Brave Care Has Closed
bravecare.com
bravecare.com
https://www.ycombinator.com/companies/brave-care
https://www.bizjournals.com/portland/news/2021/10/07/brave-c... | https://archive.today/Qd8fQ
https://techcrunch.com/2019/09/09/yc-backed-brave-care-raise...
Thanks to decades of neo-liberalism (the idea of deregulation and "free market" economy). Americans have allowed corporations to form massive entities (in health insurance, UHC + optum bank + optima rx comes to mind) to the point of manipulating the price to their advantage. Then you have to deal with some companies that deny a majority of your claims in hopes that you (the patient and/or healthcare provider) give up (delay, deny, defend policies) or pay out of pocket for treatment.
American healthcare industry is a fucking mess.
Healthcare is one of the most regulated industries in the United States.
Want to be a doctor? You've got the aptitude, the knowledge, the mindset, and the will, but a government-guaranteed cartel of medical schools won't let you in, so too damn bad. Learn to code.
Want to open a clinic? You really only need about a half-million in hardware to operate at the level of a 1980s hospital, but regulatory compliance will push your annual opex into the millions as a baseline, not to mention having to deal with the nightmare that is health insurance.
Those "massive entities" you mentioned are entirely protected from competition by force of law.
You know why healthcare used to be cheap? Nobody had insurance.
Anyone that had the aptitude and wanted to be a doctor basically could.
You went to the hospital, paid your bill, and that was that.
I'm not saying "zero regulation, caveat emptor!", but over the past hundred years, the precise opposite of "deregulation" has happened across every aspect of American life.
Healthcare is an inelastic service: people will pay everything to get it. So private hospitals in a free market are pushed to bill their services as higher as possible. Actually, their prices would go to infinity, if not limited by people total savings and earnings.
So, here the insurance companies make the problem worse: they give people access to "infinite" credit. So you can pay for those exorbitant prices. But with insurance you just increased the pool of money people can use for health, so private hospitals can and will increase their pricing. Add more free market competition and you get the disaster of the USA healthcare system.
Because of that reason, basic economics, is that for profit Healthcare cannot work long term. The only way to make it work is making it a public service. But in USA politicians will cry that is comunism, so they won't do it.
And the USA Healthcare problem doesn't limit itself to USA. As americans are unable to pay for healthcare there, they started doing medical tourism, which is making health prices in other countries more expensive too.
Those places don't have a hellish Frankenstein's monster combination of public and private and a load of regulations at the federal and state levels all adding up to high costs that have to be passed on to the consumer, but also weird niches of market inefficiencies that can be exploited by anyone who's managed to luck or judge their way into an advantageous position.
They also don't fund most of the world's healthcare advancements, which the US does.
They also cut off care at a certain point, whereas in the US you not only have access to most of the cutting edge treatments in the world that just aren't available on single payer systems, as they don't provide enough value, you also can find someone to pay to do it. You can bankrupt yourself on cutting edge treatments if you like.
I don't know what the answer is, other than "try again" and have a nice multi-insurer model, which I think one of the Scandies has, that just competes on efficiency and has its payouts and insurables defined by government, or maybe a single payer model. Or make healthcare a state-level problem and have each state solve it differently without federal overhead.
By the late 19th century, we already had general anaesthesia (developed starting in the 1840s), antiseptics (we’ve had them for centuries but their use became much more common in the late 19th century as the germ theory received broad acceptance), smallpox vaccine (very late 18th century development), a number of drugs (some known since antiquity others newly discovered), etc. Yes doctors were a lot more limited in what they could do back then, but even within those limits they saved people’s lives all the time. If your arm had gangrene, they could amputate it under general anaesthesia, antiseptics to try to prevent infection, and provide post-operative pain relief - which could literally save your life. Women with breast cancer received mastectomies (known about since antiquity but became much more common in 19th century, especially as general anaesthesia made the surgery more tolerable)-due to the lack of chemotherapy or immunotherapy, that wouldn’t do much for those with more advanced cancer, but if the cancer was sufficiently localised could be curative and lifesaving
And yet other countries have even more regulation, and manage to deliver cheaper and more equitable healthcare overall, with better public health outcomes when measured at the national level
For example: in Australia, the federal government is a near-monopsony purchaser of prescription drugs, so it has enormous negotiating power with the pharmaceutical companies. By contrast, in the US, the federal government’s role in purchasing drugs is much smaller: the end result is higher drug prices, although the downside of Australia’s model is it can delay availability of new drugs. (Those with unlimited ability to pay can still purchase drugs privately at whatever cost the manufacturer will sell them-you can even get bureaucrat approval to import unapproved drugs for personal use if you can find a senior clinician willing to assist you in it.)
