Don't hand-wave your claim of overregulation, be specific and name the regulations you think should go away.
Source: https://thedailyeconomy.org/article/how-congress-created-the... and many others
The nursing orgs are naturally lobbying hard (MD and RN orgs have an icy relationship).
The quality and capabilities of these noctors—calling themselves residents and even doctors and performing surgeries and general anesthesia—is a growing problem.
Incompetent treatment is worse than not being treated at all.
It’s not to say that noctors can’t be competent within a narrow domain; it’s that they’re being taught to increase their scope of treatment beyond their training.
If it becomes common, then it’d be safer and more cost-effective to pay out of pocket and get treatment in another Westernized nation.
Just treat them as totally incompetent and nudge them where they need to go. No need to assume or rely on competence that may not exist.
It seems like a useless metric.
It's a bit weird and disingenuous to me — if you took a bunch of MDs right out of medical school with no residency training and asked them to function as a senior staff physician in a given specialty, there would be complaints about them as well. It's no different from hiring an inexperienced computer science BA graduate to handle a complex high-stakes network security position.
"The increased deaths in emergency departments at private equity-owned hospitals are most likely the result of reduced staffing levels after the acquisitions, which the study also measured, said Dr. Zirui Song, a co-author and associate professor of health care policy and medicine at Harvard Medical School."
The issue with American healthcare is the profit-seeking capitalists.
You could hire a whole army of doctors and they'd still be there, word gets around. If the doctors are cheap enough to cover whatever you can get from debt collection agencies to sell off the debt they'll never pay, then you could hire a lot.
Cutting doctors means only the most prioritized triage cases makes it to doctors, which skews towards people that are employed or on medicare and the money can be recouped, and thus improves profitability.
It's an end-run against the requirement they take in the hordes of people with no insurance who show up to the ER for low-income cases and no way to pay it.
If doctors were so cheap as to be covered by the sales to debt collectors, the whole thing gets flipped, as it would be profitable to just hire armies of them to cover the hordes who come in with non-emergent cases.
This thread is talking about ERs so let's focus on that. Pay for a 12 hour shift has fallen by over 50% and that's without accounting for inflation. As a result, only heavily indebted and inexperienced doctors are manning the ERs now. These are critical life saving jobs that ought to attract the most experienced doctors but they turned into reassigned-to-Antartica tier jobs that only new or failed doctors put up with. Now factor in the substandard education provided by the hundreds of newly created medical schools which don't even have a hospital for students to practice in. The result is of course stupid and incompetent doctors manning ERs. I remember one guy who sent home a patient with textbook myocardial infarction symptoms without even ordering a routine EKG, obviously leading to the patient's death. Imagine being that dude's lawyer.
Depressing the wages of healthcare workers has fatal consequences. There's no reason at all to spend the best decade of one's life busting ass in medical school and residency if one is not gonna get rich off of it. You want your doctor to be the smartest, most studious, most hard working, most debt-free person you'll ever meet. You don't want to put your life and well-being in the hands of a stupid indebted doctor who graduated from a diploma mill.
It could because a larger supply of doctors means salaries would be lower, and thus the incentive to cut staff is lower.
Profit seeking capitalists would be fine if healthcare was a competitive market, like grocery sale.
But it isn't, and I honestly don't see how to make it one. Full price transparency would help, but I don't believe classical free market selfregulation can work out for the healthcare sector, by design.
You need good ability of healthcare customers to judge quality of treatment/medication, to know prices beforehand and to have sufficient choice for market dynamics to work, and every single one of those points is somewhere between really difficult and impossible.
Same for my own stuff. The first time one of my children got sick it was terrifying, so I naturally took him to the most premium pediatric healthcare institution. And what did they do? Basic tests to rule out anything particularly nasty, and fever management. The exact same thing the cheapest hospital does, except I got the privilege of paying 10x more for it and feeling like a complete sucker. From that point on - 'oh he's sick? shall we go to the university hospital, or the religious nonprofit?'
The second [2] is for all sorts of cancers, but is a large observational study without much effort to control for biases. It found an overall increase in five year survival rates of 3.6% (64.3% in NCI centers, vs 60.7% in non-NCI). That's certainly something, but it's fairly certain that biases would bring that down a healthy chunk.
However there were significantly better outcomes in more rare/lethal cancers. For instance in hepatobiliary cancers, the NCI survival rate was 33.8% vs 18.7% for non-NCI centers. And that is largely the point I'm making. For the overwhelming majority of things, care is mostly commoditized and you will be fine wherever you go. The value of high end institutions is mostly only realized in the case of rare/serious issues, for which transfer is always an option anyhow.
