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While what you are saying is all true, in general terms, but the key story seems missing: The "top of the funnel" system is very much fighting to preserve itself.

- Insurance companies are in bed with hospitals to collaborate swindling money from the govt: read about kickbacks sent by the US Govt to hospitals as Disproportionate Share Hospital payments.

- Hospitals have a PR arm moving profits to defend their monopolies, including using SALT rules to create barriers to entry by geography.

- Hospitals also use govt rules against it. They were able to obtain an absolute advantage over all other players (ASCs, Independents) by getting the vaulted nonprofit status, which independents cannot get.

- Hospitals use their nonprofit status and barriers to entry to buy out competition: nimbler independent providers that are actually able to lower prices.

So, hospitals create their own rules, drive out competition, and create monopolies that leads them to hoard cash, which then they use to buy out competition and mire them in 1970s technology so we all pay more.

Then there's also PBMs, and Insurers. That's a story for another day, but plenty of blame to go around.

I post that hospital systems are so large, that at the bottom, Hanlon's razor may apply, but at the top, there's incentives one cannot ignore - and a lot of prejudice to keep the game as-is.

All valid, but you forgot another big story, for another day: "medical billing". This, in my minimally-informed opinion, is the syndicate keeping the fence running. I've had dealings with 4 owners of separate small-to-moderately sized billers and their top-brass all owned > 1 multi-million dollar homes around the world. Also, their toy boxes contained millions in cars, boats & flying machines. It must be nice, but incompetence doesn't smell right.

Medical billing is by a product of government mandates on insurance to cover everything + medicare and medicaid.

Make those programs go away, and CPT codes would eventually die.

It is not going to go away so unfortunately we need to learn to live life with it, and instead make it irrelevant, or niche, just like a ferrari is niche.

The best way to cope is to have an alternative to CPT coding, which means, alternative to insurance-based healthcare, which means, medicine between patients and doctors.

The only way to do that is that insurance and CPTs get so expensive that an alternative system is demanded by the market.. and people opt in (and regs allow for it). In effect, ferraris vs corolla. Corollas don't care about CPTs, Medical Billing, Eligibility, Copays, Coinsurance, or Authorizations.

The only way we can get more honda's is by having more independent doctors and less hospitals.

Hospitals create monopolies, independent doctors break monopolies with competition.

Yes, I think that is correct - ending government intervention in health insurance would wither the medical billing industry. To be fair, the medical billing industry is not parasitic - it adds value by navigating health insurance billing, which is notoriously complex and time-consuming. But health insurance billing is only so prevalent because of massive government intervention. For example:

- The federal government is by far the largest health insurer - through Medicare and Medicaid it pays for 38% of healthcare in the US [1]. - The federal government directly subsidizes private health insurance through ACA [2]. - The federal tax exemption for employer-paid health insurance is by far the largest by dollars exempted [3].

All these government interventions increase reliance on health insurance, which increases the complexity of billing, which grows the medical billing industry.

[1] https://www.statista.com/statistics/237043/us-health-care-sp... [2] https://www.healthcare.gov/glossary/subsidized-coverage/ [3] https://www.npr.org/sections/health-shots/2012/12/04/1664342...

The best way to cope is to shift provider compensation from a fee-for-service model to a value-based care model. That reduces the need to code individual procedures using CPT for billing purposes. This industry shift is already underway, but moving slowly.

hard disagree.

value based care is another iteration of "pray for alternative" to non FFS model, aka the APM.

This is the road of the HMO, the RVU, the QCCS...and i could go on and on. Its the road that we have traveled on since the late 80s. Its the road of the wanderer in the desert.

It doesn't lead anywhere but more profits for the road-builders.

40 years of history with 0 decreases in healthcare costs is all the evidence you need to put this one to bed.

> Hospitals create monopolies, independent doctors break monopolies with competition.

The question might be: can we create an Uber-like business that has gives doctors the tech infrastructure to consult with patients without it feeling like a mom and pop shop?

Investors are betting that its possible.

Not in the strict uber model. Mind you. Providers will need to keep more of a share for it to work.

If your incompetence continually makes you money you aren't incompetent, you're malicious.

