The rise (and rise) of the healthcare administrator
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I'm an administrator and I'm here to help.
There is actually a symbiosis between the government administrators creating more and more regulations, and the healthcare administrators who implement them. There are also self-reinforcing effects in licensing professions, which demand more qualifications, feeding the vocational training industry. Same in finance, with Dodd-Frank, AML and KYC (all justified by fake 'wars on terror' and 'war on drugs').
It is an infestation of the western world. Social democracy is a self-reinforcing doom loop of bureaucrats and welfare recipients voting for more bureaucracy and handouts. Overheads and taxes expand to crush productivity, but not quite enough to kill it. Whatever happened to small government and small bureaucracies?
Time to invent some antiadminotics, but then they will eventually develop resistance.
> There are also self-reinforcing effects in licensing professions, which demand more qualifications, feeding the vocational training industry. Same in finance, with Dodd-Frank, AML and KYC (all justified by fake 'wars on terror' and 'war on drugs').
Call me a conspiracy theorist, but I believe accounting is one such discipline. 90% of it could have been automated out of existence decades ago - the CPA industry exists to ensure the continuation of the employment of the people in the industry by artificially making the whole thing more complicated than it has any reason to be.
It doesn't protect citizens against wrong-doing by for-profit companies, hence the regulation. There was a time when the medical field was largely unregulated[0], and it was a dangerous/misleading time. Snake oil, anyone?
0. https://www.webmd.com/a-to-z-guides/features/look-back-old-t...
I refuse to believe that we can't achieve a balance ... when there's too little regulation, add more. When it becomes too onerous, pare it back. The thing that seems to be missing is that balancing force. The body's immune system is important for regulating and protecting bodily functions, however when things go wrong, they go very wrong (auto-immune diseases, etc); I feel like that's where we are right now.
Unfortunately one man's onerous is another's not enough when it comes to regulation, and seemingly due to ideology, not rationality.
Consider those mattress tags which actually saved hundred of thousands of lives, but now seem pointless. We could probably get rid of them and nothing bad would happen for decades, but the risk is higher than you might think.
[1] - https://www.nbcnews.com/news/us-news/trump-s-epa-rolls-back-... [2] - https://www.cnet.com/news/net-neutrality-is-now-really-offic... [3] - https://www.marketplace.org/2018/02/02/business/uncertain-ho...
Without straight answers to these, every bad story becomes a mob outcry for more regulation.
Sure, imagine you could just pull a trigger and one day remove all regulations. Then see what happens. Buildings will collapse, people will organize to require building standards. Quacks will kill patients. People will organize to require testing of drugs. It’ll all just build up again. Rules (however you want to define and manage them) exist everywhere, they’re an unavoidable consequence of society.
I think the strongly libertarians/anti-regulation folks need to come up with solutions to over regulation, bad regulation, regulatory capture, etc that work within a realistic understanding that humans are humans. Then they might get somewhere, propose some changes that help everyone in the process. (Though I sometimes think there’s a contradiction there that if you do understand other humans you don’t tend to end up so far down the libertarian scale in the first place)
Sure they do. "The invisible hand of the market"! Which requires customers to have perfect knowledge of the market to work. Somehow they can't fathom that someone who is willing to harm others in order to make a profit might also be willing to act dishonestly and commit fraud in order to make even more profit.
The other argument is, "Well, it would happen anyways with regulation!" Which is true, but, just like the "bad regulation" and "regulatory capture" arguments, effectvely boils down to saying, "I don't need to go to the doctor because I'm going to die anyways."
How so?
It’s precisely because no one has perfect knowledge that markets beat central planning, as Hayek articulated in The Use of Knowledge in Society.
[0] In Free to Choose, required reading when I was an undergrad
I've started to come to the conclusion that anyone who studies economics, systems, and political science more than they study psychology, sociology, and history is at dire risk of becoming a libertarian.
Practical anarchist, though. Gratuitous rebellion for its own sake is counterproductive.