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Though I'd also add here that these examples, cancer, are on the fringe extremes of what my point was. That there is a strong argument to be made that even cancer falls within it, just further emphasizes the point. If your local hospital can competently treat cancer, they can certainly treat the overwhelming majority of reasons people go to the hospital, which are relatively far more commoditized.
No this claim, just because, is not weight-bearing. Extraordinary claims require extraordinary evidence. And I don't understand the motivation to make such a tenuous link when at a bare minimum one can look up direct data like joint commision and MPSMS safety data and related publications. There is tremendous variability in serious hospital safety events inter-institution for bread and butter admissions. One can further just examine CMS and NHS data for mortality and readmission for "mundane" MI, HF, sepsis, pneumonia, respiratory failure. OB/GYN outcomes are their own thing.
The flaw in reasoning here is that quality of care and outcomes is strongly related to the simplicity of diagnosis. A further flaw is the belief that care is "commoditized". Treatment protocols vary widely across institutions and health systems, often times based on cost factors. Certain basic things can not be done at night, or even the day for fully accredited hospitals. There's a big difference somewhere with 24 hour anesthesia airway and in-house surgery and not just an intensivist "on call" 600 miles away and staff that can't even do RSI. Transfer is not always an option, there's a reason critically ill people die more frequently in the sticks. If one is admitted to a regional hospital, they are unlikely to be accepted for transfer to a safer hospital unless they truly need an intervention that absolutely cannot be provided where they are, not simply because there is better backup provider support and a higher standard of safety. They will still remain at that higher risk for sepsis, or outdated care because the community physician group doesn't keep up with guidelines, or that hospital only offers the inferior treatment (or a limited formulary) for cost-cutting reasons.
Breast cancer and most cancers are not even typical inpatient encounters. Breast cancer is generally not managed on an inpatient basis, in fact one may never even have to visit an inpatient hospital campus for breast cancer. Upgrades for cancer are usually different than acute inpatient care. Breast cancer does not usually involve abdominal, intrathoracic or orthopedic surgery. Breast cancer does not usually involve advanced interventions like endarterectomy, ECMO. Cancer is a special case. Regardless of complexity, extrapolating cancer treatment to even the most "mundane" acute inpatient or surgical care really is beyond ridiculous.
This is a complex subject and this is a silly hot take.
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"One third of sepsis survivors were readmitted and wide variation exists between hospitals. Several demographic and structural factors are associated with this variation. Measures of higher quality in-hospital care were correlated with higher readmission rates. Several potential explanations are possible including poor risk standardization, more research is needed."
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As they're implying, this is likely due to biasing and not a causal observation. One possible explanation is that higher quality hospitals may be able to keep people knocking on deaths door a bit longer than lower quality hospitals, but it's not like night and day - they're still knocking on that door, just a bit longer. And so it makes sense that they'd actually have worse outcomes on discharge, including higher overall readmission rates. But once again the picture between the quality of hospitals is not this tremendous dichotomy that many try to frame it as.
Billionaires, in general, seek out the highest quality care money can buy, and have no limitations on the meta-factors that also improve longevity including activity, relationships, healthy food, exercise, etc. Yet their life expectancy (~85) is comparable to the life expectancy of Hispanics in America. The "Hispanic Paradox" [2] again emphasizes that longevity isn't about premium healthcare and money.
[1] - https://journals.lww.com/ccmjournal/abstract/2017/07000/seps...
MI, HF, sepsis, pneumonia, respiratory failure are among the most common reasons for inpatient admission, not fringe.
Equating acute decompensation of chronic illnesses requiring inpatient admission to "knocking on death's door" is a bit simplistic.
No data has been provided showing how the relevance of outcomes based on institution of first presentation (not definitive management) for breast cancer, that is usually managed outpatient on an elective basis, has anything to do with outcomes for the "overwhelming majority of things people to go to the hospital for".
Even pre-pandemic the life expectancy of Hispanics was not as high as billionaires. Speaking of "deaths door" perhaps at least QALY, or something else is a more appropriate metric.
Let me first describe what I meant by fringe though. Take a random adult going to the hospital, not elderly, with no other major health conditions. When he walks in the door, what are the distributions of issues that he might end up having? Sepsis is going to have a probability of near 0. By contrast the typical patient that might present with sepsis - elderly, other major health conditions, well into senescence - he is generally indeed 'knocking on deaths door.' He might not answer this time (though there's a decent chance he will!), but he will imminently.