Courtesy of Louis Rossman, possibly stealing the quote, speaking about governments screwing up their fines and regulations.

Don't forget the doctors who are part of that syndicate.

I'm a professional patient, 99.9% of the doctors I've took treatment from(not U.S.) for major ailments are businessmen masquerading as doctors and I'm not talking about some scrappy hospitals; These are world renowned hospital chains.

What happens when you optimize for profit, instead of medical science? Wrong diagnosis and prognosis; I'm a victim of one and it has ruined my life.

On the other hand, There are doctors who risk their lives every day to serve people in need e.g. Doctors without borders, Doctors who rushed to serve during pandemic(Many of them loosing their life to it) etc.

Is there any evidence that doctors in other countries have a lower rate of diagnostic errors?

I didn't include 'not U.S' for that but to not have comments suggesting I sue such doctors, hospitals etc.

I trust it will higher, because if patients was not directly killed by them, doctors always get same salary.

Huh?

They don't create their own rules. Most of the things in your list are failures of government.

Why are DSH payments bad?

Becuase they act as an incentive to raise prices with no incremental value in healthcare delivered.

DSH rules are gamed to extract more from the program

Interesting, thank you. One remark:

> Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.

It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.

Inside this richest country, the richest individuals and companies have been capturing ever-larger shares of GDP. Perhaps instead of growing private fortunes, this money could have gone towards modernising these regulated industries?

> "the richest country on Earth"

This statistic is misleading. The US is only the richest country on Earth if you consider the mean wealth. By median wealth, the US is ranked 26th. The wealth gap is enormous, and if you're in the upper echelons of the pyramid your health outcomes are vastly better than the clownshoes shitshow that the rest of the country is subjected to.

The critique is perhaps not relevant here, since it suffices to say that the country's wealth can afford a health care system not held together by "spit and twine", irrespective of how that wealth is presently apportioned. The wealth gap is, as you say, enormous.

In fact, the wealth gap is but a reflection of the underlying cause of the problem: legislators corrupted to the interests of the donor class at severe cost to the actual constituents of those legislators.

The system's complexity is a feature, not a bug. Regulatory capture is real. And much of the regulatory system in health care exists to limit competition. The AMA is a cartel of doctors that limits degrees even for qualified candidates. and the hospitals also operate as geographical cartels.

The problem is that it was built by the last 50+ years of technology and regulations. The system is a product of its upbringing. A company could starts out with noble goals of doing better and slowly year by year sink into this morass and become just another “part of the problem” before it becomes obvious to everyone that it’s now just another entity making things worse.

These kinds of reforms would have had to begin decades ago to make much of a difference.

> The problem is that it was built by the last 50+ years of technology and regulations.

So... perhaps if we'd had a better goal 50 years ago - single payer or universal medicare or whatever you want to call it - we'd have decades of technical debt that propped up a fairer system, instead of an unfairer one?

Perhaps we need to change our goals today so that 20-30 years from now things will be better then?

I wonder if it is possible to design regulations with the intent that they may change and the data may require reformatting. At least a best standards practice of how these regulations should be written should be possible.

> “… noble goals of doing better…”

Compliance within regulation is a noble goal? I should think it’s ethical goal.

Richest Country - RiCo for shorter - is not a sentient being that sees and controls all...

What you refer to is actually a collection of hundreds of millions of individuals, with all sorts of interests, sentiments, ambitions, sometimes conflicting ones.

>It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.

Voters are incredibly scared of change because it's so vital. The current situation isn't caused by a lack of resources but a lack of focused will

If the incentive is not more money in most cases then it won’t work.

And those who generously give may not oversee how money is spent and likely squandered to a certain degree.

Takes an incredibly self sacrificing individual to risk it all, which is what this requires.

> It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.

In less rich countries they use paper records, which are worse. Everything is held together with spit and twine.

There's a lot of this concept, that if it doesn't work in the US, everybody else must have failed even worse. Well, not really, many times it's actually the other way around. I won't bother with other more obvious examples but in this context, even Pakistan has a digital health system in the meantime.

