This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
Notes -
Look, I get it. You want it to be one way. You want to just keep everything the same; just stop all the change; just go into work, do a good job at doing your job, close your eyes to any dysfunction and make no changes to your mindset concerning the entire conceptual schema of the industry. That's fine. That's natural. Parts of it may even be commendable.
...but as the old saying goes, things that cannot possibly keep going the way they're going, won't. Change gon' come. I've seen this in industry after industry after industry. This is an industry that just had two different bills passed by two different congresses and signed by the last two presidents (one of whom is coming back in and may be interested in taking another bite at the apple) specifically because this stuff is a problem. The purpose of this entire thread is because a notable CEO was shot dead in the streets of NYC, possibly because of frustration with these problems; news outlets are reporting people cheering this. It's not always regulation; sometimes it's in other forms. Sometimes, the industry cleans itself up. Sometimes, there's just a shift in the case law. Sometimes, there's a disrupter. Sometimes, new regulations get dropped like bombs. And I get it, that last category is scary. I don't like a lot of new regulation. You know full well that I'm aware that it is often done shoddily, with all sorts of unintended consequences. This is the least-preferred solution in my mind. But everyone knows the medical industry is broken. Everyone knows that it can't keep going on forever without change. You know that it's broken when you say:
I've heard industry after industry swear up and down about how unique they are, how they have to do things differently, how they can't possibly change things. A silly little example from the last few months is real estate. Oh Sagan, the kicking at the goads, even after the details of the settlement became clear. You should have seen the levels of broken people's minds were; how they were constantly talking about ways to try to get around the new rules, how they simply could not conceptually wrap their minds around the fact that they couldn't just operate the same way that they always had, how their industry is a special snowflake and their special needs will always shine through. You saw some of the smart ones figure it out reasonably quickly, and sure enough, they started doing the obvious things to follow the new incentives and improve their business. I'm sure some of the folks who kicked too hard or weren't smart enough to figure it out or were simply broken by the conceptual change are struggling right now; some might already be out of business.
Change will come, no matter how unique you think you are. You really have an opportunity now. You can change your conceptual schema, evangelize the change in mindset, and begin to fix what you can in your corner of the big problem. Maybe it'll be a lost cause for the purpose of avoiding some dumb regulation, but that's your opportunity. I'm just sounding the warning, like I did long ago for IoT. We saw how that worked out when they didn't heed the warning, banking on swearing up and down about how unique they were and how things had to be different for them. They probably liked the regulation they got less than they would have liked the alternative opportunities they previously had in front of them.
So, in the spirit of helping you get a head start, a leg up on your competition for when change comes, so that you can adapt, optimize, and make bank, rather then ending up broken, conceptually lost, and possibly out of business, let's really think about what you can do. You gave an answer yesterday about the cost of a gallblatter removal. Perhaps you forgot that answer today, but I'm guessing you didn't. Think about your previous answer; what was wrong with it? I liked it; I thought it was pretty good. If you didn't forget it, I sort of have to believe that you consciously or unconsciously chose to change your answer to a less good answer. Perhaps reflect on why you might have done so. What were your motivations in trying to be less helpful? How do you think it will affect people's (possibly including potential customers') impression of you as a person or as a possible topic expert when they see that you are choosing to be less helpful than they know you can be? How do you think the mindset of choosing to be less helpful will affect your business if/when change is imposed on your business or industry?
Additionally, I suggest you seriously study how other industries manage to solve this problem. All of them do it. There are a variety of solutions. Can you think of any? If the only one that you honestly can think of is to have the head of the billing department personally perform every single estimate for every single procedure for every single patient, how do you think that will affect your business's ability to adapt to changes? If regulation comes, could your lack of insight into how these problems are typically solved leave you lagging behind the competition in adapting to the new environment? Could it even pose an existential threat to your business?
I suggest you consider these things, because some of your competitors will. They will not only survive and make money; they will thrive and eat your lunch. You have a great opportunity now.
You don't just get to declare that medicine is the same thing as everything else and call it done. Frankly I can't recall other industries telling me they were uniquely weird, my friends in most industries emphasize how similar they are to each other and go what the fuck when I explain how things go in medicine. "You get paid less for working in higher cost of living areas or for more prestigious jobs? What the fuck." "More years of training decreases your salary? What the fuck." "More complicated jobs pay less? What the fuck." "What do you mean a routine procedure could cost five thousand dollars or one million? What the fuck." "What do you mean you do 20+ hours of unpaid labor a week? What the fuck."
To emphasize: name another business that is forced to work for free and is prohibited by law from closing unprofitable businesses segments (example: the ED). Healthcare is prohibited by law from being more efficient and cost effective.
As previously mentioned we have a parade of outside actors coming into medicine in attempt to take care of low hanging fruit and apply general business knowledge because they assume everyone must be idiots. And then they catastrophically fail.
The complexity of medicine is higher than nearly every other field for a number of reasons including the fact that actual human lives are at stake. Bad outcomes are unacceptable so that makes things expensive in a way that does not apply to other industries. Voters have elected to avoid tort reform or rationing or a reduction in administrative and documentation burden and others things that might address the problems.
You are right of course that people will attempt to solve the problem by increasing regulations and doctor salaries will be likely cut. Well administrative costs are about a third of healthcare spending. Guess what is going to go up with increased regulation? Physician salaries are about 8%. Guess what's not going to move the needle if it is cut?