Your study compared hospitals based on a number of factors. The most significant was high volume, but in that case the difference between the highest volume hospitals and lowest was a 13.3% rate of readmission vs a 11.2% rate of readmission for hip replacement, and 12.4% vs 11% for knee replacement. Again I think this is another example of when you look at the actual data, outcomes fall quite close.
Beware their method of taking a sampling and breaking it into buckets and comparing those buckets. If even hospitals/patients were identical (which I'm certainly not claiming) and so the results were literally just random noise on a distribution, you'd see a major difference between the top and bottom buckets due to the nature of random distributions - 68-95-99.7 and all that. Their results show a signal beyond that, but it's generally a very misleading way of presenting data because of this issue.
Pre-pandemic hispanics had a life expectancy of about 82, which I described as comparable to the 85 of billionaires. I'd certainly expect billionaires to be higher for the endless reasons outlined in the already linked Hispanic paradox. The fact that it's only 3 years, less than 4% longer, is the point.
Two registry cohort papers on breast cancer outcomes, one only in Los Angeles county "provide extensive evidence for my claim"
The claim: For the overwhelming majority of things people to go to the hospital for, where you go doesn't really matter.
Ok, whatever.
They covered an extensive number of variables across hospitals and patients (including NCI/ACS status). They found no correlation with improved survival rates for any variable except for black women receiving their initial treatment at an ACS hospital. While that is technically an affirmation of your claims, I think it is clearly suggestive of some form of bias rather than being a clear causal association.
Incidentally, it's also the same story for colorectal cancer, the 2nd most common type of cancer. Here's another study on the topic. [1] They have a survival rate of 88.6 vs 85.9 for breast cancer, but it's a large observational study that's not normalized, so the confounders/biases there probably explain the reduction in survival rate at non-NIC hospitals. Colorectal cancer is even smaller - 0.2%.
NIC hospitals only showed a significant effect on cancers with low survival rates, and especially on rarer cancers. For instance with pancreatic cancer 93.8% of people who went to a non-NIC hospital were dead in 5 years, by contrast 'only' 87.5% of NIC hospital patients were. Feel free to look up the data yourself. I'm not searching for cherry picked studies, there are none - as there seem to be oddly few studies on this question, and they all say the same thing. What benefit there is is quite small, and heavily driven by extremely rare things.
The claim: For the overwhelming majority of things people to go to the hospital for, where you go doesn't really matter.
You win, as always.
If your local hospital can treat e.g. colorectal or breast cancer to the same degree as a specialized institution, then they can certainly competently treat the overwhelming majority of other issues that people show up to the hospital with, which are generally going to be substantially more mundane with rather more 'commoditized' treatment available.
Labelling markets "rational" is pure rhetoric. There's nothing even remotely rational about a market system, because the moral basis of calling markets "rational" is... greed.
Just greed. Nothing else.
All of the failed outcomes, deaths, pollution, lost opportunities, distortions of democracy, and other damages are a direct consequence of this moral system which claims that greed is rational - when in fact unfettered greed is clearly and objectively sociopathic, with predictable sociopathic outcomes.
Greed and desire push us to spend our energy, otherwise we'd simply conserve it.
It's normal, it's natural and it works. It's human (and animal) nature.
Altruism works fine in individuals and small organizations. But large systems based on altruism uniformly failed to provide the most basic necessities (like food) for their citizens. Can't work against human nature.
We are?
For example, I never file taxes. I'm certain I could get quite a bit back. I am far from rich, I earn medium pay in Germany - medium overall, not medium in IT. (Because I deliberately took a more rewarding and relaxing job, but that's besides the point.)
I will not fill my mind with "money" stuff. Even if that costs me some of that money.
I am sure, given that the terms used are as fuzzy as can be, you can twist and shake the words until you can claim that I am "greedy", the problem with this rationality discussions is how extremely flexible the words used are, making it quite impossible to win or lose an argument. All one has to do is insist on one's own definitions... but taking a relaxed view, I don't see good way to make not-at-all-rare positions such as mine as a form of "greed", without severely twisting the commonly understood meaning(s).
I think a lot of that world view is self-fulfilling.
When I was a kid I LOVED working like the adults. That includes taking one to four week stints in factories, as a teenager in school. That was common in East Germany and encouraged, early acquaintance with work life. I did the same helping out my craftsman grandfather and my shop-owing grandmother.
Work was FUN!
But now, the reason I don't just go - which I would LOVE to do! - and work a few hours low-level jobs here and there, is because it's all been heavily commercialized. You just don't do that! Work has to be pain, and you get paid. Only an idiot would work for free!