It is necessary that humans come together in cooperation to accomplish goals otherwise impossible without cartels, to break the Nash equilibriums. But it is also necessary to dismantle and diffuse concentrations of power when they become destructive to their original aims. The more permanent an institution, the more inefficient and corruptible it can become as time passes. Corporations need to sometimes fail and be replaced by scrappy startups. Governments need to sometimes hand over power to a different political bloc. Religions need to sometimes have ideological schisms. Statues and monuments sometimes need to be taken down and warehoused. Perfectly good uniforms sometimes need to be replaced with different designs. Sometimes, the fortunes of the rich need to be squandered, stolen, or sunk.
The impulse to rebel must be satisfied, and one would hope that it is possible without violent rebellion, but that is sometimes unavoidable, if the entrenched power structure in question proves unwilling to diminish itself peacefully.
As it is now, my primary concerns are the increasing concentrations of wealth to fewer people, and consolidating ownership of communications media, broadcast and network channels, and intellectual property. These are self-reinforcing, and can lead to a runaway, much like increasing atmospheric CO2 can trigger a runaway greenhouse effect. The healthcare/health-insurance industry is a potential future threat, but it isn't yet too late for them to sort themselves out through rational analysis and discussion.
All of those issues, as far as I can tell, are actually a BIGGER problem in the various parts of the world (and of world history) with weaker state mechanisms, in terms of the ability of the largest portion of their populations to reach as far as possible up Maslow's heirarchy.
If a problem arises in part because government was too weak, that does not imply that the problem may be fixed by making government stronger. In this specific case, the best solution for consolidation might actually be to weaken IP law, while strengthening FCC licensing restrictions.
As for the other problem, the rich seem to have installed themselves and their hopeful cronies to make governments their tools, so their humbling will probably need to come from another vector. Unless, of course, the government tools may be taken back from them. I think that unlikely, but people surprise you sometimes. Setting a higher marginal tax rate on the richest would certainly be preferable to murdering them and taking their stuff, but that's always on the table. I think unions are also a reasonable counterbalance to corporate barons, but the labor cartels are very weak now.
What do you mean?
No libertarian I know of opposes penalties for misbranding and false advertising (i.e. fraud). It seems like you’re attacking a strawman.
a) some moron couldn't color within the lines or
b) some player wants to ice out competitors.
For example it’s the courts that are reining in Monsanto. Regulators didn’t care a whit about the harm they caused. Big tobacco is another example. the list goes on and on.
Look, this isn't that hard. I'm not saying any branch of government isn't corruptible, we're all smart people here and we know that any human organization can be manipulated. But that doesn't change the fact that it's observably true that centralized power structures, like administrative regulation, are much more easily captured than distributed ones. This is basic civics, but sadly that isn't taught anymore. Even so I shouldn't have to tell anyone here why distributed systems are more fault tolerant and robust than centralized ones!
The "amount" of regulation is mostly a red herring. One needs the right regulation.
Suppose that this year, Insurer A pays $100 to Doctor B for performing Procedure 12345. Next year, they may only pay $95, and a couple years after that they may only pay $80. The doctor's costs are not going down in that time; if anything, the overhead of being in business (rent, wages for staff, etc.) will increase, at least at the nominal 2% rate of inflation.
So the doctor has higher costs year over year but is getting paid less by the insurer for rendering the same service. What does the doctor do? Turn to the codes!
The doctor finds a creative interpretation of the procedure which allows billing it as two codes, let's say 23456 and 34567. Each of those pays out $50 from the insurer. So the doctor switches to billing that way. Now the doctor gets the same payment as before for the same service as before. Of course, the insurer will start ratcheting down payments for those codes pretty soon, now it's an arms race: how creatively can the doctor find alternative ways to describe the procedure, in order to get paid the same as before, and how quickly can the insurer catch on and reduce its payments?
Except the doctor doesn't have time to do this, so the doctor hires billing-code specialists to come up with the creative ways to describe the procedures. And the insurer expands its department of billing-code specialists to figure out what the doctors are coming up with, and dispute or reduce payments.