You could consider the fact that many countries have instant bank payments, ipV6 networks, better residential internet, have chip & pin and 10x less credit card fraud, have better justice system (lower recidivism, verdict is not determined by your wealth, etc), don't have the 'social security number is an identity', etc..

Of course many countries are worse, but surely you want to look at successes of others and replicate them.

I honestly think it's because Americans are told from birth they live in "The greatest country in the world". In that context, it feels like trying to fix anything is not really a worthy pursuit, because it's already better than everywhere else anyway. So even if healthcare sucks, it's better than everywhere else. (Which everyone in a developed country knows first hand is simply not true)

I personally think it's a very dangerous thing to believe, because it means there's no driving force to improve, and it's a part of the reason the country has stagnated so badly.

My wife did part of her nursing program in St Kitts. They used paper records.

She also says that, of the half-dozen medical record systems she has used (here in the US), Epic is one of the better ones. (read: least bad)

I'm sure if you talked to medical professionals in Pakistan they would bemoan their medical record system too. It seems to be popular sport in the medical community.

Nope, they just use a single national health insurer instead of many private ones. This changes the problem from many-to-many (as is in the US) to just many-to-one, which is immensely simpler.

Not necessarily true. At least all my medical records in all the facilities I visited in the last 5 years were digitized and I live in an eastern European, post-communist country.

The difficulty of fixing and improving these systems is frankly overrated. It has more to do with penny pinching and profiteering that they haven't modernized. I don't mean a rewrite in JavaScript either, I mean sensible engineering, which many people are ready to do but not paid to do, because it weakens the upwards money vacuum the finance cabal wants to maintain. Progress isn't profitable enough according to the Excel spreadsheet.

I was in the physical therapy space for over 15 years. The penny pinching that comes from healthcare giants towards their software vendors are dreadful. It prevents any serious software engineering from happening. One customer billed over a billion dollars in a year to Medicare through our software and paid us $1M that year. I'm still not certain that we didn't take a loss to take that client.

Passing around financial data on SFTP drops is something that irked me. Having the total not add up from the line items is also pretty ridiculous. The systems in place are all about edge cases that have formed over decades.

Software engineers are not invited to the discussions in a lot of these companies. The area is gate kept by healthcare people, which tend to be people who don't know how to do technical writing or planning.

Our company wasn't a huge one. But the huge ones looked to me as run by accountants. If you can't establish an income stream for them, they won't even talk to you.

> Passing around financial data on SFTP drops is something that irked me.

I see this a moderate amount in fintech, or perhaps at least older fintech?

Had a colleague tell me about a new financial info provider he was supposed to connect with for data. "Oh this one will be easy" he was told. "They use oauth". OK... well... you oauth in, then you hit an endpoint that triggers a data build which then puts your data file in to an FTP account of your configuration. But you can't even configure it via hitting the endpoint behind the oauth. You have to log in to a web app to configure the FTP account for your account.

You hit the API endpoint and get 'OK'. But... that's it. You might get a file in your FTP account 5 minutes later. Or an hour later. It's just whenever it gets processed on their end. And... if it doesn't show up - you have no indication whether something broke, or perhaps the data service "just doesn't have any data for you today - you can't expect data every single day".

It's insanely crazy how across-the-board poor so many of these mid-level data vendors are. Colleague is currently supporting 8 different integration ingests like this - some deliver FTP daily, some you have to pull down, etc.

One delivers data which is only ever a delta. You have to continually request previous daily info from them to get to the 'first record' for that account, which can sometimes go back years, but... you don't know that up front. So you have to loop and request "day before", pull down data, parse it, then check the day before, until you don't get anything for that customer, then presume the previous was "initial balance". But you also can't just do that once, because... there may not have been any data the day before because... holiday? system down? So in practice you need to go back 3-4 days at least to verify. Oh... and don't keep looping and requesting too fast... you'll exceed the low rate limit ("we don't want people abusing our API").

I can only barely imagine how systems evolve like this, because they don't really seem to serve anyone's interest fully.

No, I also see this in InsurTech. These companies are so deathly afraid of data breaches and system compromises that anything remotely modern frightens them...sadly.

And btw, that description given by your colleague brought cringy mental flashbacks on meetings I've recently attended.