During university, during a semester break, I took a job in a chocolate factory. I did not actually need the money! My parents paid (divorced, but both paid). I actually had a lot over at the end of university (cheap dorm housing and no fees for the university itself sure helped). I took the job because I wanted to work in a factory again. It is FUN!.
Until that middle manager a..ole appüeared. I had just optimized my in-between assignment of taking care of some machine chocolate thing, some mixing, I forgot the details. I had set everything up perfectly and now had to just wait a few minutes for the machine to finish.
In comes that.... manager guy. Immediately, seeing me sitting there he yelled at me why I'm not working. FU manager guy. That was the day I realized work now is WORK, not fun. You are not supposed to have fun. You now need middle manager person to keep your lazy ass in check! By yourself, without continuous pressure, you would not move a hand! Right?
At least for the "lower" jobs, which are the majority.
> It's normal, it's natural and it works. It's human (and animal) nature.
You are definitely not speaking for a lot of people, and what you see is NOT the one natural outcome. Expectations and behavior towards people determine theirs (behavior).
The culture I describe existed all around me in East Germany. Yes we were waaayyy backwards with everything, but work culture was really good. I learned a technical profession in a large chemical factory before studying. Everybody worked, useful stuff too, all day. The ancient machinery in the crumbling buildings needed a lot of attention to keep them running. There was hardly any slacking off anywhere I looked. Sure, it was relaxed, but it was work, work, work. I've seen waayyy more slacking off in the offices of large American IT companies.
What you describe as "natural" is natural only in the context the current society has created.
Idea of people caring about money above all else and money being sole measure of things and 'more money is always better' is a huge delusion of our modern societies.
I think we are taking this idea to an extreme and we are already bearing consequences. I am afraid there will be more to come until the bell swings back. I hope it does not break the civilization as we know on it's way forward.
Yes we are. When discussing a salary offer, do you negotiate it down? When buying products and services, do you just pay the minimum amount asked or do you offer more from the goodness of your heart? When getting your paycheck do you immediately donate most of it to the less fortunate in Africa, keeping only enough to cover the bare necessities for yourself? If not, welcome to the club: you too are greedy.
> When I was a kid I LOVED working like the adults.
My kids loved helping with yard when they were little. Their reward was spending time with me and learning. It was enough then. Now, as teens, not so much. I have to pay to motivate them.
> Work was FUN!
Work is still fun, for me at least. But a paycheck makes it even better. I don't know anybody cleaning sewage for pure fun though.
> East Germany
I too grew up in communist Eastern Europe. I clearly remember the never ending lines for food and any basic items like soap or toilet paper. With the profit motivation made illegal, nobody did any work and we were all starving.
The "mixed economy" model - introduce government run hospitals to create competition.
Indian healthcare industry is experimenting with such a model. There are free to cheap government hospitals (along with medical colleges that provide cheap labour in the form of student interns) and smaller public health clinics, that work somewhat like the UK NHS model. But as they tend to be over crowded, or have high wait times to see experts, people with money (and / or insurance) tend to prefer good private hospitals. Private hospitals do charge a lot, but where there are good government hospitals, they have to be mindful that they do not charge too much. Affordable insurance (along with socialised government insurance) and medicines also make access to quality healthcare possible.
I advocated against universal healthcare for a long time, since I was worried that it would cause stagnation in health innovation, but now I see a need for universal healthcare for the 80-90% most common procedures (and leave private clinics to innovate). The only downside I can think of is less dependence on insurance, which has the potential to drive up premiums. But, if that means taking care of the poor for the most common ailments, then it's a worthwhile tradeoff.
1. patients need to be able to actually choose where to go. If they are incapacitated they have no choice in where they are taken.
2. we have to endure an unknown number of deaths for an undetermined period of time while we wait for the market to reach equilibrium.
So it's pretty clear free market dynamics are not the way to go when it comes to the healthcare marketplace.
Compare grocery shopping:
You have frequent/repeated interactions; if you always get ripped of by one shop, you can go to another. Before you go grocery shopping, you will have a decent mental model for: prices levels at each shop, quality of produce and accessibility/distance. You also have the full choice in where to go, basically every time.
Hospital interactions (especially ER) is the polar opposite:
You will have few interactions with it over your lifetime (hopefully), costs are basically impossible to know beforehand (and difficult to compare, too), quality of treatment is extremely difficult to judge as patient (because every case is somewhat unique, and outcomes can easily come down to luck/individual doctor). Especially in the ER case, you often don't even have a real choice of hospital and even in cases where you could (and had all the info) there might be throughput limitations on "desirable" hospitals that prevent you from switching (=> having to wait for 5 months).