And the cycle goes on and on. My first job out of college was at a company that processed health claims, and (manually) handling those claims was part of what I did there. And for the past few years I've been in health care again, on the software side (some of it at an insurer, some of it at a provider). I've gotten to watch this happen, and wondered what the reduction in cost would be if they cut, say, 90% of the billing specialists out of the system entirely and just went back to prior levels of payment.
> The implementation of ICD-10-CM has been subject to previous delays. In January 2009, the date was pushed back by two years, to October 1, 2013, rather than an earlier proposal of October 1, 2011
> The US has used ICD-10-CM since October 1, 2015
> The US also has the ICD-10 Procedure Coding System (ICD-10-PCS),[35] a coding system that contains 76,000 procedure codes that is not used by other countries.
The nice thing about standards is that there are so many to choose from. The corollary is you know you've got a great standard when it gives you that choice within the standard itself...
In the US all public and private insurers are required by law (HIPAA) to use a specified sst of standard billing transaction formats and code sets.
Well, at least if they do billing electronically, as virtually all of them do.
https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Co...
Implemented in 1996, but had a Level 3 for "local" interpretation, only disallowed in at the end of 2003 with electronic records only required in 2012 under the ACA... so I think the US is still making it's way to "standard".
Likewise the mandatory transaction standards prescribe semantics and not just syntax.
Another way of stating the Shirky Principle[1]:
> Institutions will try to preserve the problem to which they are the solution.
One of the founders commented[1] on the cost disease article linked elsewhere in this discussion and noted that, while they've had their struggles with the government regulators, the state government has actually provided them with some cover. This is in large part because it saves the state a boat-load of money to send their employees there for medical treatment.
[0] https://reason.com/reasontv/2012/11/15/the-obamacare-revolt-... [1] http://slatestarcodex.com/2018/06/20/cost-disease-in-medicin...
David Graeber makes the compelling case that corporations begat bureaucracy, which then metastasizes into government.
The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy http://a.co/ih4ixmv
Comparing the medical loss ratios of public vs private, single payer systems like Medicare vs private guarantors, seems to support Graeber's thesis.
Anecdotally, providers claim their overhead dealing with government is less than dealing with private insurance. I'd like to find some comparative studies.
TL;DR: Overhead in healthcare administration is driven by private insurers.
https://www.theguardian.com/higher-education-network/2018/ju...
Also, the comments on that article provide some insight into the administrator's point of view.
1. Cost of healthcare vs life expectancy for first world countries:
http://slatestarcodex.com/blog_images/cost_countries.png
2. Cost of K-12 education per student versus test scores in the United States over time:
http://slatestarcodex.com/blog_images/primary_scost.gif
3. Salaries for K-12 teachers over time:
http://slatestarcodex.com/blog_images/cost_teachersalary.png http://slatestarcodex.com/blog_images/cost_teachersalary2.pn...
Why can you not be more specific than total costs versus test scores? AFAIK school budgets are public, so surely there are more detailed analyses that have been done?
You can work a lot harder to make even more mediocre compensation -- I worked 12-hour days in manufacturing for ten years to make less, and it was pretty difficult on my body. If teaching weren't such a horrible job with little possibility of self-improvement, I would definitely envy them their compensation.
I certainly wouldn't do it for 60K.
http://www.mit.edu/people/dmredish/wwwMLRF/links/Humor/Admin...
A lot of projects have more management than people who actually implement something.
I was talking to a Facebook recruiter a couple weeks back and he told me that something like five floors of people (or ten? I cannot recall exactly) in Seattle were dedicated to the Messenger app. Seriously? That is absurd. What are all those people actually doing?
Insurance causes hyperinflation in drug prices and services. It's just a giant pool of money that nobody owns and everyone wrestles for, except instead of competing on price and service quality, they use lawfare and bureaucracy to impose costs and disincentives on each other.
Administration bloat has a few causes, some as a result of the effect above, and some from political factors.