The waiting for the patent to expire and buying in bulk keep down the costs down works. The US couldn't use the generic strategy because the drug companies get funded and create the new drugs this way. Cutting off the funding would mean no new drugs to copy so no new generics. Australia would have to start funding research.
That's not what the Australian government does.
Even for prescription drugs still under patent, the federal government negotiating on behalf of the whole country as a monopsony purchaser can demand (and get) much bigger discounts. (A monopoly is when a market effectively has only one seller, a monopsony is when a market effectively has only one buyer.)
Whereas, in the US, each insurer negotiates separately, so all but the very largest have weaker bargaining power than the Australian government has, simply because they don't represent as many insureds. The US has over 1000 health insurers, only the top two or three (such as UnitedHealth Group) have more insureds than the Australian government has (26 million).
Plus, even though a handful of very large US insurers such as UnitedHealth have more insureds than the Australian government does, the fact that the Australian government is a sovereign state and not just the purchaser but also the regulator and legislator gives it additional negotiating clout that such private insurers lack. Also, if UnitedHealth refuses to reach a deal with the drug manufacturer, they risk losing insurance customers to other insurers who are willing to do so; Australians can't realistically switch public health insurers (moving overseas is the only real way; private health insurance usually has very modest prescription drug benefits)
> Australia would have to start funding research.
Australia actually does have significant medical research funding. Unfortunately it seems to be a struggle to find good data on exactly how much (in easily comparable terms, such as %GDP) – the WHO's statistics [0] on this topic are missing both the US and Australia for whatever reason. But even in the absence of hard figures, I'd totally believe the US spends at least double (on a % GDP basis). But I think that's part of a broader economic problem with Australian underspending on R&D (both public and private) which goes beyond just health.
The other problem I know, is Australia has largely lost its ability to productise pharmaceutical innovations (outside of certain niche areas), which means even when some novel drug is discovered in Australia, they need to turn to to a US or European company to turn it into a product. But that's more a consequence of poor industrial policy (most of Australia's pharmaceutical manufacturing sector moved overseas, and what's left is mostly lower-end stuff like vitamins and herbal supplements, with rare exceptions such as CSL) than anything to do with drug pricing.
[0] https://www.who.int/observatories/global-observatory-on-heal...
That doesn't matter to this point. What matters is the US pays for the R&D that Australia gets to benefit from. You can stop R&D and drive down prices, as long as you're comfortable making world drug discovery grind to a halt.
The PBS listed medications are essentially price capped copays at the point of sale, with the bulk of the cost covered directly by the government (who negotiates prices with the manufacturer, and fronts the pharmacist distribution costs). Its the same pfizer etc patent protected medication, unless theres a generic version which chemist & prescriber can vend with patient consent.
Will be consider mostly stupid/irrational, but I'll mention it:
Learn medicine, and practice outside of of the mainstream clandestinely (a past real world example would be abortion clinics on ships). It needs a group of committed/smart people to pull it off, so not easy. Also it cannot be offered to the public at large for several obvious reasons.
As a general rule one cannot involve 'average' people in such an endeavor. All organization settle down to the lowest common denominator. When it come to large organizations in govt/health/etc. they are prone to increasing corruption and bureaucracy if average people are involved.
This is more an anti-trust problem than deregulation. In the 80s Robert Bork and some others led a charge within the court system to rewrite federal anti-trust law without actually rewriting the laws. The result was that merger/acquisition guidelines were loosened, and the focus was on whether the result would cause the consumer to pay more money. And thanks to the way health care is paid for, it's a little complicated to make that case.
Loosened antitrust rules are a subset of deregulation, it can’t be any less deregulation than it is a matter of (too loose) antitrust.
Or email me: chris@juniperplatform.com
My team at Stripe was scattered all over, during COVID our company was fully remote, and prior to that I worked remotely on a presidential campaign. All of those were great experiences and, in their own ways, necessarily/understandably remote.
Compared to the early days at Gusto and my own startup, though, in-person has very real benefits that (in my opinion) are worth the challenges in hiring. I don’t know that it will always be true and can’t rule out that we’re wrong.