I had a client medical clinic that had to use encrypted files on FTP. their old version of SunOS they ran on did not support SFTP or ssh. This was in 2017.

I also worked with a state medicaid office. They refused to use DNS, they decided it was insecure. Which was lots of fun any time we changed datacenters (3 times over my 7 years there). They would also go down, and nothing would happen until around 9:30-10am the following work day when they would finally come around and fix it.

The irony of attributing the free market healthcare disaster we have here to regulation. Things are plenty regulated in Australia and other socialized countries and they have none of the crazy billing / coverage issues we have. It's frankly, bullshit.

A common thing many tend to misunderstand, is that there's a difference between a free market, and a competitive market.

The most competitive/efficient markets generally need the optimal amount of regulation to keep/get them that way. Those regulations would ensure that these conditions continue to be met in order for it to be a competitive market: https://en.wikipedia.org/wiki/Perfect_competition#Idealizing...

Free markets that are completely unregulated will tend to veer towards collusion and monopolies, in which case they're no longer competitive and the customers suffer. Free markets that are overly regulated will also suffer, but more-so due to things like the regulatory burden/barriers for new entrants.

What we have in the US healthcare system is a demented hybrid where some parts are free market but under-regulated, while other parts are free market but over-regulated. It's the worst of free market and state-run combined.

It's not the same regulation.

Yeah. A lot of flamewars have happened: "regulation bad!" vs "no, regulation good!".

But in reality, good regulation is good, and bad regulation is bad.

It sounds silly written out because it's a tautology, but if more people internalized it we could have much more productive conversations. Instead of going back and forth on whether regulation is good or bad, we should try to figure out which regulations are good and which are bad, and then try to get rid of the bad ones and pass more of the good ones.

I’d argue that the underlying system that makes the regulation in US is broken. So you aren’t going to end up with many good regulations without changing the system. Which looks nigh impossible until some black swan event.

>But in reality, good regulation is good, and bad regulation is bad.

No one brick in the road to hell is bad. But you can definitely pave a road to hell with the accumulation of "positive" changes. People tend to define positive over too short a timeline or too narrowly.

No one square meter of nature is bad. But you can definitely doom people to horribly die because there is a natural swamp between them and the hospital. People tend to define 'natural' too narrowly, forgetting that 'things that are natural' includes cocaine, tapeworms, rape, birth defects, the Plague and cancer

Are you implying that individual regulations all have some inherent goodness on their own?

They're just rules we make for ourselves. There's nothing special about them. Opinions like that are why we can't fix messes like this.

It sounds silly because it is silly. Interested parties prioritize various policies with varying degrees of priority.

Effective regulation is somewhat of an organisational skill.

Perhaps its just low pay attracting low talent

No. It's the high profit attracting high incentive to capture the regulation.

The goal of the regulation is to increase prices (profit) while preventing other parties from competing on prices

I am always amazed by these "no-regulation" arguers - how are you doing to resolve disputes?

Suppose I want to sell my product, and find a company willing to buy, a middle manager signs the contract. When the company recieved my product, it refuses to pay, says this person was not authorised to sign the contract on behalf of the company.

Must the company prove the purchase was unauthorised, or must I prove the employee was authorised? Suppose employee was unauthorised, is it my or the company's problem if this guy 'took initiative', who eats the loss?

What if they already used my product and only realised after the bill came due? What if the deal was overpriced like 10x from market average? What if the guy's title says 'Head of procurement' but the company swears their bylaws don't allow him to authorise purchases?

They weren't talking about the concept of regulation. Just the reality of the US's ones.

And I think you're talking about contract law, not regulations.

There can be bad actors in free markets or socialist institutions. The issue isn't the system itself, but instead the people overseeing it.

It seems more regulated healthcare systems are also significantly less capable of developing innovative treatments (although this could be a misunderstanding of mine)

I think it is a misunderstanding. The two places in the world where everyone agrees it is easiest to get medtech devices developed are Australia and Mexico.

(Source: was doing medtech development for a while in the early 2010s).

You are wrong on this point. Some years ago, I’ve undergo some pretty innovative surgery procedure (I was one of the first hundreds people in the entire world).