The solution? Automation. If you want to get rid of the administrative bureaucratic layer, develop technologies, products, and platforms that decimate it.
This story is another particular case.
He envisioned them doing little more than sitting idly around waiting for the computer in the basement to churn out the game plan for the next business period.
This probably should be studied, though we'll also have to study improvements in health care along with the extra headcount.
This insane growth of bureaucrats is particular to the US health care system. While it grows in socialized medicine as well it does not do so at the same insane rate.
This is what the free market fundamentalists wont accept: that their precious private enterprise is often terribly bloated and inefficient.
I live in a country with socialized medicine and I’ve lived in others with universal health care. The most free market oriented I’ve experienced was the American one and it was by far the most bureaucratic.
In software development terminology I think it is easy to describe the issue. You got several components you want to talk to each other. In software engineering that means some central group of people create common interfaces for the components to speak to each other.
That is essentially the function of government. It is what creates the common interfaces. Except in the US this doesn’t happen because somebody is going to scream “socialism” from the top of his lunges.
Instead every component speak to every other one in a clunky manner. Through faxes, paper forms, which are never standarized.
That is what I notice most about the US. There are so often no standards for anything. People just wait for the magic of the market to create one, except that never happens and you end up with half a dozen competing and incompatible standards.
The bureaucracy is the equivalent to all the insane amount of glue code you got to write when nobody has agreed upon standard interfaces.
My suspicion about the US healthcare system is that the governments interventions in hyper-regulating the various players and introducing partial single-payer systems like medicaid/medicare, complicating the whole system and driving a need for administrators to sort out the whole incompatible mess. The free market averts this outcome because there are no mandatory systems - players can negotiate to reduce their own burdens, where regulation is not something that can be negotiated to a point of sanity. Or in other words, it's the integrated team running a 3 amigos session versus the ivory tower architect handing down mandates.
> The most free market oriented I’ve experienced was the American one and it was by far the most bureaucratic.
Private enterprise? Free market? You seem to either misunderstand these terms or make incorrect assumptions about the workings of healthcare in the United States.
A necessary component of any free market is open price signals which communicate information to all parties of a transaction, before the transaction takes place (e.g. a forest fire reduces the supply of trees; lumber companies charge paper companies more; the price of paper goes up in turn; I buy less paper because it is more expensive, and no regulatory czar needed to adjust his schemes and standards in light of the forest fire for me to know to buy less paper... I didn't even need to know about the fire to have actionable information about its consequences). Prices communicate more information with greater efficiency than is possible with central planning because they communicate information without an administrative overhead.
But the US 'market' for healthcare deliberately obscures price signals for the actual goods and services involved in each transaction. How many Americans know, upon receiving a prescription, what the listed medicine will cost? How many know the costs of each medical test recommended by a doctor? This opaqueness is a result of rent seeking by some parties to the transactions. (How many know about the kickbacks their doctors receive from pharmaceutical companies for recommending medicines and tests?) Yes, these rent seeking parties are usually corporations of one kind or other, but their business is so intertwined with and dependent upon the state, its powers, and its whims that these corporations cannot reasonably be called 'private enterprises' anymore, if they ever could have been.
The US market for healthcare is not a free market.
It is a highly regulated (as in controlled) and opaque market with no downward pressure on price from consumers because no price is visible until after the transaction is complete. That state of affairs is plainly absurd (and not at all apparent) to anyone not from the US. But it's also not a free market, either as casually or formally understood.
> That is essentially the function of government. It is what creates the common interfaces.
Disagree strongly here. People create common interfaces because they are useful, then the government codifies and calcifies those interfaces and standards (which does have some utility on a case-by-case basis). PDF is not a government-created standard. Though international and governmental bodies have standardized it after the fact, it was created by a private company and even before the format's standardization you could view a PDF on just about any computer. Linux was not created by the conscious effort of any state, but it runs on myriad hardware and is used by the majority of web servers. Even POSIX and other engineering and scientific standards are usually agreed upon by private (as in non-governmental) professional associations before the state becomes actively involved, if it does so at all.
