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Comment by starcraft2wol | Hacker News Reader

As they acknowledge, this factor is extremely difficult to isolate from demographics, geography, religion, etc.

> As they acknowledge, this factor is extremely difficult to isolate from demographics, geography, religion, etc.

No? They used "a within-facility differences-in-differences design to address nonrandom targeting of facilities" so they're measuring the change in outcomes at the same facility before & after takeover.

That is not conclusive either. If PE had not acquired them, may be they would have been worse or better? This analysis doesn't answer that.

If your standard for "conclusive" is "study must fork the universe to compare the same business with different timeline" then you may be waiting a while.

Regardless, in this case, where the ongoing harm could be very large, we have to at some point go with the best evidence available.

> If your standard for "conclusive" is "study must fork the universe to compare the same business with different timeline" then you may be waiting a while.

My standard is authors (and random internet commenters) to have an inkling of the progress in causal analysis and related progress in the last two decades.

Edit: Some resources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9300826/

https://journals.sagepub.com/doi/pdf/10.1177/1536867X0800700...

https://www.hsph.harvard.edu/miguel-hernan/research/causal-i...

From 1999:

https://liberalarts.tamu.edu/sociology/wp-content/uploads/si...

I'm quite familiar with causal analysis [1]. What are your qualifications in the field?

The paper performs half a dozen standard robustness checks [2]. Which exactly do you believe are missing? Be specific, and include reasons why we should reasonably expect the opposite outcome.

[1] Senior ML Researcher @ Google, top 3 PhD, etc.

[2] Placebo analysis, instrumental variables, MTE analysis, breaking down the effect into plausible mechanisms such as reduction in front-line staffing, limiting results to nursing homes owned by the same chain, etc

edit: Instead of linking random surveys on causal inference, please make a specific claim, such as "the authors should have used propensity scoring", or "causal inference studies should all be ignored." Otherwise, there's no way to have a debate.

That's nice of you to list where you work. On HN there are many qualified and intelligent people, so we generally prefer to talk about the issues directly.

> half a dozen standard robustness checks

My original comment isn't arguing they used tools improperly, it's an epistemology argument. It's about the limitations of what information could even be gathered from this kind of study.

This was a reply to cscurmudgeon's objection, not yours. (You can tell because my comment is a reply to his comment.)

I think it's hilarious that somebody who has been here for all of 11 days wants to tell somebody who is coming up on their 10-year HNiversary what "we generally prefer".

I'll let you figure that one out on your own.

Oh, I did. I figure it means you're the kind of person who knows he's going to be a dick but wants to do it under a disposable identity to as not to harm his score. So you're not just a jerk, but a calculated jerk.

> I'm quite familiar with causal analysis [1]. What are your qualifications in the field?

That is nonsense.

This is not a pissing contest about qualifications, or a contest cherry picking research.

It is a rolling catastrophe - decades in the making - for USA people. In general it is that money is being transferred in industrial quantities from everybody to the very rich. Specifically money is getting sucked out of the health system for the benefit of a few at the cost of the many.

FFS socialise your medical system. Spread the cost like sane people and drive out the greed heads

If you can send a rocket to the moon.....

You should have read back up the thread, and see who turned it into a pissing contest and ended up distracting from the moral and ethical arguments by vague quibbling about the methodology.

> and see who turned it into a pissing contest

Not relevant to anything

Agreed! I only mentioned it because "curmudgeon" chose an ad-hominem argument in lieu of a concrete criticism of the methodology.

> study must fork the universe to compare the same business with different timeline

Unfortunately, that might be what's necessary to know. I am not knocking the research quality, but there are limits on what we can conclude, and obviously other important factors have not been sufficiently isolated.

By this standard, should we not believe that smoking causes lung cancer? After all, a controlled experiment on humans has never been done.

Those studies aren't similar in methodology or subject at all. Can you acknowledge there are unmeasured social factors at play in this simple survey analysis, or not?