I don’t know how it works in the US but at least in France, most hospitals are part of universities so they are also doing a lot of research.

> Progress isn't profitable enough according to the Excel spreadsheet.

It's precisely the opposite. Its a racket but its not for profit. If you made a health care service that didn't have any of this cruft and just provided great care, it would not be used, because it would not be compliant with insurance, and employees would not get the tax benefit of using it.

If it were for profit, it would work better.

Yes, the fact that literally all health care goes through insurance is a big part of the problem. As my dad says, if you had to get all car maintenance done through your car insurance, changing your oil would cost $5,000.

This has been well understood in policy circles. The problem is that the employer insurance payment is tax deductible. This subsidy, along with scale, locks people into employer-based care through insurance. The Obama administration attempted to reform this by reducing the deduction on "Cadillac" health care plans but even that modest reform has since been scraped. (Insurance companies framed it as a "tax increase" when really it was closing a loophole.)

https://www.cigna.com/employers-brokers/insights/informed-on...

It is not like that at all in countries like Germany and France, where really literally all health care (for a lot of people) is covered (mostly) by general medical insurance. The pricing explosion is exclusively an US problem.

(Germany has private insurance and France as well in parallel, but the main system is "sozialised")

I wish more Americans knew this.

The healthcare systems in Canada, the UK, France, Germany and Switzerland are all distinctive (they’re main commonality I suppose is that they somehow deliver quality healthcare at a fraction of the US cost.). But to hear Americans say we should “do it the way it’s done in Europe” is to understand that the person likely don’t know how the healthcare systems operate in different countries.

The other frustration in talking about this is the tendency to “It’s just” the problems. If this were a simple problem with an obvious solution it likely would have been solved. We are where we are because of a century of organic, and often idiosyncratic, growth. Well intentioned policies of decades ago have come back to bite us with unintended consequences as likely are our best ideas today.

I don’t say we should throw up our hands and give up, but when anyone says there is an easy solution - we just need the political will to let them do what they want - I do see snake oil.

All you need for progress is a sensible regulatory environment.

"Some of you may not be in compliance. We start you off at a fine of $1. For every month this continues, the fine doubles."

All you need for a sensible regulatory environment is a complete overhaul of how your society works, starting with a campaign finance & congressional staffing system that isn't built on implicit corruption.

All you need for those things is a complete overhaul of capitalism itself.

Exactly. IT, software, systems, etc… are viewed as a cost center. Hospitals aren’t in the business of selling software. How do you increase profits (or get yourself promoted, a bigger bonus)? One way is contain or reduce cost centers. The incentives are stacked against overhauling antiquated systems and modernizing, at least until the issue is forced by major business disruptions or regulations.

Right, and the fact that they are in this mess of tech debt in the first place is because they've cut corners and pinched pennies over many many decades. We shouldn't just nod our heads and be all like, "ah yeah, that's annoying, no way it could be helped". I'm so tired of companies continuing to be short-sighted about technical debt. Clearly it's been that way for more than 50 years, and we continue to validate this sort of behavior with understanding and extending deadlines.

Fine these people out of existence and let someone competent (if such a person exists) pick up the pieces and start anew.

> The difficulty of fixing and improving these systems is frankly overrated. It has more to do with penny pinching and profiteering that they haven't modernized.

Eh, I'd rather listen to duffpkg, with his extensive, real world experience in health tech, than a random comment.

FWIW, a former coworker of mine spent a few years at a health technology company (also worked with MUMPS), and legal compliance was the number one hurdle to modernizing. It was expensive, and created a huge drag.

I wasn't exactly disagreeing with duffpkg in my little rant there; just reframing the "difficult and expensive" as an unwillingness by various actors to spend the appropriate engineering cost on competently built systems.

On other hand looking at experiences here the projects to change these systems seem not to go well... So there is also not promise that things will get better...

Interesting to read mention of MUMPS

I'd never heard of it -- until I was at an afterparty at last year's AWS ReInvent and started talking to an older couple near us over some drinks.

The guy was well to do and had been in technology a long time. We had a great discussion where he told me about things like MUMPS and other tech I'd never heard of.

When they left, his wife gave me his name. Looked him up, it turns out he was C-Suite at a company nearly everyone has heard of (but is not known for being a tech company).