Another factor I think is that hospitals gain less from being "good": As a "good" grocer, you get to steal market share from your competition at low cost and risk to yourself; for the hospital, scaling up is more difficult and risky, thus "good" competitors are also less threatening comparatively (thus less of a motivation to improve things).
That would come as news to the French.
The TL;DR of the French system is that you pay for your outpatient care at the point of service. Later, your insurance company will reimburse you for 80% of the "reasonable and customary" charges for the service. It's up to you to pick the provider that matches your budget.
Emergency care is understood as not amenable to the free market, and that doesn't have the same payment flow. Having said that, I could tell you some stories about folks who wound up worse off because the care was still rationed, just by the state instead of an insurance company.
I'll preempt the common next argument, and that is that emergency care is ~ 10% of US medical spending, so it's probably not Pareto efficient to start with that case when designing how this all works.
I wish this would stop being used like it's a credible argument. The truth is that we can find these cases in any healthcare system. The only valid evidence when weighing system versus system is aggregate numbers.
I would literally expect overpriced snake-oil from actual free market healthcare, and there is significant empirical evidence that this would happen from my point of view.
Your complaint against for-profit hospitals would apply just as quickly to a nonprofit hospital in a socialist regime. The fundamental problem is monopoly. Because most people don't behave nicely unless they are forced to by market pressures. Whether those markets are economic or social in nature.
Even if you ignore present-day socialist economies, you can look to NIMBYism in the developed world as a flagrant example of what happens when "normal people" gain collective control over a resource without any competitors. They immediately weaponize it to the harm of greater society. If not for financial purposes, then ideological ones.
Admin bloat is a far larger problem, and so are the pharmaceutical companies which get to charge the government whatever they want to develop new drugs that often are only marginally effective.
But this "semi-monopolistic trade union" not only inflates their wages (which maybe that's a good thing), but it also harms the lives of the population they purport to serve. Many (most imo) people in the US simply cannot afford the monopoly's prices, and the monopoly has little incentive to innovate. This cartel of doctors actively prevents lower-cost, more efficient alternatives from coming to market.
https://www.noahpinion.blog/p/insurance-companies-arent-the-...
https://www.noahpinion.blog/p/service-costs-arent-exploding-...
However, at the core, US insurance system is the problem because it gets compounded by government trying to regulate such a system, so people do not die needlessly, but not destroy these profit seeking enterprises. So, what you end up with is a massive mess that leaves everybody cranky.
there is no regulatory cap on the number of new residencies
there is a cap on _federal funding_ for new residency slots; yes that impacts hospitals' willingness to add new positions, but it's _not_ the same as a regulatory cap
- The majority of states still maintain "certificate of need" laws for new hospitals, ambulance providers, etc.
- The AMA holds a state-enforced monopoly over physicians.
- Many states still limit NPs/PAs, requiring physician supervision for things for which those people were trained.
- Lack of interstate reciprocity in licensing means mobility is constrained and supply can't follow demand.
- Costly medical equipment usually requires first-party repairs; mfgs claim a third-party modification (repair) constitutes remanufacturing under FDA regs.
- Stark law makes e.g. physician/hospital value-based care arrangements very hard. It's quite strict and everyone has to tiptoe around it a bit.
There's also the huge problem of malpractice insurance costs due to insane tort settlements. Awards need to be capped yesterday because it's too easy to talk a jury into bankrupting people over things that legitimately just sometimes happen.
I'm guessing others could give you an even better list. Some of those are a bigger deal than others but it's a huge issue. Insurance net margins just aren't high enough to blame it and drug costs aren't enough of our total healthcare spend to be at fault.
It comes down to humans being too expensive. There remain many areas of care where we can't cut man-hours down without sacrificing safety and quality. As such, we should reduce the insane byzantine co-ordination and compliance overhead.
Oh, and patient value isn’t considered for these units. They are explicitly defined as input driven, so a procedure that is less costly to perform but has higher value to the patient will be billed at a lower value. Hospitals are incentivized to choose procedures that they can bill at a higher rate, and so because of these perverse incentives, they necessarily will ignore cheaper more effective treatments and choose the more expensive ones.
I’m a lefty, but the older I get the less I believe in the old New Deal style leftism I’ve been sold my whole life. As systems get more complex, they simply become a way to obfuscate oligarchic control.
Do you have a hypothesis as to why CON requirements are driving inferior outcomes and increased cost metrics at PE owned hospitals? (A hypothesis that accounts for the fact that PE owned hospitals underperform even in the absence of CON requirements.)