Having internal users and domain experts there in person makes a huge difference. It’s not impossible to do remotely, and maybe the tradeoff doesn’t make sense forever, but it’s worked well thus far.
For myself, I’m past the point of moving for companies. If they happen to be nearby I’ll make it work. If they’re not nearby, its either remote or I’m not at all interested anymore.
There are obviously huge, huge exceptions to this the moment you add hardware to the situation; or you need something you can't replicate well with screen-sharing.
Addendum: but I'm also mildly frustrated because it's a type of work I would be interested in; but I'm on the other coast, so I can't easily apply :)
(The health care industry is a mess, I agree!)
Medicare is better than private insurers at regulating prices (to wit: when Anthem tried to adopt Medicare's rules for anesthesiology comp, they were excoriated, and the governor of New York proposed a statute preventing them from doing it). But they still wildly overpay for services; in fact, what they pay is not really materially different from what private insurers do (it's less, but not by that much).
How does that work? Do the providers have cartels that set prices?
Unless you're Kaiser, in which case you're the insurer and most of the providers, which is the whole idea behind Kaiser. But every other insurer --- and overwhelmingly, Americans aren't on Kaiser --- is beholden to providers. And of course, Kaiser competes with providers for service providers and vendors.
HMOs, for all their problems, have many advantages as well, such as the aligned incentives you allude to.
I agree with you about the efficiency of HMOs, but customers hate HMOs.
A useful Google search: "National Health Expenditures by Type of Expenditure and Program: Calendar Year 2022". It's a single spreadsheet, and it's really something. It covers insurers (public and private), providers (hospitals and outpatient), facilities, state health care programs, even dental, all on one sheet. The numbers are hard to get around.
inefficiencies with private payers
What would insurer overbilling even mean?
https://www.nytimes.com/2017/05/19/business/dealbook/unitedh...
Or this:
https://www.sacbee.com/news/local/health-and-medicine/articl...
Fuck if I know what's going on between Medicare and UHC. It's a mess. Medicare Advantage is a hybrid Medicare/private system; once again, whatever fees were being passed to Medicare, they were coming from providers. Insurers can certainly inappropriately deny coverage, but they don't generally make de novo charges up. Charges come from providers.
Upcoding scandals, which literally appear to be what the UnitedHealth link you provided was about, were exactly what Anthem was trying to control for with its new announcement.
Providers is also kind of vague. You show up at a hospital, does the nurse practitioner who does your intake set the price of your ER service? Who specifically sets the prices?
The downside is that because Kaiser operates as an HMO, any specialists you need to see must be approved by your primary care physician (typically GP, ob-gyn, or uro). They have an abysmal record with mental health, and folks who need chronic non-routine care often struggle to get that care. If all you need are routine checkups, cheap prescriptions, routine immunizations, etc. they're quite competent.
Who specifically sets the prices?
It's worth noting that all insurance companies are required to emergency care at any provider as if it were in network. If a Kaiser member were to go to a non-Kaiser ER they would see the same cost as if they'd gone to a Kaiser ER. Whatever Kaiser pays to the out of network hospital/staff is almost certainly negotiated beforehand.
to wit: when Anthem tried to adopt Medicare's rules for anesthesiology
comp, they were excoriated
Clearly not, because this is how Medicare operates.
In fact, it's the whole premise for why Medicare is meant to bring prices down!
From Medicare's policy manual:
https://www.cms.gov/files/document/chapter2cptcodes00000-019...
A unique characteristic of anesthesia coding is the reporting of time units.
Payment for anesthesia services increases with time. In addition to reporting
a base unit value for an anesthesia service, the anesthesia practitioner reports
anesthesia time. Anesthesia time is defined as the period during which an
anesthesia practitioner is present with the patient. It starts when the anesthesia
practitioner begins to prepare the patient for anesthesia services in the operating
room or an equivalent area and ends when the anesthesia practitioner is no longer
furnishing anesthesia services to the patient (i.e., when the patient may be placed
There is a fixed component per procedure (base unit). This is based on the complexity of a procedure and roughly how long it's expected to take. That is why CMS would track how long a procedure is expected to take. There is a time based factor (time unit), and that is not limited in the way that BCBS was proposing.
Later
(The comment I replied to was edited extensively after I replied to it.)