Makes me wonder how many billions of dollars are being pumped into tech I wouldn't recognize the name of.

I heard of Mumps for the first time from tdwtf. https://thedailywtf.com/articles/a_case_of_the_mumps

What the...?

Back when I was leaving school and looking for a job, I came across Epic and MUMPS.

From what I read, MUMPS is actually very performant. Although other companies use it, Epic is the giant. Epic was considered a decent company to work at - good reviews, good work/life balance. The downside is mastering technologies that no one else would value. Or so everyone thought. The reality was that if you become well versed in MUMPS and the Epic stack, a lot of hospitals would pay good amounts of money to you - a lot more than what Epic paid.[1] The only catch was that Epic had a 1 year non-compete clause.

At the time I considered them, they were starting to develop stuff with Visual C++ and .NET, so there was a chance you'd learn more transferable skills.

Fun story: The first time I encountered them at a career fair, I knew nothing about them. I was a grad student. At the booth, they asked me my SAT and GRE scores and were crazy impressed, and immediately booked me for their "entrance exam". At the time (perhaps even now), all candidates had to do a written exam - they'd arrange for the university to conduct it. The exam was mostly assessing logical skills, etc. No advanced material.

I didn't know anything about Epic at the time, and was extremely turned off by anyone being so easily impressed by things like SAT scores. I didn't bother to go through with it. I was studying an advanced degree, and wanted to work for a place that was not so superficial.

Fast forward a semester later when I really needed a job. I researched Epic and it actually didn't feel so bad. I felt I would easily ace their logic exam. So I applied to them. This time, though, they made me do an online behavioral screen first. The type where they ask questions like "Are you more of a X or Y?" where you feel you're neither X nor Y. Apparently I flunked that test and they didn't invite me to take the logic test. Bummer.

[1] Not FAANG level money, but still a lot more than industry average, and a relatively cushy job with you being treated as "the expert".

> Epic was considered a decent company to work at

heard this is no longer the case with the pandemic. Apparently the CEO had some questionable perspectives on COVID for someone who managed health tech. None of my friends who had jobs there made it through covid without quitting or watching their team quit.

Anecdotally, their recruiting is a mess and the IQ test type interviewing is very common for them instead of FAANG style interviews. I reached out to them at a career fair and they laughed at me and told me I was unqualified because by resume said "medical engineering with a focus on software" and said they only wanted software engineering. That day I re-wrote my resume to say "CS with a focus on medical tech" (I was formally un-declared as a student at the time) and the same person who threw out my resume offered to interview me - I declined.

* I also would later graduate with a degree in computers not medicine, in large part due to that interaction, despite forming a very negative perception of that recruiters behavior.

What do you find to be a mess about weird IQ tests compared to FAANG interviews?

From my brief time working there, it seems their recruitment pipeline is wonky for the devs while the support staff are open to applicants of any and all backgrounds (provided they can pass the IQ tests)

As a side note, Hanlon’s Razor is applied so liberally and in ways to shut down criticisms of what very well could be a number of root causes, some of which could include malice and greed.

At the end of the day, Hanlon’s Razor is just something some dude came up with to explain what is the most likely but not even necessarily correct assessment of a given situation. It is often unjustifiably treated as some immutable law when it is really just a flourish of rhetoric.

You've touched on regulation being one source of this problem. But do you think prices will become more normal if regulations disappeared? What do you think is different between the US health care regulatory structure, vs. those in other countries? Can we have the same desired effect with regulations that are easier for hospitals to follow (so as not to be dependent on Epic)?

It's really convenient to cherry pick parts of "healthcare" or the "healthcare system". The thing is, it's 20-25% of our entire economy, so it's really hard to make meaningful comparisons to other countries and their distinct economic systems, in my opinion. To compare you end up having to get into labor, education, taxation, political systems, etc. The most obvious thing is that the USA is a federation of states and with regard to healthcare the federal government has relatively little direct power (but a lot of money). I think the transparency regulations are an excellent small step, I think that there is a little bit of disconnect in regards to timeframe. It will take several more years to see how that plays out.