Serious question. I'm trying to get my head around this.
PEs seek to make profit, and are looking for places where they can either raise prices or lower costs (which will quickly correlate with worse outcomes) while not losing customers (yes, you could call them patients, but PE will view them as customers), or at least losing so few that the overall numbers result in more profit. One way of doing this is looking for barriers to competition/moats. CON is just one type of moat, and so is one factor PEs evaluate, but the presence or absence of other moats can still override the presence or absence of this one moat. One could try to work this out from data with some sort of regression, but with so many possible moats and a relatively limited number of data points, it would be easy to overfit the data.
In comparison, non-PE hospitals might have some profit motive (or keeping to budgets, not going bankrupt, ect.), but will be less driven by this mentality and thus their relationships to moats will be more complex, and so something like a CON requirement won't be as fully exploited to raise prices or lower costs.
This also fails to account for other ways that PE can seek to make money, which involves more complex parts of law and financing that I'm not well versed on (I've ready some things about real estate, but don't know enough to fairly analyze the claims).
You respond questioning how that could explain why PE operated hospitals have worse outcomes. I agree, this doesn’t seem to have an explanatory power for why PE operated hospitals have worse outcomes, but how does that relate?
Which "finding", presumably, being that PE owned hospitals have substandard metrics.
My question is natural given the context of a discussion that's literally titled:
"Death rates rose in hospital ERs after private equity firms took over"
It's literally the entire subject of the discussion. Why would anyone think it's irrelevant?
I also generally think there's a lot of choice that could be encouraged in terms of drug access. I generally think people should be able to buy medications and drugs without a prescription, or at least under the monitoring of a pharmacist or something, or at least in most cases. I can think of medications that there have literally been papers written saying that they are safe to give without a prescription decades ago and they still require a prescription; there's also medications that people take for years safely, and it seems kinda absurd to require them to get a prescription for them. My thoughts about the FDA itself are complex and could probably an essay in itself.
I'm very in favor of public healthcare, and public healthcare institutions but I also feel a lot should be deregulated or reregulated toward greater openness, choice, and competition. There's probably a lot of areas where there should be more regulation too I suppose — I think antitrust principles should be applied to insurance and hospital consolidation more often.
Elsewhere, quality of a good or service is traded against cost. But in medicine, there's a cost ratchet as ever more expensive and marginally more performant treatments are introduced.
There may be such a reason, but you haven't outlined it in your post.
Regulations that prevent construction of new hospitals without some sort of "demonstration of need".
Regardless, you have to explain how removing CON solves the PE issue mentioned when states without CON had the same issues.
- There is a specific list of regulations that cause the problem
- Each regulation in that list is present everywhere the problem exists
Neither one of those are true. Instead, there are many regulations and, combined, they add up to causing the problems. The specific regulations can and do vary by location; but the result is the same.
No. You are 100% wrong.
The context of this discussion is PE. So comments discussing this involve PE. So while you are correct in general, you are wrong specifically.
In light of that, I stand by what I said: you have to explain how removing CON solves the PE issue mentioned when states without CON had the same issues.
Maybe this isn't possible, but then we accept that this is not an answer to PE, which again, topic of conversation.
The problem is not restrictions on medical facility construction, it's inefficient use of what we already have.
In general, America has an issue with defaulting to "building new", as if we have an everlasting greenfield, rather than careful provisioning of the already overbuilt infrastructure base. Capitalists love being freed of prior obligations, with no regard for how they contribute to an even more unwieldy set of obligations in the future. Enough. You can't just do as you like. Help solve the actual problem.
Any other goal lines you want to redraw? Let's get that out of the way now instead of going back and forth.
(To answer: in my personal experience Illinois also has such a regulation.)
Isn't that just more infrastructure, administration overhead and staffing that victims have to pay for, in the end?
A “need” certificate is similar to the cap that med schools have - it’s effectively a pricing cartel to keep salaries/revenue high
Overall we have a crisis of hospitals shutting down, not a crisis of oversupply.
I don't see how this could be true for emergency visits. Would an ambulance drive you to the cheapest hospital within some fixed radius?
https://ij.org/report/striving-for-better-care/overwhelming-...
If you are arguing that the customer is not paying for inefficient providers, then I strongly disagree.
Customers always end up paying for inefficient supply chains. If you end up with an inefficient allocation of hospitals/doctors (local overprovisioning), it's always gonna be the patients that are gonna pick up the bill for this in the end through higher average prices.
Inefficiencies are doubly bad because you potentially don't just pay the pure cost for the inefficiency (middlemen, waste etc.) you even pay for margins on top.