If so, I'm happy to speculate about the epistemology of tobacco studies.

> Those studies aren't similar in methodology or subject at all.

They both used observational health data to create a causal conclusion on mortality. How is that not a similarity in methodology?

I mean... people who go to cancer clinic have cancer at a higher rate than those who don't. Cancer clinics cause cancer. And therapists create mentally unstable people, etc.

You wouldn't have to fork the universe. I think a randomly distributed trial would work, and could be reasonably made to work. Not sure though.

FWIW, I think we should prevent private equity in lots of places, especially hospitals.

I think doing a randomly distributed trial would be very challenging. How do you imagine funding it? How do you imagine getting PE to agree to buy random things rather than strategic things? Do you expect them to turn down 50% of almost-closed deals to keep it closer to random? How would you keep things being distorted by the money you'd be giving to PE to get them to change their behavior?

And what additional knowledge do you hope to gain versus a study design like this one that would be justified by the much larger expense?

I mean... people who go to cancer clinic have cancer at a higher rate than those who don't. Cancer clinics cause cancer. And therapists create mentally unstable people, etc.

You wouldn't have to fork the universe. I think a randomly distributed trial would work, and could be reasonably made to work (woth Gov. help). Not sure though.

FWIW, I think we should prevent private equity in lots of places, especially hospitals.

But it is not difficult to isolate from common sense. No one should profit from denying someone healthcare. All systems have ration care but it is immoral for someone to profit by denying care. Profit motive does not make for a good healthcare system.

Should a Lasik surgeon provide Lasik to everyone regardless of their ability to pay?

The lasik surgeon in your example isn’t profiting by denying care. Their profit does not increase by declining service.

Is a PE hospital profiting when it denies care too? How is that different from a lasik surgeon denying care?

I didn’t make claims about how PE hospitals make a profit. I just said that no one should profit from denying care. I can think of a situation in which a hospital’s owners want to make sure their return on their investment exceeds x% per year and the hospital administrators deny care based on this consideration (otherwise they might get fired for not generating enough profit). This isn’t the scenario I had in mind when I wrote that no one should profit from denying care. WhenI wrote that I was thinking of insurance companies and wanted to convey a sense that profit driven motives in health care can have bad consequences. Some things ought not be profit driven.

> Should a Lasik surgeon provide Lasik to everyone regardless of their ability to pay?

Yes

Nobody should profit from healthcare at all. I don't care if doctors and nurses and board members and janitors all make fuck you money, or if hospitals reinvest tons of money to perpetually have state of the art facilities. But the profit dynamic is too much.

How would vaccines and new drugs be invented without any profit incentive?

Isn't a lot of that coming out of universities already?

Many are but they also work with for profit pharma companies to fund the work.

> Many are but they also work with for profit pharma companies to fund the work.

It is sad to think that making profits for your masters is the only incentive to do good.

It is the way the system has been built.

It is not done much for many people's suffering

https://en.wikipedia.org/wiki/Neglected_tropical_diseases#Ec...

Don't people live long enough already? We can't pay for our retirees.

Old age medical care costs $1M+. I know the morally correct thing to do when I get old - give that money to kids instead.

Vampires.

What's the right age for us to start decrying someone's continued existence? Is it wrong for people with chronic health conditions to seek treatment rather than just dying?

> What's the right age for us to start decrying someone's continued existence?

It's not about age, it's about the cost of living vs the quality of life. These "miracle treatments" are often anything but. In many cases, they are a million-dollar ticket to a tortured existence.

If I live 60+ years, I've had a good run... if I need a $1MM treatment, my body is likely in a very bad state. My quality of life can't be very good at that point.

So when I think of my options:

- Extend my medical-torture hell for another 2 years

- Buy a home for both of my children

- Do a LOT of cocaine for 3 months

I'm really not inclined to go with the medical-torture hell.

