Hacker News Reader

Comment by giantg2 | Hacker News Reader

The thing that doesn't get mentioned much in these conversations that I've personally seen play a big role is the regulation. When you have highly complex regulations, you end up consolidating practices. As regulations increase, the number of distinct providers/owners decrease. Many individuals don't want to run their own practice due to the complexities (insurance, etc) that exist beyond the work (treating people). It doesn't make a lot of sense to deal with the insurance, billing, recordkeepeing, etc for a single physician or two. They wouldn't be able to compete with the larger and more effiecent practices that have more bargaining power with insurance companies anyways.

View on HN

> The thing that doesn't get mentioned much

This gets mentioned every time. The regulation boogeyman always shows up. If only there were fewer rules... everyone could make more money, the little guy would be able to enter and play fast and loose, and nobody would do the wrongdoing those rules were meant to correct/prevent. Yes, there are regulations in health care. There are regulations in almost every industry, and yes, they can be a pain to deal with. Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on. As part of the general public, who are often the victims of business's negative externalities, I'm grateful that our government still manages to regulate businesses.

Then maybe the government (i.e. the public) should pay for more of these regulations, as opposed to unfunded mandates, which small operators cannot afford.

In the example of the individual doctor's office, perhaps the government should provide software and billing systems to adhere to their mandated processes, inspectors, fund regulatory agencies, legislative support, etc.

Otherwise regulatory capture can drive out much of the competition, potentially leaving us worse off than we could be otherwise.

Tell me you don't know anything about healthcare without telling me...

Sheesh.

Doctors are medical technicians, not lawyers, and the more you bury them in (largely billing) regulations, the worse care you get and the less time with that doctor you get, and the more money you pay for worse healthcare.

>Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on.

One such regulation is "certificate of need" laws, where you effectively need to ask the incumbent for permission to open your would-be competitor.

https://spn.org/articles/certificate-of-need-laws/

Or maybe regulation is in fact a problem. In my country there is less regulation in healthcare services. I can walk into multiple private facilities in my town, get full blood panel with almost everything you can think of included (hormones, vitamins/mineral levels, liver markers etc) for around 100$. The results are going to be available online the same day (with the exception of those that require more lab time). This is fully private enterprise which has nothing to do with "universal healthcare" my country has.

I don't need prescription or doctor recommendation to get it done. I can also take my own urine/hair/swabs, walk into a lab, pay and have the requests results online in a few days.

If I need MRI I can usually schedule it for the next day in multiple private points and again the results are going to be there the same day. The price is around 200 bucks for say cervical spine.

How is it in your country? Do you know how much is required to get those basic services in other countries?

In the US you can have similar labs done at Labcorp or Quest. Prices are similar or slightly higher. MRIs are prescription only and higher priced. One main difference is that most labs here require a prescription, which means you need to go to a different provider just to get the piece of paper and pay them. Of course these providers are both massive chains. Not sure if either are PI owned.

Quest and Labcorp have started doing many tests for a direct fee. You just pay upfront and get it done, no prescription/insurance needed.

It’s not all the tests I think, but many.

Exactly what I was saying. The majority of tests still need a prescription, but there a a few dozen out of the few hundred total.

200 dollars for an MRI with no referring reason is inexpensive for sure. Where is that?

Poland. For all the faults of my country healthcare is actually run pretty well. There is a public option where you have to wait but people are free to run private practices/labs/facilities.

Because the public option exists they can't run the prices up however they want so it's usually very competitive.

Which country are you in?

"This gets mentioned every time."

No, this gets mentioned in other healthcare conversations but rarely in PI takeover conversations.

> Yet people still start businesses, make money, grumble endlessly about those regulations, and society marches on.

But that's the problem, isn't it? They don't. The smaller providers actually do go out of business or get bought up by private equity and then the quality of care suffers -- which is the thing the regulations were sold as improving.

Everyone knows the US healthcare system sucks. But the United states medical system is not uniquely under regulated compared to the rest of the world. It's uniquely poorly regulated.

Many individuals don't want to run their own practice due to the complexities (insurance, etc) that exist beyond the work (treating people).

