Comments on “Post-apocalyptic life in American health care”

From Eliezer’s new book:

“For our central example, we’ll be using the United States medical system, which is, so far as I know, the most broken system that still works ever recorded in human history. If you were reading about something in 19th-century France which was as broken as US healthcare, you wouldn’t expect to find that it went on working when overloaded with a sufficiently vast amount of money. You would expect it to just not work at all.”

Porting between ontologies is the full time profession of the atomized world.

Sounds similar, but even worse, than my grandmother’s situation about 10 years ago. Blessedly, she did not have to deal with cancer on top of dementia. But she was transferred to an SNF without any notification to family members, or management of her residence! It is both fascinating and depressing that a new class of professionals has arisen, simply to be one’s “agent” within the system.

My family recently went through a similar sort of situation. It’s really tough and I’m sorry to hear that you have to deal with this. Best wishes to your mother, you, and the rest of your family.

I’m sorry to hear of your mother’s situation and your difficulties. I wish you both well. While I realize the post was epistemological and ontological commentary rather than political, and knowing that in the US healthcare is a political football, I say the following in the hope that it can be seen as something other than a political comment. There is a context to these systems that you describe. There are assumptions embedded in both the description and the speculation. Some of the assumptions are ‘political’ in nature. Maybe I agree with them, maybe not. But let me make the following empirical point - we know that despite spending massively more both in absolute terms and on a per capita basis, the US healthcare outcomes rank well down the pack, so why use the US as the paradigm of what is possible or likely for the future? That’s a narrow perspective at best, and it’s the kind of narrowness that becomes self-fulfilling. Anyhoo, I used to live in Japan. No lack of medical technology or capabilities there. Significantly better outcomes. Much less work expected of patients, and much less stressful to deal with than the US system. And the really big difference is that the Japanese don’t think of their medical system as a “trillion dollar free market” or whatever. They think of it as a social good and design structures, processes and incentives accordingly. You see where I’m headed, obviously; the reason that a return to primitive modes of engagement is a subject of this post might have something to do with limitations in the set of assumptions embedded within both the system and the way the writer thinks.

A more conservative estimate of the costs of admin is around 27% ; this is the percentage of staff employed in the American healthcare system solely for billing administration [1].

The UK NHS by comparison is simpler - noted for it’s efficiency yet still primitive in terms of technology (fax!), plenty of room to improve - and manages to provide universal healthcare to the UK for less than half the cost per head of the US. You actually pay around 30% more per head in taxes spent on healthcare than we do. The fact that the majority of you get no healthcare at all for that should be causing riots all up and down every state.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4283267/

Your so-apt comment that healthcare offices are like a pre-modern town had me and kept me. I am still in health care administration (nonprofit, upstate NY) and was previously (in the 1980s) and SNF administrator. Thank you and I am sharing this post widely.

Jim, Geneva NY

“Maybe an ethnomethodological understanding of how health care organizations operate in practice could make the systems work incrementally better.”

Very hard work, to be sure, but deeply insightful.

I had been advocating for Integrated Health Care Platform - even tried building one in India, a country with less regulations and more private hospitals. I have worked in United States with Kaiser Pharmacy division and Blue Shield of California. Lot of people have right intentions to fix the system, but no where to begin. With the on-going changes in the political system makes it more difficult.

With the electronic medical records, EPIC (http://www.epic.com) is almost the monopoly and between their systems they can exchange records (Stanford and Kaiser did this for me), but when it came to Sutter Health they couldn’t, so all my records had to be faxed from Stanford to Sutter (this is because of change of my Insurance). Beginning with two major players as like you proposed Insurance and Hospitals, we do have systems (for ex: http://www.trizetto.com/PayerSolutions/CoreAdministration/Facets/), but not exposed to patients. The biggest challenge apart from fragmentation of the data and information, I notice is lack of transparency to patients.