I think the assumption that such inefficiencies could lead to actual savings for customers (by magically making the providers decrease their profit margins) is highly overoptimistic.
Obviously not. There is nothing that compels a customer to do business with an inferior competitor, if there is an alternative. The end result of having a sufficiently inefficient supply chain can be that the company involved goes out of business, as it cannot operate at a profit.
2. One offers bananas to walk in visitors, but the others have a minimum wait time of 1 month to a year.
3. One is a mile away. One is an hour away. Still in the same county.
4. None of them offer an easy to understand menu. You can't just order a banana. You ahve to order Banana Services and meet with Banana specialists. You can't take the banana home.
5. You wake up in a banana shop and you didn't get a chance to shop around before being presented with a bill. They don't take your payment of choice, so it's 10 times as expensive.
6. Some won't let you buy a banana. Instead, you have to buy a banana service. Per banana pricing is the lowest here, but the total cost is higher if you just want a banana.
Which banana store do you buy from? A, B, C, D, or E?
I'll take the first choice you make and let you know if you picked correctly. Anything other than the correct choice is a failure.
I'm not defending the "Certificate of Need" regulations, but your thinking is sloppy: healthcare is not a product like bananas. That analogy will mislead more than it will inform.
If every person has to buy 10 bananas a day or they will die, the town with 5 stores may have more expensive bananas, because they can just raise prices to cover the excess capacity and people will pay.
The same works for non-emergency surgery as well. Take a look at https://surgerycenterok.com/ it's such a breath of fresh air to see the full price for each procedure right there. People travel there from all over the country to get needed procedures. So competition clearly works but the system doesn't really enable it. For example insurers don't want to work with the linked center because they won't give them rebates but charge everyone the same price. More details: https://www.econtalk.org/keith-smith-on-free-market-health-c...
Not necessarily. They're all under the same pressure. If they all provide similar services with little differentiation, the price will probably settle at a higher level to cover the fixed costs of 5 stores instead of 1.
> In my local market we literally got a scan for 2k where the hospital we'd usually go to wanted 10k.
You kind of get at it below, but I wonder if that's an effect of insurance negotiations (e.g. the hospital you usually "usually go" gave in to insurance discount demands in one area, but pushed back on scans pricing to get the revenue they need to operate).
I do think the totally fictitious nature of posted healthcare prices is a serious problem.
That’s still 4-6x what it would cost at a private clinic in Canada.
There are two things that set healthcare apart here. One is that sometimes people need unusual treatments to stay alive that are extremely expensive, and our desire not to let people die is at odds with the normal market mechanism where products that cost too much just don't get purchased. The other is that sometimes people have emergencies so urgent they can't really choose their provider.
But the vast majority of healthcare doesn't fall into those categories, and normal market mechanisms work fine for those. Competition would lower prices for most healthcare just like it does for food and everything else.
Unlike grocery stores, hospital ERs don't get frequent repeat customer interaction, so that makes the competition aspect basically completely inapplicable.
As typical ER visitor,
- You wont know what "quality" of care you are going to get beforehand
- You will have very limited capability of selecting the hospital
- You will be unable to compare prices beforehand
So why would any of those 5 hypothetical hospitals decrease prices?
More competitors won't do shit if the market is uncompetitive by design.
Oh yes they do. I can think of any number of patients I'm familiar with who end up in the ER multiple times a week. Practically daily for some people. And a few who are known for getting discharged from one hospital and immediately heading to another nearby one.
I have a bunch of people with serious conditions in my "bubble" (spontaneus penumothorax, diabetes, ...) and none of those needed the ER more than ~1/lifeyear.
If weekly hospital visits were typical, competitive free market hospitals would be more feasible IMO but I don't think we're close to that (and I don't want to be, either).
Medically fragile elderly people trying to live on their own when they shouldn't be. Frequent falls with injuries, etc.
A friend of my mothers was in and out of the ER and med/surg floors for months with mysterious cardiac symptoms that ended up being a new reaction to a medication she'd been taking for years.
People who are just psychologically, hmm, needy and looking for attention. When I worked on an ambulance there was a lady who'd call weekly because she said her blood pressure was high (it never was) and we couldn't refuse to transport her.
And more...
This happened with a friend's mother during her last year of life. She had dementia, cardiac problems, infections, breathing problems, a whole litany of symptoms of slow death. But she didn't have any one clearly terminal condition (like late stage cancer) that would justify a switch to hospice, so she lived in an assisted nursing facility and also had to go to the ER more than 70 times in that last year. It was horrifying for everyone and the costs were astronomical. The state is now trying to seize her daughter's house to partially offset the accumulated expenses.