It’s interesting that the one specific thing you mention is insurance. That particular complexity doesn’t come from regulation. It comes from the immoral insurance industry.

The federal government is one of the largest insurers, and dealing with them entails a lot of effort and expense.

The widespread need for medical insurance only exists because regulation has introduced many artificial inefficiencies within the health care sector that in turn severely distort the pricing of medical services and medical products.

We'd see far more reasonable pricing, and much less need for something like medical insurance, without the regulations that artificially limit the supply of practitioners and clinics, that prevent competition, and that introduce unnecessary costs, among other distortions.

The fact that healthcare is far cheaper in every European country that has universal healthcare suggests that you are wrong.

Healthcare is cheaper in every country everywhere regardless of whether they have public or private coverage. This implies that the difference isn't public vs. private, it's some other regulatory differences which are driving up costs in the US.

… it's some other regulatory differences which are driving up costs in the US.

It suggests regulatory capture and/or lack of proper governmental oversight.

"Regulatory capture" is the regulations the people complaining about regulations are complaining about.

"Lack of government oversight" almost never leads to high consumer prices. It can lead to externalities, but if there are no regulations preventing anyone else from competing with the incumbents, it's very hard to sustain monopoly rents.

Most people in the U.S. think regulations are bad in and of themselves. Regulations as a concept are the wrong target.

Lack of government oversight and regulations almost always leads, eventually, to cartel pricing and/or monopolistic type pricing.

> Most people in the U.S. think regulations are bad in and of themselves. Regulations as a concept are the wrong target.

Regulations as a concept are the category of thing which is causing the problem. You then have to look into which specific regulations are contributing to the problem, but there are 10,000 of them. You can name some of them, like Certificate of Need laws, but that's just a representative example rather than an exhaustive list of every problematic regulation. So people say "regulations" or "inefficient regulations" because what else are they supposed to call them?

Hardly anybody thinks the ban on leaded gasoline is a bad regulation.

> Lack of government oversight and regulations almost always leads, eventually, to cartel pricing and/or monopolistic type pricing.

Only if you're specifically talking about lack of antitrust regulations, which is the exception rather than the rule in the overall category of regulations.

Most regulations simply increase costs. This is true whether they're good or bad. The ban on leaded gasoline increases the price of gasoline; lead is a cheaper stabilizer than what they use now. The ban on circumventing DRM increases the price of playback devices (or reduces quality at the same price); device makers have to pay to license the stupid DRM and it impairs competition by preventing anyone from making a device with features Hollywood doesn't like. But the ban on leaded gasoline is a good regulation because it's preventing a major externality, whereas the ban on circumventing DRM is a bad regulation because it doesn't do what it was sold as doing and instead is used by the studios to capture the market for playback devices.

Getting rid of bad regulations improves efficiency and lowers prices.

We tried the no regulation method after the Civil War. It lead to robber barons and an overall shitty country. Regulations as in the concept is not the problem. Bad oversight and governance is.

I honestly don't understand why someone can't say "we should get rid of these bad regulations which are causing problems" without someone hearing "we should get rid of all laws of any kind whatsoever".

Because for 40 years now the Republican party has demonized regulations as a concept. So now we are in a situation where people like you write:

Regulations as a concept are the category of thing which is causing the problem.

No sensible person thinks regulations as a concept is bad but, well, roughly 1/3 of the U.S. population is not sensible on this topic. No sensible person thinks all regulations are good. Regulation is not the thing to talk about since the issue isn't regulation but bad governance and oversight. The issue is politicians in the pockets of insurance companies. The issue is that we live in a country where profit is the holy of holies that must not be messed with.

The actual problem is that "regulations are bad" has become a decent heuristic, because such a high proportion of the existing and proposed regulations are a result of regulatory capture. Your objection seems to be that you want to call this "bad governance" instead of "bad regulations" but it's not clear how that's even supposed to be different.

The number of people who think that all regulations are bad is limited to a handful of actual anarchists with no real power and a presumably larger number of rules pedants who want to play different definitional games where they use "regulations" to refer to the things they don't like and call the things that they do like "laws" or "rights" or some other allegedly distinct thing where the distinguishing criteria is doing all the work.