Regulation is one piece but ultimately dysfunction stems from huge differences between what different constituents want from a healthcare system and what they want it to be (and not be). People hold extremely different views about it. Depending on your circle and where you live you may not realize just how far apart your thinking is from people in other circles and places. Creating palatable compromises between those groups has proved almost impossible and so a lot of what we have in lieu of a compromise occurs by default and accident.

> Everyone is deathly afraid of making too many changes too fast because when those systems break the money stops flowing and a health system will literally go insolvent.

Isn't this the desired outcome, that such organizations go broke? And let their assets, employees and customers go to some other organization that isn't saddled with technical debt?

The code looks like this:

``` I X?1.N1"H" S X=X3600,%H=$H,@("X=$P(%H,"","",2)"_Y_X),%=$S(X<0:- 1,1:0)+(X\86400),X=X#86400,%H=$P(%H,",")+%_","_X G RT D DMW G 1^%DT:'% S @("%H=$H"_Y_%),%H=%H_","_$P($H,",",2) RT D TT S %=$P(%H,",",2) D S S %=X_% I %DT'["S" S %=+$E(%,1,12) Q:'$D(%(0)) S Y=% G E^%DT PF S %H=$H D YMD S %(9)=X,X=%DT["F"2-1 I @("%I(1)*100+%I(2)"_$E("> <",X+2)_"$E(%(9),4,7)") S %I(3)=%I(3)+X ```

I mean, I can see why reimplementing could be scary even with org churn.

That is from VA Fileman, right? I did a "lite" replatforming a few years ago.

https://www.hardhats.org/fileman/pm/index.htm

Binary looks like this 010100101001010 or something, surely the task of writing a mumps parser is long done?

What language is it?

From the context I'm guessing MUMPS, and it kinda seems to resemble it, if it had more line breaks: https://github.com/programarivm/mumps-examples/blob/f160bfb6...

"There are some bad actors, absolutely true. However 'Hanlons Razor' -- never attribute to malice that which is adequately explained by stupidity -- definitely applies."

In healthcare especially incompetence opens the door for bad actors to exploit weaknesses in the system which amount to huge amounts of money being wasted. Medical fraud, for example, is one of the most sophisticated organized criminal activities in the United States. Mafias setup hijack doctors offices and pharmacies (or setup fake ones) and they know exactly how long it will take until they get caught. In the meantime they can extract tens of millions of dollars from insurance companies in fake claims.

And the fraud pales in comparison to the blatant waste. Doctors office's who order unnecessary CT scans when they or their affiliates happen to own a CT scanner. Pharmaceutical companies who market brand name pills that are no more effective than generics. Insulin manufacturers who manage to charge $1,000 a month for a product that's over a hundred years old.

In the case of pharma specifically, there are a lot of pricing inefficiencies that are deliberately not corrected due to political corruption so that they can be exploited.

$1000/month insulin is not 100 years old. Your comment is like complaining that because penicillin was isolated in 1928, nobody should have a patent on any antibiotic.

Humalog insulin was patented in the 90s, and IIRC, is what Walmart sells for $25/vial. Novo Nordisk (among others) continually improves the product. Those improved products are where you see the $1k/month prices.

From the Mayo Clinic:

The 3 main reasons cited by pharmaceutical companies for the high cost of new prescription drugs do not apply to insulin. First, the “high cost of development” is not relevant for a drug that is more than 100 years old; even the latest and most commonly used analog insulin products are all over 20 years old.8 Second, the pricing is not the product of a free market economy. Free market forces are clearly not operational; there is limited competition on price, the person who needs the product is not in a position to negotiate the price, and there is no relationship of price increases over time compared with overall market inflation. The price of insulin has risen inexplicably over the past 20 years at a rate far higher than the rate of inflation.9 One vial of Humalog (insulin lispro), which used to cost $21 in 1999, costs $332 in 2019, reflecting a price increase of more than 1000%.10, 11, 12 In contrast, insulin prices in other developed countries, including neighboring Canada, have stayed the same. Insulin pricing in the United States is the consequence of the exact opposite of a free market: extended monopoly on a lifesaving product in which prices can be increased at will, taking advantage of regulatory and legal restrictions on market entry and importation. Third, the arguments that high costs are needed for continued innovation and that attempts to lower or regulate the prices will hamper innovation are not a valid excuse.13 There is limited innovation when it comes to insulin; the more pressing need is affordability.