The UCLA health network has bought up so many private practices in and around LA that it carries at least some of the benefits of an integrated system. However, it also seems to cause a 300% price increase. It’s all somewhat reminiscent of the Mythical Man Month, but at least the doctors all have access to the same body of records …

I know MMM is an old book with antiquated prescriptions, but the problems of communication overhead remain very prescient. It seems to me that once systems scale beyond practical boundaries of communicating they decay into a chaotic background noise that seems to naturally invoke tribalist stylings

Sound familiar? It was written in 1972. The core of the problem is trust and incentives. When you contact Fedex to ship that envelope to an island in Lapland, you KNOW where you want it to go and you know what you want to send. FedEx would not look so great if you had to show up at Fedex and the worker there got to recommend (or demand) where the envelope would go and what was in it.

We can’t know as much as the doctors and nurses. So we have to trust them. You could trust the counter worker at FedEx. But would you still trust that worker if her income depended on where she told you to send your package? (Fee for service). Nor could you trust them if she got a bonus for only sending your package across the street? (Managed care). And if the envelope or packing supply companies could pay her on the side, it would get even crazier. (Drug companies and medical device companies.)

The instant these financial incentives spring up you get (if you’re lucky) the 1,600 pages of regulations necessary to keep them in check.

You wrote:”Back-of-envelope calculations say a working health care system would deliver dramatically better quality at 10-20% of the current cost.”
Surely you don’t mean we really could save 80-90% of current cots?

Welcome to my life. Everything about the system is insane. The payment system incentivizes questionable behavior- but if you don’t do these things you will go bankrupt. The insurance companies do anything to reduce payments which then means providers have to become ‘creative’ as a counter measure to the inevitable dramatic payment reductions. Organizations have appeared between providers and the insurance companies to help the insurance companies save money and they cause the provider to be paid 1/2 of the money they need to be paid to survive, and that organization no doubt pockets a ton of money. The amount of record keeping required is exhausting, so it’s not just the administrators that spend time on paperwork- a huge amount of time is spent by the practitioners themselves on paperwork. Small offices are paid less than large organizations for the same procedures, and there’s nothing that can be done- small offices don’t have any leverage. Workloads are too high, in order to save money, so it’s a wonder that anybody gets any of their communications to somebody else. Major amounts of energy goes into protecting against lawsuits. High tech medicine for acute conditions gets all the resources and attention, and virtually nothing gets done for prevention because there’s no money in it, no incentives. By the time people get out of school they are so much debt that profit becomes a big focus. The entire industry is built to maximize profit and minimize risk exposure. It’s a wonder than any medicine gets done at all. The incentives of the industry are the drivers. Also, there is no easy answer for what is an inherently limitless cost, keeping people healthy- when there is a limit to what is possible with a given amount of money, but not to people’s needs. Healthcare is a public good and it doesn’t do well as a private business, but I don’t think anybody trusts a politicized system to do a good job, and medical businesses assume that they will get the short end of the stick if any changes are made. Also, the people in the business are people oriented, and not techies. It’s not that kind of a field, and doesn’t in general attract those kind of people- it’s a caring oriented business, not a tech business, and it’s hard to switch between those modes of thought- but I have to do it constantly anyway, and it’s not easy.