There is no cap for billing, but realize when an operation goes long it not only means we make less per hour, but there is also usually a good reason for that. Even if there isn’t a good reason, it’s not like we have control over how fast a surgeon operates.
This isn’t unique to America. In countries with government healthcare, the government determines your rates. Typically government rates are lower than private insurance rates in the US, too.
For as much as Americans like to complain about insurance companies, we actually get a lot more care and pay higher rates to providers than other countries. There’s a reason doctor pay in the United States is so much higher, among other things.
We get a lot more care, pay higher rates, and have worse outcomes.
That last bit is why people are pissed.
But hey, it's not like the US is a democracy exactly given that public opinion generally doesn't translate into policy changes anymore.
Life expectancy in general in the US could also be due to the amount of gun violence, as well. Nothing to do with the quality of healthcare.
The fact that Americans intuit that it’s not is a worrying sign of just how broken our system is
Any evidence for this?
I don’t think this is a broadly held belief, I think it’s the “eeehhrm actually…” contrarian belief that’s trying to discredit the consensus view that our healthcare system gets very poor results for the money. So it shows up in places like this exact HN thread.
The US government does not care that much about obesity, gun violence and all that jazz because it is not the one paying for the damages it does.
All these factors contribute to the comparatively poorer life expectancy of Americans, which is, I agree, only a surface metric.
The more important dynamic you’re pointing to is that private insurers don’t care because our insurance is tied to our employers and therefore is expected (by insurers) to churn every 4 years or so.
It literally makes zero sense for a private insurer to invest in an American’s healthcare results more than 3 or so years down the road.
Surprise surprise, we have best-in-class care for emergencies and complex acute cases, and absolutely atrocious management of early disease and lifestyle problems (which is when it’s most cost-effective to solve health problems).
One of the strongest levers we have to improve the “inputs” you’re describing is a better primary care system. America’s has been absolutely gutted over the last 20 years by interactions of various economic and regulatory dynamics including (notably) the anti-competitive vertical integration of pay-viders and pay-vider+PBMs like UnitedHealth Group.
It is absolutely not true there aren’t system-level changes we can make in healthcare and insurance to help address this.
Having access to doctors helps to manage disease.
Obesity is a disease.
In particular, having access to PCPs helps to manage obesity.
Our healthcare system yields poor access to healthcare.
In particular, it yields poor access to PCPs.
Ergo the obese population is in part an output of and not an external input into the design of our healthcare system.
Ergo changes to the healthcare system absolutely can — and in fact should have as a key goal to — yield changes to levels of obesity.
> “ Rearrange healthcare/government insurance models all you want; it can't fix that.”
This claim is false. The mental model of an obese population being exclusively an input into our healthcare system does not track with what we know about the relationship between healthcare and obesity.
Healthcare insurance in the US is heavily subsidized, and no number of revolutionary care delivery models will put you on level terms with the behemoth of US govt insurance subsidies.
Your only hope as a non-provider is to come in with your own a-la-carte insurance that is able to take those subsidies, while you set your moat and innovate in the delivery front.
Health insurance is undisruptable, unless you’re ready to light billions of dollars on fire over several years, or take decades to do it by growing extremely slowly.
The provider side is equally difficult, but I think it’s at least doable. Though you’re still screwed having to deal with CMS or insurance carriers.
There is a fifth one that imposes costs: our comprehensively unhealthy food, health, and lifestyle in America that capitalism feeds upon with addictive high-margin food and drink, with overworked workers that can barely have time to raise kids (our healthy demographics are due to immigration) much less a healthy lifestyle. The entertainment complex certainly doesn't help either.
Providers: you need comprehensive family care to avoid specialist care being needed, an increase in supply of doctors, decreasing their educational loan burden (which strongly incentivizes specializataion, and a system that involves specialists). I think advanced AI systems can do much more day-to-day tracking and diagnosis/information, but of course that is a personal information nightmare. Actually I don't mean advanced. I think current AI is plenty good enough. Unfortunately only insurance companies will employ these systems or pay for them.
Insurance: Probably need a medicare-for-all option. We were close to this with Obamacare but FUCKING JOE LIEBERMAN killed it. Exhibit A in why the Democrats with full control of government will never get anything done.
Drug/Device companies: reduce patents, I don't know, maybe allow price negotiation (which is just mind blowing in a "free market" economy), reform the FDA to make bringing drugs to market cheaper.
