The US has the highest per-capita cost of medical services of any nation. At the same time, average life expectancy has been going down. What can be done to reduce costs while at the same time improving our health?
Change won’t be easy. There is a monopoly of providers, health institutions, insurers, pharma, regulating government agencies; all of them want to increase their power and business. The medical-industrial complex is a growth engine. Worse, most people accept the medical doctrines (marketed as science) that underpins this power. While much can be done to improve costs and outcomes without challenge to medical doctrine, the best results can only be achieved by taking a fresh look at medical givens.
When you want to make big changes to something as large, powerful and complex as this, incremental change is nearly impossible. It’s like the world of business in general: innovations are primarily made by small groups of motivated people who give birth to the new approach. This pattern has lasted for many decades. It's even tougher here because of the interlocking monopolies.
At a high level, the overall ways to change are these.
Zero-based re-engineering
This is a fancy way of saying, imagine you were starting from scratch: no assumptions, no nothing -- what would you do? Even in a supposedly fast-moving field like software, there is at least a 10X difference between doing things the “standard” way that professional managers require and the optimal way. The gains in medicine and health could be at least as large.
https://www.blackliszt.com/2015/10/secrets-of-software-super-developers.html
Here's a specific example of zero-based re-engineering for 10X gains.
Automation
Automation is the proven path to quality improvement and cost reduction. The principles have been established for centuries. Automation is why food production took 90% of the population at the time of the founding of the US, and less than 1% today. A key part of automation is that work organization, job requirements and skills are re-thought from scratch. Otherwise, all you're doing is "paving the cow paths."
https://www.blackliszt.com/2020/01/the-fundamentals-of-computer-automation.html
Automation of clinical decision-making
This is an essential aspect of automation that is strongly resisted. It has been a central part of general automation ever since Jacquard looms were driven by cards centuries ago. It directly addresses the always-incomplete knowledge in doctors’ heads and enables vast expansion of personalization and accuracy.
https://www.blackliszt.com/2025/01/ai-can-automate-what-doctors-do.html
https://www.blackliszt.com/2016/12/what-can-cats-teach-us-about-healthcare.html
https://www.blackliszt.com/2020/01/luddites.html
In-old-vation
The medical world claims to support “innovation.” This is propaganda. The fact is that the vast majority of effective innovation has been proven in other domains for a long time, and “just” needs to be adapted. I tell the story of how an innovation that transformed the management of oil refineries in the 1960’s began to transform the management of medical operating rooms and infusion centers more than fifty years later.
Data-driven evaluation of treatments
The medical system brags about “evidence-based medicine,” random controlled trials and the rest. But the fact is that the vast majority of spending and treatments are not backed by solid data, and huge parts of standard practice are proven ineffective and/or harmful by data. Anything that is done should be tracked by a continuous feedback, closed-loop system that includes patient input.
https://www.blackliszt.com/medical-science-research/
Regulation
While often well-intentioned, government regulation drives up costs and stifles innovation without improving quality. The FDA has a staff of lawyers and bureaucrats writing mountains of regulations that spell out in voluminous detail how software should be written, for example. This stifles innovation and drives up costs dramatically for medical devices.
https://www.blackliszt.com/2016/12/regulations-that-enable-innovation.html
https://www.blackliszt.com/2023/01/how-to-reduce-the-cost-of-medical-imaging-and-pacs.html
A similar concept applies to drug development.
https://www.blackliszt.com/2017/01/using-software-methods-to-speed-drug-discovery.html
Education and credentialing
Practice licenses and requirements sound reasonable, but in practice they are a way to enrich the relevant organizations and restrict supply while keeping prices high. Example: why should a person who performs a specific kind of surgery require an MD and 5 or more years of further training? Why isn’t performing a breast lumpectomy like being a phlebotomist – an important job that requires physical skills and must be done correctly, but only requires weeks of training and then apprenticeship? This is a huge subject.
Optimize the system for maximizing patient health
You'd think would be obvious, but it's not. Today, the growth and profitability of the participants in the medical-industrial complex are optimized, in spite of many individual providers sincerely trying to optimize patient health. For example, the essential data in the EMR is owned and operated by the medical system. Yes, they sometimes provide interfaces for patient access, but it's clearly theirs.
https://www.blackliszt.com/2016/01/i-want-an-emr-app.html
Conclusion
The medical system has achieved some amazing things -- just take knee replacements which are now routine but unheard of by earlier generations. The trouble is it has grown into a multi-faceted monopoly that grows endlessly while the patients take ever-more drugs and submit to ever-more procedures that have the net effect of making us pay more to live shorter, less healthy lives. While the defenses of this castle are tall and thick, the peasant/patients who serve the masters inside the castle walls have got to find a way to create a revolution, helped by the growing number of disaffected medical professionals. The nightmare anti-scientific response to covid has sparked doubts in the minds of many. When are we going to storm the Bastille?
PS: Here is a complementary earlier approach to these ideas.
https://www.blackliszt.com/2015/12/healthcare-problems-and-opportunities.html
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