[methehack]

https://en.wikipedia.org/wiki/Carte_Vitale

France's system is universal and private (private docs, insurance, and reference pricing -- a service has a single fee across coherently regulated payers). They have had a standardized medical record for 20+ years. One system and one medical record for everyone. WHO ranked #1 healthcare in the world (to US ~40th) at 1/2 the cost per capita of US healthcare. This is catastrophic legislative failure for a problem largely solved by lots of other people around the world.

The legislative failure has created vast administrative overhead (10, or more, staff per doc at a hospital) and corrupt insurance companies. When an insurance company has to pay a claim, they call it a "medical loss" (they had the money and they lost it). They make their money on poor service and deceit -- charging wildly different prices for the same product where they can get away with it). In France, an insurance company, by law, has to pay a claim to a practice in a few days. Imagine the decreased capital needs for running a medical practice or a hospital.

The hospitals are not blameless in all this, but the heart of it is the payer system/s.

[mumblemumble]

There's actually been a pretty good report by the President's Council of Advisors on Science and Technology on this subject a while back:

https://www.healthit.gov/sites/default/files/pcast-health-it...

It did not place the blame on insurance companies. Which I think is correct. Insurance companies affect billing, but they do not drive health care records management. That's driven by an entirely different set of companies such as Epic and Meditech.

And the poor state of EHR in the USA is not entirely their fault, either. A lot of what went down is that universal standardization was not a major part of the requirements when the US government started requiring health IT. So health care providers decided to favor preserving their existing policies and procedures, which meant choosing extremely configurable EHR systems that allowed them to computerize their old paper-based systems with minimal modification. Since easy computer interoperability was never a design goal of those paper-based systems, it was not inherited by the EHR systems they grew into, either.

This creates a situation where even two Epic customers, despite being on the same EHR platform, are still hard-pressed to directly transfer records between their systems, and are as likely as not to still just fax or email each other printouts because it's easier.

And standardizing and perfecting insurance and billing would do nothing to fix this situation. The two systems are likely to be connected, but they are not the same thing.

[pjc50]

> The legislative failure has created vast administrative overhead (10, or more, staff per doc at a hospital) and corrupt insurance companies.

Other way round: the corrupt insurance companies have created legislative failure, through entirely legal bribery and entirely legal lying to legislators and the public.

Mind you, the public are hardly blameless in this, given that detailed careful policy wonkery is boring and yelling about grand conspiracies is far more exciting, many have chosen to indulge in the latter.

[labcomputer]

> They make their money on poor service and deceit -- charging wildly different prices for the same product where they can get away with it).

You have that backward. Hospitals and doctors charge wildly different prices for the same product when they can get away with it. That's why you can... wink, wink, nudge, nudge... pay a lower price in cash. Because the hospital knows a cash price means that you are paying the bill directly, not a rich insurance company. In economic terms, hospitals have economic power to set prices.

The elephant in the room is that medical doctors in the United States earn between about 2x and 4x (depending on specialty) more than medical doctors in France or England. Yes, two to four times as much. Where, exactly, do you suppose that extra income comes from? And that's when they're honest--medical claims fraud is a major issue.

You know those "this is not a bill" explanations of benefits you receive when you go to the doctor? Well... it turns out that a fantastic lead for finding medical claims fraud is when a member phones their insurance company and asks "Hey, I don't remember this... why does it say ____?"

Removing insurance companies from the equation will not radically change the landscape. The ACA set a lower bound on the medical loss ratio at 80%. That is, insurance companies must pay out in claims at least 80% of what they charge in premiums. Yes, some of that 20% is profit, but some is also intrinsic overhead for storing medical records, validating claims, etc. Do you think AWS lets France store medical records for free?

So France pays 50% as much as the US. Let's say we take out insurance companies and pretend that you can administer claims with 0 overhead in fairy-tale land. Now USians pay 80% as much.

Where did the other 30% go?

At worst, insurance companies are a second-order effect. The first order effects are that we pay too much for doctors (because the AMA is a cartel that limits access to medical school) and too much for drugs. Just look at how forcefully doctors groups have pushed back at state attempts to expand the scope of work for PAs and NPs (whose licensing is not under the thumb of doctors, and thus can't be restricted in the same way).

[paulmd]

Doctors have to be paid a shitload in the US because they come out of college with an average of $250k in student loan debt (for GPs, specialists are higher). Those other countries that pay doctors a half or a quarter of US salaries will generally be somewhere between "very small costs", "no costs", or "actually paying students to attend", leaning towards the latter two, so doctors don't graduate with a home-mortgage worth of debt.

However, a lot of people in the US are morally opposed to "giving someone else a free ride", you can see the current hubbub around student debt cancellation. And doctors heavily fall towards the higher-income side of the scale, so they are precisely the kinds of people that everyone points to as being undeserving of student debt relief.

It is what it is, Americans are a selfish (ahem, libertarians would say self-interested) people, but you can't make this cost go away. People may not explicitly state it, but their preferences are obvious, they would rather pay 4x the amount to a private actor than have 1x the cost in taxes, same as the rest of the problems with our health care system. People are more worried about micromanaging what everyone "deserves" than overall cost efficiency, and they vote accordingly.