Lawyers: caps caps caps so there isn't costly malpractice insurance. Maybe would also necessitate a federal review board to weed out "bad doctors".
But the biggest is probably governmental direction to actually get people to be able to eat and live active lives. Maybe GLP-1 will help, but the quiet time bomb of increasing obesity in Americans each decade is probably a sneaky large amount of our costs.
Otherwise, on the nihilistic side, keep doing whatever our society is doing which is causing men to kill themselves in huge rates (soma ... uh... I mean opioids were also doing this as well) before they reach their ultra-expensive late stage of life.
Anyway, none of that is happening (except, sadly, the nihilistic solution is the most realistically happening).
Maybe setup huge provider networks across the border in Mexico and Canada served by high speed transit, so large portions of the world get health maintenance in functioning health care systems, and only do hospitalization and emergency care here?
We recently tried this with some vaccines and now a large segment of the population is now vaccine-hesitant.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10257562/
> Lawyers: caps caps caps so there isn’t costly malpractice insurance.
Caps don’t always result in improved health outcomes.
https://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?p...
> Maybe would also necessitate a federal review board to weed out "bad doctors".
This exists; each state medical board has a procedure for reviewing medical licenses.
Forced vaccination was the problem here.
Uh, definitely not. The drug discovery and trial process is every bit as complex and expensive as it is for a reason. If you're serious about lowering the cost of getting compounds through the pipeline the first thing that should go is private equity's growing chokehold on the provider practices that perform clinical studies.
But, a lot of people don't like Kaiser. You have to be ok with getting good enough care, and not really be trying to seek 'the best' care. Integration is so nice though. I'm sure Kaiser never puts you in the situation where the Dr says I'm not sure which drug will be covered, let's try A, the pharmacist says A isn't covered, ask your Dr to write a script for B, and your Dr doesn't answer the phone so you have to decide to either pay $250 for A or wait over the weekend to start your kid's treatment.
If we could use tax dollars to make Kaiser national, and scale that large without losing the efficiency and results, we'd be in darned good shape.
Eliminate other private health insurance and if people want above and beyond service they can negotiate directly with providers and pay out of pocket for that.
It's hard to do that without turning it into the NHS.
I certainly don't want a free for all system like the US has (and I suspect the Tories want) but it isn't great at the moment.
You can but as soon as something gets serious they dump you back on the NHS.
Politicians - mostly the tories but Blair's government take a lot of blame too - have defined "not privatising the NHS" as only meaning keeping it free at point of use. But in the background, NHS trusts have been forced to sell land and buildings that they used to own and rent it back from the new private owners, and many areas have seen both staff and equipment privatised, from agency staff (where instead of hiring cleaners or nurses or whatever, they instead hire agency staff, where the hourly cost to the NHS is double or more what an employee would cost with most of that increase going to the agency companies not to the workers) to private hospitals (where instead of investing in a new operating theatre, or whatever, they pay to have NHS patients operated on in private hospitals), etc.
The NHS is far from perfect, but the lesson we learn from those imperfections shouldn't be that nationalised healthcare is bad, but that underfunding it and then using that underfunding to justify privatising lots of stuff in the background is not a good way to run a nationalised health service.
The root problem is that many politicians would like to see the NHS fall to pieces so that an American healthcare system can create lots of opportunities for companies to make money, but because the NHS is hugely popular it would be political suicide to make that an official policy, so instead they've taken this approach which not only creates these short term opportunities for companies to come in and profit as mentioned above, but also gradually erodes the it's popularity with the long term goal being that eventually it won't be political suicide to say "Look the NHS is a failed experiment, we need to replace it with American style private companies and healthcare insurance".
Linky?
Doctors: It's like working for any other hospital; it's not bad.
I was never healthier. The other Kaisers in Oregon aren’t geographically collocated so there’s less of an effect and they’re far away from me so I don’t use them anymore, sadly
But it all starts with voting for people who want to fix it, and not for people who just want to burn it down or maintain the status quo.
Learn medicine, and practice outside of of the mainstream clandestinely (a past real world example would be abortion clinics on ships). It needs a group of committed/smart people to pull it off, so not easy. Also it cannot be offered to the public at large for several obvious reasons.
As a general rule one cannot involve 'average' people in such an endeavor. All organization settle down to the lowest common denominator. When it come to large organizations in govt/health/etc. they are prone to increasing corruption and bureaucracy if average people are involved.