I agree with your analysis. It feels to me that each node in the system is battling for its life against every other node, so cooperation is etremely suspect. Every medical office is in competition with the other offices for patients so aren’t necessarily interested in working with them, unless a reliable referral relationship could be worked out- but even that is still suspect. Practitioners are in fear of enslavement by larger medical organziations- for good reason. Every medical organization is in fear of enslavement to the insurance companies, so any cooperation is extremely suspect and frowned upon, because the payors mostly just want to ream the providers and make more profit by reducing costs. Patients can be difficult and some very litigious so providers are wary of giving the patients too much because when you give them an inch they are almost guaranteed to demand a mile. Payors are terrified of being enslaved to government demands so the relationship is very adversarial. Everybody assumes that any government involvement will be corrupted and controlled by big money so nobody really wants the government involved, becausee the government is enslaved to big money and does not have people’s interests at heart. Then the regulations become impossible to understand so we try not to pay attention to them because I have no time to read them anyway. We are all forced into trying to do what we think’s best and hope that that will work out. I only trust personal relatioships with other medical professionals, attorneys, and payor employees because this is the only way to not give screwed in countless ways. I am very reluctant to work with somebody I don’t personally know to some extent because it always turns out bad if I violate that rule. Village life principles are the only reliable ones in this field. The attorneys I work with operate this way, and everybody wants to minimze the information accessible to others because it only exposes you to risk and to losing patients, business, or payment. The only medical practitioners in my field I will openly communicate with are ones outside my market, across the country, and even then I’m wary because the information can make it back to my area and hurt my business. We all assume that an integrated system will only hurt us because it will lower the barrriers to the big players taking control and screwing the little players, and we will not be able to do anything about it, so it’s better to have roadblocks everywhere for defense.

Perhaps emotional intelligence training will be useful for preparing technical people for post-apocalyptic America. Among other things, it helps people pick up on social cues and the emotional states of the people around them.
More importantly, however, it appears to be capable of getting people to a Kegan’s stage 4 level of self-regulation without them needing social support.Perhaps it can help prevent some of what you’re predicting.
(The version of emotional intelligence training I am familiar with is the one in the book Emotional Intelligence 2.0)

David, how do we pay you?? I cant seem to find a patreon or donation link on any of your sites, but I want to support your work (because I love it!) Do you have a way for your readers to support your blogs?

Hello, I’m doing some research and I’m trying to connect the dots from Dreyfus’s critique(what machines still can’t do), “representations,” connectionists (all the way up through the current dnn, cnn - ilk stuff), to the present, and would like to get your perspective on what, if anything remains of your work (and agre’s ) in the “continuum” (in Dreyfus’s view) of AI. I did buy your book some 25 years ago, and managed around that time to obtain Agre’s “Dynamic Structure of Everyday Life,” but have not been able to pick up any current threads on where your stuff has gone. I know this is over simplified, but I am hoping you can provide a brief perspective of how, if at all, your stuff has evolved and/or is being used.

If this “comment” is out of context and/or inappropriate for this “venue” I apologize, but it was the only way I could find to communicate with you directly without getting wrapped around the axle of social media.

Thank you for your time. Robert

This is the paradigm case of what I call a Coasian hell:

http://www.harrowell.org.uk/blog/2018/01/31/in-the-eternal-inferno-fiends-torment-ronald-coase-with-the-fate-of-his-ideas/

Good blog, many good comments - I particularly liked the one about the Japanese system, and the one introducing Coase-ian Hell. For my sins, I´m a (reluctant) economist.

To add my own two bits. The blog concentrates on communication between institutions, which is fine. it also mentions in passing, but does not emphasise, defective communication between purely medical teams even within US institutions, e.g. hospitals. If that is not tackled it will become an increasingly serious problem, because more and more older people have multiple conditions, as: neurological, urological, cardiac, pulmonary, orthopedic … If medical teams do not communicate effectively, the consequences will be (a) worse treatment and (b) as a knock-on effect, assuming the patient survives, unnecessarily increased long-term costs.

My experience, as a relatively elderly person myself, with the NHS in the UK does not extend much to communication within hospitals. But its various ´out-patient´services and personnel do seem to communicate and cooperate effectively and efficiently on diagnosis, tests, treatment, and follow-up. The manifold institutional writhings and tricks which you report from the US are not necessary because the system is unitary and has effectively only paymaster, HM Govt-

There is a truly simple solution. Alas it is political. Publicly funded universal healthcare. Cheers from north of the 49th.

I have not lived through this myself, but the description reminds me of light reading about Soviet tolkachi (“pushers”) and Cuban sociolismo (buddy-ism, but only one letter off from “socialism”). It seems a universal (or at least pan-Europeanoid) response to system breakdown.

