The US health-care system looks awfully like post-apocalyptic chaos


#1

Originally published at: https://boingboing.net/2018/01/08/the-us-health-care-system-look.html


#2

What system is the one in which people must ask for costly “favours” from “connected” people they personally know in order to keep living?

And thus do the “free” market obstructionists of single-payer universal health insurance (sometimes) inadvertently put Americans on the dreaded Road to Serfdom.


#3

Well, the article doesnt say anything about costly directly, except with the part about the “consultant” which yea, sounds bad.

Which is an important bit but is more of a consequence - see, the main issue is that internally the system doesnt work either, and it depends on the knowledge of people. If my job is to do X, my ability to do X is dependant on knowing people at other companies/teams/agencies, personally. Because I dont have a way to deal systemically with my dependencies - I just need to go to people I know and trust and owe me because I do the same for them in my tiny little fiefdom

The rise of a class of “fixer” is a consequence of that chaos.


#4

I feel compelled to plug this GNU project: http://health.gnu.org/
It is very much still under development but a step in the right direction. IMO competing closed software systems are likely the land lords that the author alludes to in this segment:

Standardizing an interface between health care providers and insurance companies would be a huge win. No matter how badly designed, it would be better than the current mess, and save several percent of US GDP. That would need cooperation from most of the major players in the industry. Other industries manage that routinely: machine screws and futures contracts come in standard sizes, without which manufacturing and finance would be as inefficient as health care. The need for a standard insurer/provider interface is obvious. Since it’s lacking, I imagine some powerful group extracts enormous rents from the inefficiency. I know nothing about that, so I won’t speculate.


#5

Yes, this is all true, but look at all the efficiency that the invisible hand of competition and um something something…greatest health care…thingie…in the world…


#6

The symptom of the fixer is one egregious example of the many needless costs of a diseased American system which prioritises profits and shareholder value above outcomes. For an example of a less direct cost:

They’re definitely self-preserving tools of the feudal lords/capos/padrones/caudillos (translation for Libertarians: job-creating tycoons). If ostensible competitors in this type of market were to agree on a standard interface and coding system (especially a FOSS one) it would raise uncomfortable questions with the public about how the other costly inefficiencies might be addressed by moving toward a not-for-profit system.


#7

With the experience of my spouse experiencing a tsunami of medical issues over the past two years, I can say that while the specifics of insurance company buck passing talked about in the article are American, the overall pattern of left hand and right hand not knowing how to talk to each other afflicts health care here in Canada too.

In June, my spouse spent three weeks in the hospital being treated for kidney failure. There was quite a bit of time wasted trying to find out the cause for the blockage causing her kidneys to swell up and die. It took a full week of the medical team trying to find out if she would fit inside the CT machine (she is quite large) before, finally, some CT technicians came up to her hospital room and looked at her and said, yeah, she’ll fit.

The scan showed that she had multiple large kidney stones blocking both ureters. So they cut holes in her back and inserted tubes to drain her kidneys, and then we were referred to the one clinic in town that does kidney stone removal surgery (as opposed to ultrasound dissolution, which only works for smaller stones). After months of waiting for an appointment slot, we were seen by a resident at the clinic who said, get a contrast CT scan and then we will see exactly where the stones are so we can make a removal plan, and then our head doctor will see you and plan the surgery.

After a series of Kafkaesque delays, we got the scan, and finally, in late December, she met with the lead surgeon, who took one look at her and at her scan and said, these stones are too dim on the scan to be calcium, they are probably uric acid. Take lots of potassium citrate for two months and that may dissolve them enough that we can zap them with a laser, which is far less invasive and risky, especially for someone with your risk factors. Then get another set of scans here and I will look at them the same day and plan the removal procedure.

And we were, gee, it would have been nice to have that option provided to us six months ago. Considering that she’s had plastic tubes inserted into her kidneys causing constant pain for six months now, and now we have another two months, plus, added onto that. And that’s just one plotline in the saga, I could tell tales of numerous other dysfunctional episodes.

Even if you fix the insurance industry and get costs under control, the medical system in North America is still filled with data compartmentalization and medieval-style fiefdoms and excessive buck passing, with far too much of the complexity and bureaucracy being offloaded onto the patient.

eta: grammar and spelling, clarify that we are still stuck in the damn tunnel of medical woes.


#8


#9

First, I’m sorry that your spouse went through that and am glad she ended up with a non-invasive solution, albeit more than six months later. I shudder to imagine the level of added stress if you’d also had to spend time negotiating prices and costs with private insurers.

I would say that, in all fairness, that sort of thing probably happens in all medical systems, no matter how enlightened. Better communication and data-sharing systems* are needed to avoid situations like yours, but I’ve found in connection with some of my work that doctors are very resistant to change in this particular area for a mix of good and bad reasons. A doctor’s office is one of the few remaining places in the industrialised West in 2018 where you’ll still hear the phrase “I’ll just fax this over right now.”