The function of government is to institutionalize the use of force in society, recognizing that force of some kind will always exist and it should be limited in some way (unless you disagree with the latter two propositions, in which case you might be a philosophical anarchist).
> That is what I notice most about the US. There are so often no standards for anything. People just wait for the magic of the market to create one, except that never happens and you end up with half a dozen competing and incompatible standards.
Can you give examples?
I grew up in America, have lived elsewhere, and 'no standards for anything' isn't part of my experience, either as an American or in comparison to other places I have lived. I would argue that maybe Americans don't wait for the magic of the state to create standards, and set about the business of creating standards and doing work for themselves. Sure, you sometimes have competing standards, but I don't see how that's a problem. A better, more robust, more useful standard is likelier emerge from that competition in-the-field than it is to emerge from the diktats and musings of bureaucrats in-their-towers.
A more free market oriented approach than today would just make the US system even worse. Health care is not a natural market. There is too much information asymetry, and wrong incentives at play.
As for standards, you seem to have a rather naive idea of how government makes standards. Usually it will heavily involve industry. It is not like government just dreams up arbitrary shit.
As for example of lack of standards. I remember when living in the US having to deal with 4 different incompatible cell phone standards. I remeber arguing with an American on how it was better to standarize on GSM. He made your point that the market would eventually produce a much better standard than GSM. Except by the time the US market got anywhere we were already moving over to 3G. Sorting stuff out in the market is often simply way too time consuming when technology moves at the current pace.
Anything with banking and finance in the US seems to sorely lacking standards. But I am sure things must have improved since I lived there 15 years ago. Then there was no standard for electronic bills, sending payment to other bank accounts electronically, simple stuff like the formatting/layout of a paper bill.
I'm not sure how you draw 'naive idea of how government makes standards' from my post. I specifically point out that the government mostly does not make standards... Non-governmental industry/professional organizations agree on standards and then the government (maybe, and sometimes usefully) adopts them. Often, the (admittedly bureaucratic) teams of professionals establishing standards by committee within these non-governmental organizations are merely formalizing and documenting work already done by individuals and companies. My point is that the state is not a creative (driving) force. It follows after the people who know what they are doing... if it is working well and if it needs to participate in a standardization process at all (usually as it relates to commerce). Maybe that is all naive, but your quoted sentence above is not engaging with what I wrote.
GSM/CDMA were competing standards, and their coexistence was largely an artifact of Sprint & Verizon-forerunners switching to digital systems at a time when CDMA was a newer and (debatably) better technology. Let me point out that the standardization process was corporate-led, government-following as I have described: 3GPP (created GSM) was an old AT&T/Nortel partnership which European public/private-ish telecoms eventually joined, and which governments later legislated into force as you describe.
I'll agree that American banks have (and still do) drag their feet about adopting new digital standards, though what you describe (moving money between accounts) hasn't been a problem in my adult lifetime.
I'm not sure why government needs to actively legislate the layout or formatting of a paper bill/invoice. In a common law system, a bill is just some (among other) evidence of a transaction/contract in the event of a dispute. Fraudulent bills are already against the law, and what constitutes fraud (including deceptive/hostile formatting) is extensively defined by common and case law (precedent). Bills over a certain amount (I think $500 or $600) require standardized accompanying IRS forms (further evidence of the contract/transaction). The standards are there, but maybe not recognizable to someone coming from a civil/Napoleonic law system, which is most of the not-formerly-British world, and where such things would need to be legislated in extensive detail.
Ironically, the link below is a Swedish article about how the Swedish admin-to-doctor ratio is bloated and problematic.
[0] https://hbr.org/2013/09/the-downside-of-health-care-job-grow...
[1] (in Swedish, Doctors vs. Admin) http://www.lakartidningen.se/Aktuellt/Nyheter/2018/05/Admini...
Some of it has to do with common law. Common law means a lot of stuff always has to be spelled out over and over again while in civil law things default to the law if not spelled out. Hence you don’t need the same amount of disclaimers e.g.