The providers have leverage and the ones with the most will screw you over unless you’re big enough to throw some weight around.
I honestly don’t see much change unless the government comes in and sets new rules that actually make sense.
Health insurance is undisruptable
The same applies to insurance. You can't take crap contracts that don't work for you, so maybe create a contract of your own based on 1st principles and going back to the definition of insurance.
Or is it that the Healthcare industry has tilted the government into making rules that favor the status-quo?
Ultimately, it is the government, not the industry, that sets the rules, and it is the government, not the industry, that is accountable to us.
Even without the argument that ultimately voters are responsible for the government they get in a country with free and fair elections like the U.S., health insurance is a very direct example of voters explicitly opting for a worse option.
The ACA was being written in 2009 and 2010 and the argument was whether it constrained the insurance industry too much or not enough. The very specific policy proposal on the table was the public option which would have allowed the govt to offer an insurance policy that would have effectively set a floor to the quality of policies the healthcare industry could offer and a ceiling on the cost.
And the 2010 election fell right in the middle of the debate and American voters overwhelmingly chose the politicians arguing against the public option and for fewer restraints on the insurance industry.
Beyond that you can just look at every other developed country in the world, and all of them have better healthcare because their voters constantly vote for politicians who offer better healthcare policy, as opposed to the U.S. where voters choose the opposite.
It's not an easy market to jump into; you spend a huge amount upfront on site construction (particularly if you're building standalone clinics outside of existing medical buildings, which is not unusual for urgent care), labor cost and complexity is high, and reimbursement cycles are long and painful. Healthcare chains scale like retail, not like software, with all the attendant cash management problems.
It feels like they did offer a superior service with lots of effort put into getting into the community, but I question both their decision to try and build a custom EHR -- yes, EHRs suck, but once you start building your own, you're no longer a medical services company, you're now an EHR company -- and not to pursue a regional-centric expansion strategy aligned with local health systems via contract or JV, instead choosing to build a small number of clinics across the country, which goes against proven successful buildout strategies in healthcare.
It's a shame they've gone under -- again, superior service, obviously a lot of care for their patients -- but "we went under because of cash management problems and inappropriate growth strategy" is a pretty standard story in the healthcare world.
Children are an attractive selling point for a company in the same way as cancer of some altruistic goal. Though here, although elder care exists, to me that seems like the market to disrupt and minimize costs in.
One account is that the US has too many medical facilities in urban areas. In other words, there might be five hospitals each with its own radiology equipment. That equipment is idle some of the time, so you could close some of the imaging departments and leave just one or two for the metro area. That would obviously inconvenience some people, but the gist of the criticism is that the US duplicates medical capacity for the sake of convenience.
The other criticism is that there are too few clinics and such. That's why there was a big push to open health clinics in pharmacies and urgent care locations recently.
Now I know these aren't mutually exclusive; you can have too few clinics and too many hospitals. But I would like to know if anyone is more informed than I am what validity there is to each criticism.
I'm curious what the truth is regarding the number and character of brick-and-mortar healthcare facilities in the US: too many? too few? Because it looks like this company was opening physical clinics.
> The other criticism is that there are too few clinics and such. That's why there was a big push to open health clinics in pharmacies and urgent care locations recently.
Funny enough, germany has the exact same two problems.
* Too many small urban hospitals do too many things, but have no speciality, leading to high cost, underutilization and higher risk procedures.
* Too few specialist doctors for checkups leading to long waiting times.
I'm curious what the truth is regarding the number and character
of brick-and-mortar healthcare facilities in the US: too many?
too few? Because it looks like this company was opening physical
clinics.
Even within urban areas care is uneven. Hospitals are concentrated in the more wealthy parts of San Francisco and the poorer (e.g. southeastern) parts see sparse coverage. One of the big points of contention when Sutter Health bought out St Luke's hospital in SF was that Sutter wanted to transition from primary care to more profitable specialties. This would've left the neighborhood bereft of primary care.
In more rural areas you'll find that funding is a political football. As that funding wanes so does the level of care. On top of that the post-Roe v Wade environment encourages some folks to migrate towards urban areas in more "permissive" states.
