The US has the highest degree of industry meddling, most middlemen cashing out and the least governmental regulation. You are objectively being lied to.
thisislife2•4mo ago
Regulation can indeed be balanced to create a fair and competitive capitalistic environment. A great example of this was the telecom industry in India during Dr. Manmohan Singh's government. Both the economic and telecom policies created a very booming and competitive telecom industry in India, with many foreign and local businesses trying their best, to be the best. It also ensured that the technology was accessible and affordable to all, providing a further fillip to the indian economy that increased connectivity delivers in a society. Contrast that 2+ decades later with the current telecom industry scenario in India where only 3 major private players (and 1 government owned company) survives today due to flawed and corrupt policies of the Narendra Modi government. (As the government owned telecom enterprise now doesn't really "compete" with the private players, the 3 private players have already formed a cartel to dictate pricing, and keep gouging the public, with increased pricing, with the connivance of a government that believes in oligarchy vis the South Korea Chaebol model).
And let's not ignore that regulation is necessary in a democracy because capitalists are only (rightly) focused on creating capital. But obviously they are not the only contributing members of a society (nor, do I dare say, the most important ones) and the rights and needs of others in a society are just as important in a democracy. That is why everyone today also realises that things like monopoly, hoarding or black marketing, for example, aren't good for the overall well-being of a society, even if that's how capitalists can derive "maximum" value (i.e. make the most profit). History says that imperialism is the capitalist model that delivered peak "efficiency" in terms of deriving the maximum "value" for the (low) capital invested in it. But obviously, imperialism, even in its limited form today, is not compatible with democracy or concepts of sovereignty.
burnt-resistor•4mo ago
someguynamedq•4mo ago
tptacek•4mo ago
ben7799•4mo ago
They've almost always got a state approved monopoly or duopoly and then magically the state always allows them to raise their rates.
joe_the_user•4mo ago
That is not wrong, literally stated. But know a lot of hn people imagine that this means making things completely unregulated might be one reasonable alternative. The obvious problem in this case is scams and unsafely/deadly treatments. Here, one can point countries with functioning, lightly regulated systems. The problem is that these countries depend on cultural and institutional factors keeping people honest, keeping fake medicine at bay, and etc.
But the US has a cultural of religious irrationality coupled with huge, profitable and predatory organizations (the ones soaking health care dollars as well as alternative medicine cults and scammers). Before the last hundred years of regulation, 1910 or so, unregulated US medicine was a deadly, heroin soaked shit show and if you back to that, all the "alternative" scammers along with Stackler types are ready to jump in to try to equal that situation.