[* this is one endeavour where adding the word “blockchain” could also add real value, but without a single and preferably government-imposed data exchange standard it will go nowhere]


#10

We hope. The potassium may not shrink them after all. And it’s pushed everything further into the future, again. We went into the appointment thinking it was going to be signing consent forms and scheduling the surgery, instead we have another two months of waiting before we can schedule removal of the fucking things and get the tubes out of her back and get her life back.


#11

In the year 2380, when we have colonized the moons of Neptune, the medical profession will still be using pagers and fax machines.


#12

I think I saw a tweet like that recently.


#13

I think that part of the problem is the tendency to extreme specialization, with many doctors knowing a lot about their narrow field, but not that much about closely related areas. It seems that the incentives are just not there for doctors to acquire and maintain a more rounded knowledge, or to consult with other doctors, resulting in a field populated by a number of medical fachidioten.


#14

So what your are saying it is now a Libertarian ideal system?

Well, mission accomplished!


#15

I work on the medical field and I can confirm eveything in the publication is true. There is also more: dr’s offices all have electronic medical record systems but those systems are rarely compatible with each other. There is no unified system that can transfer patient records to one place to another. Office personnel need to call/fax records just like 20 years ago. Since all offices are understaffed, requests can take days to be fulfilled. You are lucky if the office personnel know someone who knows someone to get those records fast. It’s the same as the secretaries’ circuit at most places.
Re: costs: regardless to the real cost of treatment, patients are billed the maximum amount that a “Cadillac” insurance company would cover, regardless what insurance the patient has or if it is self-pay. It is so because: A: the health care provider want the maximum amount out of an insurance company and the patient, to cover the cost of non-payers and also because they like money. B: the amount they bill for the same services has to be the same for every patient/treatment (it’s just common sense).
This is how a 48000$ hospital hospital visit is billed to a patient with no insurance. If you have ANY insurance there is usually a line on the bill that says “contractual adjustment” it can add up to 80% reduction to the bill. The reduction is the result of the contract between the hospital and your insurance company. So the bill is now around 9000$. Your insurance will pay 10-30 percent of it and you end up paying the rest. Except for the “Cadillac” insurances, they may pay all of it.


#16

I don’t think so. I mean they don’t use either here in Ireland as far as I know. They do have paper records in the hospital though. with sticky barcodes and all that. But I have seen the doctor/consultant looking at these in document management systems as well.


#17

At one point in my life I was on Xanax to deal with a panic disorder (It didn’t work) but I was addicted so I would call my doctor every month and get my prescription.

I was having a hard time getting though so I drove there to find a sign on the door saying they were closed for good. Turns out they went bankrupt and my medical records where trapped in there.

Took forever to find a place to call and fight but in the end I never got my medical records transferred and I found out they were all destroyed.

So that’s how I lost 30 years of my medical records.


#18

That’s more an aspect of the professional culture, so I doubt it’s going away. Ideally, though, a GP should have that more rounded knowledge and also should stay involved (if only as a physician-advocate for the patient) when a specialist is brought into the mix. As it stands now, the referral to the specialist is more commonly seen as a hand-off than as the start of a collaborative effort. This problem is only exacerbated by the American health insurance system.

When they’re not busy figuring out the billing codes and negotiating with the for-profit insurance companies to get $0.50 on the dollar for claims because “capitalism! freedom!”.

In the U.S. you’ll find that going on within hospitals and hospital networks, especially the more profitable ones. But once you get outside those orgs and their proprietary systems (e.g. a GP, an ER at another hospital, an independent lab) you’re back in fax-land.

Physicians are almost comically resistant to using new communications methods, but they do adapt at a snail’s pace. I’ve seen it in some of the discovery work I’ve done. A single-payer system would tend to nudge them in that direction a bit faster.

In most medical systems the GP owns the patient record (or portion thereof), or the specialist owns it, or the insurer owns it. Imagine a system where the patient is seen as the primary owner of his own data.*

[* granted, from what docs tell me a lot of patients would basically turn that ownership into the start of an on-going freak-out, but that’s a different issue]


#19

I don’t think “costly” necessarily meant direct monetary cost to the user at the time of use.

From the article:

The short version is that at least seven experts spent roughly ten full-time days trying to find out a basic fact about my mother’s insurance, and finally failed. Meanwhile, many thousands of dollars were wasted on unnecessary hospitalization.

It’s hard to not describe that as “costly.” And if we want to talk about cost for the individual, out of whose pocket was all that useless running around paid for?


#20

There is an entire ecosystem of dueling administrators…Half of the are trying to get their employers paid for performing medical procedures, and the other half are trying to prevent their employers from having to pay out. One of the effects of this is the amount of “patient sorting,” that goes on…Old => medicare…indigent =>medicaid …has employer provided health insurance=>insurance company…Veteran=>VA etc…The ACA added and widened some of the lanes, but did little to get rid of the “sorting system” that allows so many people to fall through the cracks…