In terms of too much urban coverage. When I needed an ultrasound through UCSF I had to book it out months in advance. It's not clear to me that there is a ton of duplication there — more the point if I'd looked elsewhere I would've had to figure out what was/wasn't in network with my insurance provider. Last I looked Kaiser has a grand total of eight urgent care clinics in the Bay Area. There are nine counties in the Bay Area. That's efficient from a business standpoint but leaves plenty of customers out in the cold as Kaiser covers out-of-network services in very limited circumstances. Likewise, try to find a GP that accepts insurance and is taking new patience. When I checked eons ago UCSF had a nearly year long wait.
As far as convenience vs efficiency, the argument was that to achieve the efficiencies found in other countries, which often have longer wait times for services than the US, you do have to sacrifice convenience. The US, by treating healthcare like a consumer good rather than a rationed utility, has built out excess capacity for the sake of convenience. This is, according to the argument, part of the reason we spend more on healthcare than peers. (Healthcare must always be rationed; the US does so on price rather than wait times.)
The lack of rural providers is largely a staffing issue, but once the staff go whole departments (e.g. obstetrics) get shuttered and it then becomes a larger problem than merely finding physicians.
Having been through the meat grinder a few times I don't think there's as much "convenience" as proponents of for-profit health care would like everyone to believe. Attributing the uneven distribution of care to convenience misses the mark. Profit incentivizes specialties that can charge higher prices and disincentives primary care. That's not convenience, it's profit. Again. St. Luke's.
Crucially, among those who leave are not just patients. There are also doctors leaving.
I work for a hospital chain that has done similar things. A lot of the failing hospitals in little towns across the US is because of this, and the consolidation that's happening is to remove similar inefficiencies. People that live in these little towns with failing hospitals see any move towards correcting these inefficiencies as evidence that our medical system is failing and use it to vote for right wing politicians who make empty promises.
If you have 2 hospitals and one takes your insurance and the other doesn't you still get service. If you consolidate to one and they don't take your insurance you may have to drive hours to get medical service.
A huge failure of the system is how health insurance works.
Or outright kill them due to a delay in a critical finding. This is more than a convenience factor, and moving patients between facilities is non-trivial.
It's likely the other way around from what you are saying, with limits to market entry enabling the existing facilities to charge more than the efficient price for the service.
I visited their clinics for my daughter several times when she was a toddler for ear aches and other ailments— I found the experience refreshing: instant online booking, no BS registration and online communication with staff was seamless. Very sad to see them go so abruptly.
Up until this morning when I was told they were gone, I had no idea they were YC or otherwise VC funded. Just came here to pour one out for a genuinely helpful and pleasant medical company.
Currently, there’s a doctor shortage problem (supposedly, they can’t hire, or there aren’t enough positions, depending on who you ask), which has caused issues with the quality of care (according to the doctors that went on strike over this, and personal experience).
It’s unclear what the root cause or solution is.
Anyway, you can get the experience you described, and it’s great until you hit an understaffed corner case health problem.
Most taxpayers have to realize the loss to take a tax deduction against their gains, but some tax elections allow you to do the same without finding a buyer for the worthless shares, which narrows down the incentives
Mark to Market election
as well as non-profits
some non-profit investors have stricter scrutiny as their charitable distribution requirement is based on net assets. so there is an incentive to arbitrarily mark malperforming investments down to lower values, but being able to get the business to announce their failure supports it better
Just thinking out loud
[1] makes it sound like they were assuming a never-ending stream of venture funding and didn't make a sustainable business. It'd be interesting to see where the money went.
[1] https://www.oregonlive.com/business/2022/09/portland-pediatr...
Could you explain "indigent" here, please. It looks like a typo.
Effectively it is no cost care for those who are sufficiently poor.
You also said "What will happen to the bills?" - what does that mean?
Cheers Jon
My mom refuses to leave the US healthcare system despite the costs because
1. She pays for insurance, not surgery (in her mind)
2. regardless of the keening US healthcare system is the best in the world
The problem is not that pediatric urgent care is not a viable business.
The problem is that it's not a great VC-funded business.
VC investors are hoping for huge growth and eventually earning back multiples of their investment.
That's going to be really hard to do in this segment of the health-care market.
We've got a wonderful pediatric urgent-care place in our area, backed by the best children's hospital in our metro region, and it seems to be doing great. But does that mean it could ever grow at the rate needed to satisfy VC investors? Probably not.
With the decline in birth rates in the US, didn't seem like a sustainable model from the get go.