I'm not afraid of death, we are all going to die, and in a finite universe, I consider it morally wrong to use limited resources on a project with awful diminishing returns. Especially when the project doesn't even make me feel good.

So what does it get me? 2 more years of talking to my children? If I've lived 60 years, I've taught them enough. My life is enough, and enough is enough. No need to be greedy about it when your life is already good.

> Is it wrong for people with chronic health conditions to seek treatment rather than just dying?

I don't think so, personally. The same arguments do not apply, this is a completely different situation.

https://slatestarcodex.com/2013/07/17/who-by-very-slow-decay...

>What's the right age for us to start decrying someone's continued existence?

Either 22 or 30. There was a great movie about this, based on a novel. In the movie, it was 30, but in the novel the age was 22. When your lifespan is up, you go to a show called "Carousel" where all your friends watch you being killed.

Anyway, I think the OP, plus almost everyone here on HN, is overdue for Carousel.

> How would vaccines and new drugs be invented without any profit incentive?

The same way they were invented before.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6351694/

    An interviewer once inquired about the ownership of the polio vaccine patent, to which Salk famously answered, “Well, the people, I would say. There is no patent. Could you patent the sun?”

https://www.t1international.com/100years/

    On January 23rd, 1923 Banting, Best, and Collip were awarded the American patents for insulin. They sold the patent to the University of Toronto for $1 each. Banting notably said: “Insulin does not belong to me, it belongs to the world.” His desire was for everyone who needed access to it to have it.

Individuals often respond to social status incentives more than cash. Undoubtedly this invention helped Salk's financial and personal outlook in other ways.

Also the models of development of these is just completely different from what modern medicines often requires. Specifically, operateing large research labs (which are heavily regulated) and then pursuing the marathon that is FDA approval. Individuals will still tinker, but those industrial scale developments are not going to happen without funding.

I dunno, the reason that we have such long patent periods is supposedly to pay for all the losses in Phase 1/2/3. However, if we merely let scientists do clinical research, as per usual, and license the right to conduct these studies to contract research labs, and then license the production rights for the successful trials to contract manufacturers, we could probably cut out a huge amount of the waste and marketing spend by Pfizer/Novartis et al and still achieve the better goals.

In fact, because the people in this chain would be less incentivised to focus on diseases of rich people, then humanity might overall be better off.

> Individuals often respond to social status incentives more than cash

Incentives matter. But they are not the whole story.

People act for reasons other than incentives, also.

Modern vaccines and new drugs are vastly more expensive. It costs for example over $1 billion to fund a new drug.

Yeah, but does it have to be?

Like, definitely there's costs associated with Phase 1/2/3 etc, but right now the actors in the chain have absolutely no incentives to limit these costs, as they help to justify the huge profits gained from the temporary monopoly of patents.

Also, it's worth noting that all the big Pharma companies spend much, much more on marketing than they do on research.

> Yeah, but does it have to be?

No. Definitely not.

We learnt that during the mad scramble for a Covid vaccine.

Followed up by a sickening cash grab.

A large majority of people going into scientific research do so for a love of the subject and not to become rich. They just want to make enough money to live a decent life and pursue knowledge.

Yes and their university medical research typically requires infrastructure and funding, which are often provided by for profit pharma corporations.

The following is sarcasm. If only one could think of a mechanism by which an entity controlled by people elected by the voting public could fund such things.

Strawman. PE and hospitals aren’t the ones inventing drugs and vaccines.

Some people like fixing problems for their own sake and giving away the fruits of their labor to maximize the overall benefit. The notion that the profit motive is the only reason anyone gets up in the morning is false.

How are people going to make fuck you money if there's no profit?

Honestly I've had this happen multiple times recently, where people don't understand revenue vs profit. Profit is what you put in the business bank account after you pay operating costs which includes salaries. You can make fuck you money by making idk $2MM per year. That doesn't come out of profits. Profits are commonly paid out to owners/investors in the form of dividends.