Of course, getting people to spend all day arguing about terms is to the advantage of the people who like the status quo, because then they can get the people who claim regulation is generally good to pass their regulatory capture rules and get the people who claim regulation is generally bad to repeal or fail to enforce the e.g. antitrust rules intended to protect people from their predatory behavior. But then you're just playing into their game -- the Certificate of Need laws etc. are of the first category.

But not sure americans would be okay with the limits on healthcare you got in europe. I'm from sweden and here you often have to wait several months to see a doctor if it isnt "im dying right now"-urgent. And if you got something complicated that isnt easy to diagnos but isnt killing you they will just not do anything about it.

The healthcare is good if you got something well defined and urgent like a hearth attack or cancer (but less good than cancer treatment in the US). But if you got something less urgent then you are kind of screwed.

The healthcare outcomes in most European countries are better than in the U.S. The wait time of someone without access to the healthcare system is infinity. In all healthcare systems there is rationing of care. In the U.S. we ration in an immoral way.

I think the causality runs the other direction. Europe has an efficient system so they can easily afford to give everyone health care. We have a very expensive system so we don't.

Medicare costs do not look like the rest of the world. Medicare has slightly lower costs than private insurance but that's mostly bargaining power not any increases in efficiency. They free ride a little off money made off private insurance.

High costs are certainly present in socialist medical systems, they're just somewhat obscured.

I'm more familiar with Canada's taxpayer-funded, "universal" provincial health care systems than the European ones, so I'll describe the costs we typically see with them.

Government health care spending makes up a huge portion of the provincial budgets each year. This results in costs like high tax rates, and significant government debt. (Those, in turn, introduce other costs, such as the stifling of business development and employment, among others.)

Another significant cost is the poor quality of service. Long delays are the norm. This can mean single-digit hours-long waits for emergency service, double-digit hours-long waits for semi-emergency situations, and weeks to months for routine diagnostics and specialist appointments.

A lot of Canadians don't have a family doctor, and walk-in clinics are typically quite busy and have relatively short hours, so people end up going to emergency rooms even for relatively minor health issues. That only exacerbates the problems there.

Even once you're finally seen by a practitioner, there is little incentive for them to do a good job because there's pretty much no competition, and no punishment for providing poor service. Don't expect a favourable outcome, especially for anything requiring in-depth investigation or long-term treatment.

Common dental, vision, and pharmaceutical costs often aren't covered by the provincial systems, which results in many Canadians paying even more money for costly private medical coverage on top of the "universal" coverage they've already paid for via taxation and public debt.

It's very revealing that despite paying a lot for the local health care systems, Canadians with the means to do so will often seek treatment in the US anyways. Even if they have to travel and pay a lot more money to do that, at least it tends to result in much faster, and much higher quality, service than they would ever have received in Canada.

> artificial inefficiencies

To be clear, the "artificial inefficiencies" here include treating poor people, treating elderly people, and treating people regardless of their conditions.

The alternative, which we have lived, is those people just dying. We, as a collective society, decided these features are "non-negotiable". Hence, the US has a semi-socialized system in the form of insurance.

The reason your premiums are so high is because some homeless man somewhere is getting Narcan as we speak. Your woes of a communist future have come to fruition, but it has been packaged in such a way that the average American does not realize it. We have the worst of both worlds - the sheer greed of the private sector, with the burdens of a public policy.

If we seek efficiency, as you say, the answer is obvious. Abolish insurance, and provide single-payer healthcare. Delete the middle men on top of middle men.

"That particular complexity doesn’t come from regulation."

Considering the ACA requires insurance, it indirectly does. While there are cash-only doctors, it's very rare.

You would be onto something if the ACA was the cause. The status quo ante was an equally complex mess that covered far fewer people. The ACA more or less kept the same system in place but now covers more people.

Regulations for healthcare exist are complex in every developed country, but in most everything works fine for a fraction of the cost, so I don’t think that’s the main issue

Ironically this statement glosses over the indisputable issue of the specifics of the paperwork volume, and the change in it over time. "Regulations exist everywhere" is far to general an argument to be meaningful in my opinion. Humans are forever limited by time and their labor capacity within it.

