One of the many things I learned during my wife’s cancer treatment is that healthcare is designed with the cost development systems insulated to resist external influence. There is little accountability for the base cost architecture, often to the point where no one can identify the architect.
This makes addressing inefficiencies, exploitations, and shortcomings almost impossible.
From a regulatory standpoint, legislative action has little to target. The doctor, the technicians, the hospital, the supply vendor, the pharmacist, and even the insurers rarely set their own prices. Between every transaction there is at least one middleman who manages the cost and often their pricing guidelines are set by yet another middleman. The structure eliminates the cash flow variable from the parties in direct patient contact and leaves only the profit component as a variable. This undermines free market cost controls and performance incentives.
For hypothetical example, a hospital billing for a $10000 procedure does not receive that $10000. Third, fourth, or fifth parties receive the money and redistribute it back to everyone in the chain. That means the hospital is left with a negotiable amount of just $600 (above the line, $200 below). This phenomenally granular disintermediation of the cost structure means no party has a vested interest in individual transactions. There’s simply not enough money at that level to invest in higher stakes negotiations one might expect in a $10000 transaction. This makes volume the success defining metric.
As I was spending countless days in hospital over the course of a year, I started counting keystrokes and mouse clicks performed by various hospital staff. Roughly 60% of all computer interaction was performed solely for billing purposes, not patient care. Billing purposes are also the primary driver in wait times. The doctors review patient records before each visit and spend much of that time reviewing what treatments they are allowed to use based on the patient’s financial means and their insurer. The highest performing doctors (a volume metric) are the ones who memorize the treatment approval criteria and don’t have to refer to the computer as often.
The scope of the disintermediation is vast, so more examples are not useful. At the end of the day, what it boils down to is that the individual parties involved in the minutiae of patient care are insulated from each other. This makes YIMBY activism ineffective because enacting change that way only affects one tiny group within the chain and everyone else adjusts to compensate. It’s like trying to eat Jello with a cooked noodle. Huge effort with little to no reward.
I do not have any reasonable solution. Americans have proven time and time again that adopting healthcare like developed countries have is unacceptable. The focus has to change to actual healthcare where patient outcomes are important (as opposed to focusing on billing outcomes for providers). Increased frequency of Luigi Lobbying is unreasonable, but I think more people are beginning to see it as justified.
The argument against R&D of contemporary systems because of future systems capabilities has always been shortsighted. Two examples of this are nuclear weapons controls and line level commenting of programming code.
In nuclear weapons development the safety advocates argued for safety measures on the weapons themselves to prevent misuse. They were overruled by arguments that future systems would be so physically secure that they couldn’t be stolen and the controls were centralized to the launch control process, usually with one person there having ultimate control. Proliferation and miniaturization eventually made theft and misuse a major risk and an entire specialized industry sprang up to develop and implement Permissive Action Links (PALs).
It wasn’t until the late nineteenth 1980s that the entire U.S. nuclear weapons inventory was equipped with PALs. Which is nuts. Even then, malfunction concerns were paramount, and they continue to be concerns, creating real risks in deterrence based defenses. Even today PALs are still being upgraded for reliability. It was the fact that PALs had to be retrofitted that was responsible for the 70 year timeframe for implementation of devices with questionable reliability. Safety R&D as a primary R&D focus during the pioneering era of nuclear weapons could have prevented that mess. Trying to shoehorn it in later was unbelievably expensive, difficult, and created strategic threats.
The finance and defense sectors have a similar problem with software. High turnover iterations led to a culture that eschewed internal comments in the code. Now making changes creates safety concerns that are only overcome with fantastically complex and expensive testing regimes that take so long to complete the problem they are trying to solve has been fixed another way. It’s phenomenally wasteful. Again, future safety was ignored because if arguments based in future capabilities.
Most importantly however, is that R&D of contemporary systems is how we learn to study future systems. Even though future generations of the technology will be vastly different, they are still based, ultimately, on today’s systems. By considering future safety as a contemporary core competency the way is being paved for the study and innovation of future systems and preventing waste from adhoc shoehorning exercises in future.