Siderea

> What do you think you need an MD for, in your primary care visit, that an NP can’t do?

I guess not much at this point where PCPs don't seem to do much beyond use rubrics, prescribe, and refer. Which is why I used the word enshittification - it's part of a continual gradual march down in quality/services to a captive customer base. Basically the opposite environment of innovation aiming to serve customers.

> How much time, in a day, do you think doctors are spending on “insurance”,

I'd say at least half their time, if not much more. They certainly aren't scheduling these 10-15 minute appointments back to back all day. By "insurance" I am of course including all of the extra documentation and runaround they have to do simply to satisfy the third party beancounters' demands. I'd say this even includes a good number of patient visits themselves.

https://www.astralcodexten.com/p/what-your-doctor-spends-80-of-their

https://siderea.dreamwidth.org/1182366.html

Observations in my personal experience line up with this:

- Number of signs at my primary care office about their procedures for providing/processing referrals, like this is the majority of their work

- The numerous questionnaires every office makes you fill out ahead of every appointment, that they themselves never actually read

- Experience with a not-terribly-large specialist office who employed an entire full time "nurse navigator" whose job it was to help doctors prepare documentation for "prior approvals"

-…

This is the best explanation of (my take on) this I've seen so far.

On top of the article's excellent breakdown of what is happening, I think it's important to note a couple of driving factors about why (I posit) it is happening:

First, and this is touched upon in the OP but I think could be made more explicit, a lot of people who bemoan the existence of software development as a discipline see it as a morass of incidental complexity. This is significantly an instance of Chesterton's Fence. Yes, there certainly is incidental complexity in software development, or at least complexity that is incidental at the level of abstraction that most corporate software lives at. But as a discipline, we're pretty good at eliminating it when we find it, though it sometimes takes a while — but the speed with which we iterate means we eliminate it a lot faster than most other disciplines. A lot of the complexity that remains is actually irreducible, or at least we don't yet know how to reduce it. A case in point: programming language syntax. To the outsider, the syntax of modern programming languages, where the commas go, whether whitespace means anything, how angle brackets are parsed, looks to the uninitiated like a jumble of arcane nonsense that must be memorized in order to start really solving problems, and indeed it's a real barrier to entry that non-developers, budding developers, and sometimes seasoned developers have to contend with. But it's also (a selection of competing…

One hopes he has read this, a classic slate star codex post on leadership: https://siderea.dreamwidth.org/1209794.html#cutid1

Sincere questions for Musk would be:

How are you supporting your management team when you've asked their subordinates to bypass them with good ideas for exposure, leaving them only to provide risks and bad news their subordinates didn't want to bring forward?

How do local team leaders take risks when their team is encouraged to defect and draw in the exec at the first sign of controversy, or just opportunistically?

How do your teams commit to shared outcomes when an arbitrary member can call in a veto from the top?

How do you as the owner not become the bottleneck (and blocker) while everyone clambers to have your support their pet issue because they know nothing is going to get traction without your royal assent?

How do managers not just fire people who call in your air support for things they are in fact wrong about, and how do managers trust those people to be a part of the team after?

His company, his rules. But having seen this kind of naive abdication of responsibility for effective delegation in practice, it is reasonable to ask how this thing scales when you add the uncertainty of a random super veto, and encourage and reward transgression.

edit: better link to "The Asshole Filter," article.

To participate in an American healthcare treatment you need to interact with a private for-profit company which will shut down if it doesn't on average attain significant profitability; Let's say 30% goes to shareholders, taxes, receptionists, keeping the lights on.

But they don't deal with everything. They have to interact with upstream providers! And they have to pay somebody to negotiate with them. So another 30%, and add 5% just to pay somebody to bargain the price with the Flu Shot Distributor.

But the flu shot distributor has to interact with yet more upstream providers - the flu shot packager, who interacts with the flu shot pharmaceutical company, and the syringe company. Everybody adds their overhead and then their premium; "Price signals" become exponentially complex and more a matter of the mood of the negotiation than anything else.

This is all an externality of a non-vertically-integrated capitalist system, which is somehow, somewhy, supposed to be regulated by your desire to get a flu shot relative to your ability to pay; It is not at all optimal in the market system for everybody to get a flu shot, that defeats the fundamental mechanism of the supply-demand curve.

https://siderea.dreamwidth.org/1179450.html this essay series offers some of the better hypotheses on cost disease that I'm familiar with.

It sounds like the whole field is contaminated with mind-body dualism. But there's a bigger problem; even once you accept that humans are fully physical, embodied minds in a sea of whatever chemicals can cross the blood-brain barrier, the scope is wider. Humans are part of a society that can harm them without effective means of redress.

Also, from the original paper, via the linked LJ: https://siderea.dreamwidth.org/1388220.html

"I began taking blood samples from everybody who came to the clinic. At times it seemed like Transylvania Station. The state Department of Public Health's laboratory tested blood free for anyone under the age of 12 and provided plastic pipettes, finger puncture equipment, and even mailing envelopes at no cost. So, for a while, everyone in the clinic was declared to be under 12 years of age."

Both a nice public healthcare hack and a risky thing to admit in a journal article.

Blogger siderea has talked about this a lot in relation to patreon, and the challenges for any platform wanting to replace it.

EDIT: https://siderea.dreamwidth.org/1824441.html and https://siderea.dreamwidth.org/1371510.html

Apparently it comes down to how card processing fees work, as long as there's a constant fixed cost per payment (whether or not there is also a percentage fee), "microtransactions" become uneconomic for the platform.

Apparently the problem with letting people pay say $10 into an account and then dispense $1 a time to read articles is that makes you a "payment processor" in some states which comes with strict regulations and extra costs.

EDIT2: and yes, we've already tried blockchain for that too.