Regulation is where protectionism and corruption manifest.

Regulation is a tool that can be used for many ends. It's not very helpful to speak about them collectively.

But they obviously aren't the exact same set of regulations everywhere.

Measuring burdensomeness of regulation by number of laws is an incredibly poor measure. Though I'd still be surprised if many countries healthcare laws were as complex as our own.

For example

All doctors require 1 year of schooling 2 year 5 years 10 years 20 years.

Each is 1 law but has each also has very different level of burdensomeness.

I'd actually be in favour of deregulating a lot of healthcare, but probably not for the same reasons as you. I think a cheap but unverified device/consultation/surgery is better than none at all (where only an unaffordable regulated option exists). But that's miles away from how society, even American society, functions. Without some mechanism to manage trust you can just remove the safeguards. It's actually quite possible to keep the safeguards and run a half-decent healthcare system, and this is surely much easier than finding a way to let people take calculated risks without causing mass deaths and a collapse in social cohesion.

It's not just regulation. You have electronic health record systems and the like that are often beneficial for consumers. My personal experience is that a lot of older docs, one doc practices, and the like hate this sort of thing. But I personally love the modern systems that a recent merger brought to my local hospital system. It's no longer about (maybe) faxes getting to the local lab for tests after calling them a week before the physical.

There are one or two doctors here who operate individual cash-based practices. They don't deal with insurance companies or their paperwork. The seem to mostly focus on services that insurance is unlikely to cover anyway: weight loss, hormone therapy, but also still run a general/family practice.

They stay in business so the model seems to be viable, but perhaps only because there are so few of them doing it.

You're being downvoted but I wish you weren't.

I've worked in healthcare, and pretty much my whole family does in all the professional roles you can think of.

I have mixed feelings about this article and others like it because the motivation to strip the system of everything until profit is left is a serious problem throughout US healthcare. However, it's not unique to private equity — private regional monopolies, or even privately owned clinics and hospitals, can have a similar effect. These articles then have a way of shifting the focus away from the underlying administrative practices that result in these problems, and toward private equity per se.

The regulation problem is real too, and I can give lots of examples. It's unlike a lot of other fields too in the scope and how ingrained it is in the system. EHRs are just one example: although well-intended, they were mandated with no "organic" roll-out, and pulled what was in-house staff and services and pushed it outside into large monopolies like EPIC (who are now the subject of an antitrust lawsuit IIRC). This happens over and over with all sorts of aspects of US healthcare.

I also have problems with the focus of these types of articles — for whatever reason, they often start with or are centered around this kind of wistful new physician (or very old physician near retirement) longing for the romanticized old days where physicians were in charge and ran everything. Should that be the case though? Do we really need MDs to do and approve of everything? Aren't there things that are done as well by PAs, DNPs, and other types of providers that don't even exist yet because of how calcified the healthcare system is? Can't patients do more at home without a middleperson — e.g., needing to approve of some medication that the person has taken for decades without incident and is really truly pretty harmless in the grand scheme of things?

The problem you described is very real. It's overregulated, in ways that incentivize large monopolies, either of clinic and hospital owners, or provider rent seeking guilds, infrastructure providers, etc.

I guess I feel like these types of articles point to one type of problem, but then tend to implicitly suggest the solution is to just roll back time to some earlier era, not recognizing that that earlier era had a smaller patient population, with less regulation, less monopoly where there was no need to scrutinize whether a certain type of degree is really necessary, where there weren't huge hidden overhead costs of all these monopolies permeating down to the patient.

Fixing US healthcare is going to require a bunch of things that collectively will cause pain for a lot of entrenched players: lots of antitrust lawsuits and laws, lots of deregulation aimed at giving patients more choice and self-care options, more public payer options, lots of eliminating or restructuring licensing requirements to create more types of providers, and so forth. They don't map on easily onto current US political party platforms either.

Healthcare is essentially a creature of regulation. It owes its beginnings to the requirement that care must be effective.

Reply on news.ycombinator.com