First–what a nightmarish situation you describe. I’m sure seeing your mother’s decline into more severe dementia is heartbreaking, and to spend this time battling colossally frustrating dead ends is the last thing you (or anyone) needs.
Second–the for-profit insurance model is inherently bad–especially medical insurance. Customers pre-pay for a service (paying their medical bills) that, if delivered, eats into the insurer’s profits. So their incentive is to dawdle, confuse, stonewall, etc.–and if they do that long enough, the patient may get better–or die–and they are off the hook. And not only do the customer’s pre-pay, they are required to buy the insurer’s product, and often have little choice which insurer to go with–and changing insurers is made absurdly difficult.
Third – I wonder if the move to concierge medicine by the wealthy is exacerbating these problems, as those with power and influence to enact big changes have removed themselves from this syster and thus, for the most part, from caring to fix it. (analoguous to private jets and the joys of economy commercial)

My mum suffers dementia. Luckily in Australia she is receiving free health care and is based now in a fantastic dementia ward (with 13 others) in an aged care centre in her home town (2100 population). Dad lives in their home in the same town. He cracked some ribs last year in a fall and had to be taken by ambulence to the nearest big hosptial (60km away). Luckily that was all free. He was there for almost 3 weeks.
As the eldest son I had to organise Mum’s aged care, and it was made very easy. The government organisations seemed to ask the right questions.
Very professional staff. We appreciate how lucky we are. Mum and Dad don’t have much money, they ran a small business farming, and a taxi service for 60 years. Good to know that the government is supporting them so well.
We hear many stories about health care in the US , frightening stuff.

The whole situation is very simple. The United States has a private for-profit health care system where private insurers are expected to foot the bill for a bloated and overly expensive industry. Private insurers like receiving your monthly premiums from you and your employer but don’t like paying health providers for services as it cuts into their “profits”. Insurers can’t tell people to “F’*% off, we ain’t paying” which is what they want to do, but they can insist on only communicating by Fax or burying you in paperwork and Kafka-esque bureaucratic tail-chasing while claiming it all serves some greater unknowable purpose related to their well-meaning, but unfortunate institutional ineptitude. This is utter bullshit. It is an overly elaborate ruse. The system appears mind-numbingly complicated because insurers don’t want to pay. The American private insurance health care system is a “market failure”. Insurers have a perverse incentive not to serve their purpose (paying claims/providers) unlike FedEx or Amazon. They fight with paperwork and obfuscation, along with “mistakes”, “oversights” and “delays” that are deliberate policy. Delayed payments are payments denied if the patient dies in the interim. Providers fight back with more paperwork and policy. You get stuck in the middle - paralyzed, sick, stressed, in debt, but paying premiums and fearing bad credit scores, debt collectors and bankruptcy.

I am 73 years. I have no medical condition or diagnoses. I take no prescription medication. I have long stopped needing the Quackerie. I don’t give them a penny and know better than to consider their advice. There are no magic beans. Real science says you will live longer and happier by staying away from garbage medicine.

I spent 30 years as a medical science director. A more corrupt, lying, greedy, racketeering bunch doesn’t exist.

My mother is 94 and doing pretty well. She fired the doctors who were junking her up on stupid drugs and got better.

The United States spends almost double, per capita, what any and every other nation spends on health care. This extra spend totals at least 2 trillion dollars a year. The maze put up by insurance companies is the tip of the dagger in Americans’ backs. The “waste” you describe in the form of additional hospital billing - that’s all good from an insurance company’s point of view because they just end up passing this through to their customers while getting a percentage off the top. It is literally the equivalent of a hedge funds “investments” on which the managers get 2% of net and 20% of “profit” each year.
We need a public system of medical care in the US. Not a public option for insurance - that’s like saying we can tame Godzilla; while Medicare for all is better than nothing, the actual solution as seen in the rest of the world is health care as a public utility.
As for health care being a political football - I disagree completely. Health care reform is the true third rail of American politics.

Every system is perfectly designed to get the results it gets.

Donald Berwick