It's rather sad, in a way, that Americans can't grasp that having a more highly educated, more skilled society benefits everyone in the long run. Those people go on to pay taxes, and educated people will contribute a lot more in taxes over their lifespan than they cost in education, it's a long term financial benefit, but people abhor the idea of someone getting "a free ride", despite it being the most financially vulnerable and unstable portion of people's adult lives. It's just straight-up "I chose to be a plumber, why should I have to pay for some fancy doctor's education!?".

[methehack]

Replying to my own post, but to the OP's point -- we can't research very well on US healthcare data in aggregate because it is so error prone and inexact to aggregate it. Data scientists should imagine what we could do with 20 years of la carte vitale data...or better of data in a regulated medical record format that was designed to be researched in aggregate. That's the second order failure here.

[nradov]

That is simply false and misinformation. A "loss" is just a technical term in the insurance industry generally. It doesn't mean that a medical insurer had money and then lost it. The Affordable Care Act (Obamacare) imposed a minimum 80% medical loss ratio.

On most policies the "insurance" companies aren't even providing insurance any more. They simply act as third-party administrators for self insured employers. So the insurance companies have no financial incentive to deny claims. In most cases where claim payment is delayed or denied it's because the provider organization failed to follow the rules for claim coding and attachments.

[clairity]

you're talking about singularized/centralized electronic medical records as if it will solve all the ills of the healthcare industry, especially the rampant corruption, but it certainly won't, and certainly isn't the reason for the differences with french healthcare. sunshine can only go so far. the root problem of healthcare, as with many american industries (e.g., education), is the lack of competition and (uncaptured) regulatory function.

and as with many gigantic, mult-faceted problems like this, band-aid solutions like centralizing medical records will do nothing (e.g., banning plastic bags) but distract us from the core hard problem. we need medical insurance, regulatory agencies, emergency services, care providers, medical training, pharma, medical devices, and a whole host of other interlocked industries to be subject to the pressures of a fair competitive environment, and we need to allow them to fail (and even punished) without that being life/career destroying (a crucial precept of our bankruptcy laws, incidentally).

spiraling costs and flagging care are a result of systemic rot, and it needs systemic solutions.

[gumby]

I read metehack's comment completely the opposite way: that a working records system is part of a functioning medical system and a consequence of a decision to have such a system.

In other words I interpreted the comment as making the point you make.

Having benefited from the French medical system (and having it treat my dad when he was visiting us) it's really quite good. People in the US (where I live) would laugh if they heard the way French people complain about their health care system: it's a dream by comparison. French complaints are like an American complaining that there is "too much room"

[clairity]

i mean, they focused on medical records as the core difference and referenced metrics to support that position.

it's true that functioning medical records could be a (small) part of an overall better and more efficient medical system, but it was positioned as the core solution that would unlock a better system overall. perhaps they had a different positioning in mind, but that wasn't the argument presented.

[robbiemitchell]

> They make their money on poor service and deceit -- charging wildly different prices for the same product where they can get away with it

This is the same thing medical providers and drug companies do. It’s price discrimination all the way down.

I often what would happen if medical providers (doctors, drugs, etc.) were REQUIRED to have standard rates published that didn’t fluctuate by insurance network or type of insurance plan.

[shigawire]

Hospitals would not get paid enough and many would go broke.

Now if you coupled this with a single payer then it could work.

[yung234]

A rational strategy would be for America to fund ML medical research in France.

[paulmd]

as someone who worked in this area (not ML on records, but aggregating and ingesting EHR/ELR data) the problem is not just "the standardized record" but getting providers and hospital systems to use the record in standardized ways.

HL7 and FHIR are sort of like XML or CSV - they're just formats that define fields and delimiters. You can still emit HL7 or FHIR that can't really be consumed by anything else, and there's a huge amount of work to getting it "right". One of our perennial projects was a validator tool to help onboard facilities to produce data that was actually compliant with state/CDC systems. Unsurprisingly, from memory (that wasn't really my direct fief) basically every single system (from memory it was something like 80% of attempts) failed their first couple times and needed hand-holding to get it right.

https://fhirblog.com/2014/03/28/pictorial-representation-of-...

One of my projects was integrating a clinical recommendation tool with various EHR systems. That project didn't really end up going anywhere, but even just from the sample data being used in the various sandboxes I could tell that it was gonna be a massive slog actually getting it onto client systems, because every single client system was coded differently and there was different "quirks" to the data/etc. Fixing that wasn't really my task, just dealing with it, but the point is that even if you define a system that allows these relationships/etc to be expressed, there's no guarantee that a client system is outputting well-formed, properly normalized/denormalized data. It's rough.

And unfortunately it's 1000% a XKCD "there are 14 standards and systems still can't intercommunicate, we need a 15th standard" effect. There is already so, so much work mapping around between the various editions of ICD, CPT (procedures), and usually there are instance-specific (specific to the hospital system usually) coding systems underneath that (since in many cases eg CPT does not really convey enough information about the exact specific procedure - it's enough for billing but not enough for a radiologist to actually know what scan to perform in a medical sense). And the existing coding systems are already super generic and can express basically anything in multiple ways, which just feeds into the "it's possible to emit valid records that nobody else can really consume" problem.