And of course price controls lead to shortages, which we already see quite a bit.
You seem to think that everyone in healthcare is stupid and that nobody has tried to apply general business knowledge to these problems. Of course they have. Some well run places have managed to improve things slightly, but we don't have to speculate as to how hard this, just point to the parade of corpses that tried what you are suggesting.
And of course you have things like HCA which seem to be legitimately profitable! Great. Oh wait no they are grossly unethical and constantly under investigation for illegal business practices and nobody who works there wants any of their family members anywhere near those hospitals.
EDIT: Let me add one more - where else in modern America do you see costs kept down by using indentured servants? The closet thing to Residency is visa abuse in tech and that's not anywhere near the same level of insanity.
post offices in some countries
this does not stop them from clearly stating prices
Good example! However that specific point is meant to illustrate the oddity and complexity of healthcare delivery, not be the specific reason for lack of price transparency.
More options
Context Copy link
More options
Context Copy link
Don't need to. That does not in any way prevent you from giving a price. You know that it doesn't. You know that you can do it. You've basically admitted such by your responses and non-responses.
You have an opportunity in front of you. Perhaps you'd like to respond to the questions I asked rather than not responding.
This is hilarious, given that you were just defending a claim about residency slots that looked extremely poor upon even a cursory look at the entire data you linked to. Maybe your industry is like other industries from an economic point of view when it comes to cartel behavior restricting supply. Like, economists know how systems like this lead to abuse, and perhaps if we stopped restricting supply and truly opened it up to competition, where if one hospital was known for abusing their residents or even paying them poorly or whatever, they would likely have other competing options. You might not be such a unique industry, impervious to literally all traditional analysis, as you think.
But yeah, you know there are atrocious problems. You can keep making bad arguments, pointing to data that you know doesn't show what you say, avoiding answering questions, choosing to be less helpful than we know you can be, etc. And one set of results will flow from that. There is another way, and hopefully another set of results to go with it.
EDIT: There are indeed many different dysfunctions in the medical industry, and one can always say, "Well, we can't spend time focusing on X, because there's also A, B, C, D, E, F that cause weird problems, too." That results in just spinning wheels and nothing ever gets done. When someone later suggests, "Here's an idea that can improve D," you will again say, "But we can't spend time on D, because there is also A, B, C, X, E, and F."
For IoT, I had originally suggested that people just focus on one thing, a little thing. You had to figure out a way to get default passwords out of the industry. It had to be done. It absolutely could be done. But it had to be done. Instead, we got the same distraction tactics, the same Obvious Nonsense claims that it was actually impossible, etc. We saw the results that followed.
I think it is plausible to start with one thing (I suggest just providing prices), especially one that we all know is actually, totally possible. There is no real reason why it cannot be done. If you adopt the mindset that it must be done, it must be the first step to changing the mindset of the rest of the culture, you at least have a chance of success. It requires admitting that there is dysfunction, admitting that the mindset needs to change, admitting that the old mindset and the old dysfunction was fundamentally built on lies, and here is one very straightforward, very easy way to demonstrate that it was built on lies and that we're going to have to call out those lies if we're going to have any hope at broader change.
Giving prices is possible. It will not break other things. It will not make other problems any worse. In some cases, it might not matter much; in other cases, it will. But it is an easy first thing that you can do to break the cycle of lies built upon lies and give us any hope of an alternative solution to something like the haphazard, chaotic mess of additional regulation. Not doing something like this is simply resigning to whatever other, possibly incoherent, change will come. The same dysfunctional mindset will persist, and I, for one, would have little hope that anything will be fixed anytime soon if we can't even do one little thing.
Let's go back to basics. We can estimate the price of a given surgery prior to providing it but that estimate is misleading due to the frequency with which it is wrong, often to the degree of orders of magnitude. You might say "yes you can give me an average that's an estimate" another person might say "an estimate is only meaningful if it is reasonably correct."
In my experience people get pissed if they ask how much it is going to cost to renovate their kitchen and they get a bill for 3 million dollars instead of the initially stated 30,000.
So
Estimates cannot be provided in the same way they can be in most other industries due to an intrinsic excess in variability secondary to the complications involved in human health.
Giving estimates reduces bargaining power with insurance companies and is therefore disincentivized.
Estimates have no value to patients because your insurance is going to be paying not you.
Please pick one or more of these you disagree with and explain why.
Let's go back to basics. You already gave a vastly better answer. Did you forget what you said two days ago?
Dawg I have no idea what you are saying, I've been consistent in my messaging with you which is that this stuff is hard and complicated.
You don't seem to want to engage with any of the most important details here which include things like "medicine is not like other fields, maybe it could be but it is not allowed to be - and we have evidence of this!" and "the specific cost is not relevant in any practical sense."
You appear to have forgotten your answer from two days ago. I suggest you go back and re-read your prior comments.
You have made this accusation multiple times, I have consistently maintained that it is fundamentally unknowable (because it is) if you loosen your definitions of knowable you can know some things about it. Additionally, it ultimately is not relevant and not our job, but we do know some things about it anyway.
If you think you "got me" in some way you will need to clarify.
This tack is not helpful, unlike last time I've tried to give examples of things you don't know and would need to know in order to understand the complexity at hand, but you need to actually engage with them. Every example I've given you about how healthcare is not like a car repair shop has been ignored.
Can you remember what your answer was two days ago?
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link