That's sophistry. Yes, accountingwise, revenue and profit aren't the same thing, but if healthcare is going to be raking in so much money that the hospitals are throwing fuck you money at the janitors, it's clearly highly profitable for a lot of people, and they want "nobody to profit from healthcare".

You are now engaging in sophistry. Doctors in England can be paid more in their system than they make now without putting in profit motives. In a publicly funded system one can pay lots of money to workers without profit in the system.

It’s as if Americans don’t understand that government can provide services and not be profit driven.

>Doctors in England can be paid more in their system than they make now without putting in profit motives

Could their pay increase without the doctors profiting?

This is a nonsensical response. You know what is meant by “profit” in the context of this discussion. You argue in bad faith particularly since you deliberately left off the motive part of my statement.

Obviously what is being discussed is that non-workers should not reap monetary rewards from denying care or otherwise siphoning out money from the healthcare system. You may nitpick each word and be as pedantic as possible but none of that will demonstrate that having PE firms in charge of hospitals would be better than a government or nonprofit entity running things.

>but none of that will demonstrate that having PE firms in charge of hospitals would be better than a government or nonprofit entity running things.

You accuse me of arguing in bad faith while repeatedly implying that I'm arguing for things I haven't even remotely approached?

Are we in agreement then that it’s best for PE not to be able to buy hospitals? Do we agree that nonprofit (as that term is applied colloquially) entities should run healthcare? I hope we are in agreement on this. If not then I hope your view does not gain support.

What? Sophistry? Are you insane? I've factually described the difference between revenue and profit, and you're saying I'm deliberately trying to deceive someone?

You are both correct in that salaries are net counted as profit of a company, but that a person who receives pay (salary or otherwise) may be, or be seen as, profiting.

"Nobody profiting" might reasonably seem to mean that even employees have little or no net gain from their involvement. Perhaps "no company profiting" fits the intended meaning better?

"Making fuck-you money" might cause somebody to assume "making more money than is acceptable, and uncaringly taking advantage of others", which would seem at odds with not profiting.

The claim of "sophistry" seems unfair and provocative, given lack of agreement on definitions. I am tempted to regard the ensuing reaction to the claim as "a shocked and puzzled look".

Ironically with no profit there's lots of cash left to pay employees fuck you money.

The point is pay your employees well not your investors when it's human lives at stake.

The same way how some non-profits and endowment funds operate. They are designed to produce a constant, predictable supply of money for their cause, and not try to maximize their profit and take over the world. Think about the way the Nobel Prize is funded, for instance.

> But it is not difficult to isolate from common sense. No one should profit from denying someone healthcare

How does one profit from denying services?

Is this a serious question? You can’t think of a scenario in which a company in America profits from denying care? You should research insurance companies and understand how it is they make a profit.

Medical insurance in the US has strict limits on profits. If they deny a little care, they can hit their cap, but if they deny too much, they have to send premium refunds. Really, the way to increase costs is to increase spending on care --- then they have more profit available, if they also increase premiums.

The CEO of United Healthcare makes around $50 million a year. The Medicare administrator makes around $400,000 a year. Administrative costs for Medicare are around 10%. Healthcare companies balked at being held to the same standard. Health insurers have their profits regulated but not lab services and whatnot. There are ways around the limits.

What is your overall point though? Do you think it’s a good idea to have profit motives governing healthcare? Do you believe PE owned hospitals are good? Do you disagree that there are instances of companies profiting from denying care?

Ask your health insurer. They have an army of people whose job is exactly that.

That's using the theme of the study to support what you already believe, without examining what the study actually shows. I don't disagree that your reasoning sounds plausible, but that's irrelevant of the study's quality.

We live in an imperfect information world. We do studies and try our best to determine cause/effect. Rarely can such a study be a proof. This is where common sense comes in. Sometimes it is wrong too.

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