https://www.mayoclinicproceedings.org/article/S0025-6196(19)...

You’re right about the comparison between airlines and systems like SABRE and healthcare.

You are mischaracterizing MUMPS which is now called M and has been updated many, many times since its invention and has a robust standard library of functions from M vendors.

If ever there was a need for an antitrust litigation and investigation such as United States vs. Microsoft (see below), then "Epic Systems" (see below) would seem like a corporation that needs to be investigated, penalized and broken into tiny pieces to prevent its predatory practises.

https://en.wikipedia.org/wiki/United_States_v._Microsoft_Cor.... https://en.wikipedia.org/wiki/Epic_Systems

What kind of pieces should it be broken into?

Hanlon’s Razor is the most stupid meme I have seen. It doesn’t matter that X did not implement a way to cancel their subscription easily because they were “incompetent.” The key point to ask is, if the incentives were reversed, would X suddenly become much more competent? If yes, they are very much a malicious agent and must be dealt with accordingly.

For those unaware of the travesty that is MUMPS please consult the following article.

https://thedailywtf.com/articles/A_Case_of_the_MUMPS

Would rewriting healthcare systems in enterprise Java or modern JS or Clojure actually improve them any compared to MUMPS? From my brief experience, the #1 MUMPS problem is that the syntax makes Perl and regex look legible. The two points that I miss in modern languages are:

1. There is absolutely nothing special you need to do when handling values out of the database compared to in-memory values 2. The nested data structure—it's like a nested Python dict, except each level can contain a value and children.

I remember getting educated about MUMPS when we were researching about health informatics and interoperability in my PhD programme. My superviser said it was the earliest record system and also most reliable one. I was then opened to a rabbit hole of sophisticated electronic standards for health information exchange and standardisation for multi-domain medical knowledge/terminologies in hospitals. To this date I think it's still pretty much the same status quo if someone is to do research in this area and go for an introduction.

I work in the payments and billing area for my company. So, this idea of medical billing being so out of date is interesting.

Can you share your insight as to why it is not something that smaller companies or starts up have tried to fix? You can also email me (email is my HN username at Gmail dot com). I'm interested in learning more about this on a technical/"behind the scenes" level.

When modernizing processes becomes too hard, it is almost always a sign for the processes being way too complex and needing a complete overhaul.

US healthcare billing certainly could benefit from a massive simplification, and the reason of the success of neobanks/fintech is the same: they always started from green fields and didn't have to fight internal politics battles to change a data entry mask.

In other words, it is a matter of priorities. If the fines were significant, the initiatives would be prioritized. It is that simple.

I don't think vendor lock-in is a sufficient explanation here, respectfully.

I feel this is why efforts like FHIR are very important, though certainly scratching the surface.

As someone who works for an HIE and in the interoperability space, I feel like we have been talking about FHIR for the last decade. Hopefully it hits critical mass soon but I doubt it.

Have you ever heard about OpenEHR? https://www.openehr.org/

FWIW, pretty sure duffpkg was involved in the creation of OpenEHR, and therefore probably has heard of it.

but doesn't it solve problems he wrote about (Epic and vendor locking of data?)

Conceptually, yes, it solves a small corner of them.

I'm going to ballpark migrating from Epic to OpenEHR without losing data would probably cost you something around $500/patient. So consider a medium-sized hospital that has 250k patient records. $12.5m project. That takes 2 years. (I'm considering all the places that Epic has custom integrations with other systems, with your insurer, etc, in that $500/patient, which is probably low, but gotta start somewhere). Add in the cost of re-training staff to use the new EMR, finding out after implementation the 'shadow IT' systems like someone exporting data to an excel spreadsheet and then doing a huge workflow on that that no one outside the department really knows about but is absolutely vital to the pharmacy's ability to operate...

OpenEHR can help address some things for one part of the system. But that is like saying fixing OpenSSL bugs will make all the internet secure.

So just post the amounts actually billed/collected instead of a "price."