If you go in because of a killer stomach ache you could end up needing a CT and emergency surgery. Or you could end up getting some pepto-bismol.
And if you are taken there by an ambulance (which you also have no ability to compare any price to). You'll be sent to the hospital the paramedics decides to drop you off at.
There is an inherent complete lack of information when going in for a medical situation that can't be fixed by the free market. You need (or believe you need) treatment now. There's no way for you to know what that treatment will be.
Even going in for an annual physical can be the exact same. Some dicey numbers on your blood work and you might be looking at some huge unplanned bills that are completely unavoidable.
Number of competitors is only one of the inputs for how competitive a market is, and price intransparency + lack of information on treatment quality make it moot for the healthcare sector in my view.
I don't think higher hospital density would hurt, but we would have to pay for this and I don't see it help drive down prices.
Yes, there are some kinds of care that aren't very amenable to competitive market forces, but the vast majority is.
We do need price transparency though.
No. Preventing rapid unplanned end of life is the main purpose of hospitals in my view.
Enough time to make a choice of hospitals (or even to collect information on specific hospitals) is a luxury that I would not expect patients to have.
The labor to produce, ship, and shelve the banana determine it's cost along with whatever margin the store that sells the banana is willing to take. Walmart, for example, could be perfectly willing to sell a banana at a loss if they think that will get you in to buy a TV.
This is why dollar stores exist and often kill off local grocers. They can sell a lot of non-perishable goods at a loss and win back by understaffing the location and overcharging on non-perishable goods.
I live in a city with probably around 50 different clinics, but they are all associated with 3 major medical groups. It isn't a lack of buildings that's preventing competition.
Which is all to say, my gut is it is far more complicated than that allows for. Not a useless model, but also not a very actionable one.
Tell that to the waves of cupcake shops, craft breweries, and now cannabis dispensaries in my area.
Yes? That's the idea. I won't say it always works, but it's the idea; preventing the existing facilities from closing.
> They aren't devastating in an oversaturated market.
It certainly can be, if the oversaturation puts all of them on shaky financial grounds.
Should also probably drop requiring an ER for Medicare certification and just directly subsidize ERs.
What, specifically? Just abolish them all, and return to the pre-1938 status quo (e.g. marketing radium water to cure what ails ya)? Or specific reforms to make the drug approval processes more effective?
Sounds like something the current US health secretary might actually like.
Turn it into a pure R&D effort and not one driven by profit.
Same way the NHS previously funded medical research. Grants and grant review. You can expand that department and effort.
> What's their skin in the game and their feedback mechanism?
Believe it or not, some people just want to research and look into cures for diseases. Shocking I know. Feedback can be reviews of their work and blackballing bad actors that consistently kick out bad research.
> Why will they do a better job picking what to research than current pharmaceutical companies?
Because they already are. Pharmaceuticals aren't doing the majority of research, they are taking NHS funded research and running it through FDA approval.
Ozempic, for example, didn't come from pharmaceutical research, it came from grant research into lizard spit.
I don't think we should cut all public funding for research, but we also need private research. While semaglutides were discovered in Gila Monsters a long time ago it was Novo Nordisk that put in many years of leg work to actually turn it into something useful for humans. The more interesting argument might be that Novo is controlled by a non-profit org.
Pharma companies are pretty terrible (e.g. pricing a cure for a kind of hepatitis just under a liver transplant, not because it costs that much, but because they can make the most money that way even though access is severely restricted). Getting rid of that market-driven terribleness may be a enough gain to justify the reform.
Personally, I'm so sick of the business-all-the-things approach and its well-known failure modes that I think society needs to put some effort into making other models work. Either straight up nationalization (with perhaps internal competition between research centers), or stricter oversight (e.g. putting government officials, patients, etc. on pharma company boards with enough power that the shareholders have to take a back seat).
Each and every one of these regulations can in abstract, be justified by some useful idiot looking at only the first and second order inputs and outputs and not looking at the totality of the effects.
Nobody with a brain would defend shitting in the river, but here you are asking for individual turds so that they may be justified on the basis that the individual dropping them was relieved and their individual impact on water quality was minor.
It beats anything open air by miles. Sure, an outhouse would be better but river > street.
>Trying to "just count" the regulations to determine quality completely discards this critical dimension and betrays an almost childlike view of the world.
You're grasping at straws here. I am under no obligation to give such an infantile opinion (the one I initially replied to) a response at length. This is not the venue for such minutia.
Responding with “I know you are but what am I?” is just proving my point.