Shop around and see what others are offering. I believe your anecdote, and I've also seen several other anecdotes about how rents have dropped - someone said as much as $1k.
Someone should try this with medicine. Instead of subsidizing insurance (demand side), let’s spend the money to bring doctors to the USA from all over the world and have them work in free clinics (supply side).
Good luck getting the federal government to stop doing what the unio..., I mean, what the American Medical Association and representatives of the nation's medical schools ask for.
Not just residency. Fix the cost (and capacity) of the education system as a whole, especially for mid-levels. There’s no reason this country should have such a chronic NP shortage, and you don’t need MD/DOs for most of the healthcare gaps we have.
You also make rural care viable when you don’t have folks who need to pay off astronomical loans.
How are NPs not just the trend of enshittification? Most doctors already aren't very engaged in the tiny 15 minute slices of appointments, and now we're supposed to be happy that they'll be even less educated? The most straightforward way to address the doctor shortage is to make it so doctors are spending most of their time on healthcare, rather than appeasing "insurance" company bureaucrats with onerous paperwork.
What an oddly personal reaction. Did you get bored of infosec or something?
Being HN, we're talking about systems and cohorts, not individuals. I've had some great individual NPs that were more actively engaged than most doctors. PAs as well. And I've had plenty of crappy MDs just phoning it in. But none of that is really relevant to the system meeting higher demand by simply lowering its standards rather than actually being reformed.
Finding good (and available) primary care providers has always felt like going to the casino in my experience. Currently seeing an older NP who has been great. I could see a future with many more NPs. Obviously, if you know a guy or need a specialist, then do what makes sense.
What a weird comment. What do you think you need an MD for, in your primary care visit, that an NP can’t do? What do you actually know about their education? What do you actually know about licensing? How much time, in a day, do you think doctors are spending on “insurance”, and what specific experience leads you to believe that?
(Because the actual answer is “near zero for literally any provider who isn’t completely independent, and almost none of them are, anymore”.)
Or was this just a way to memetically add “enshittification” to a conversation it doesn’t even slightly apply to, but you think that’s currently trendy?
You can be an NP in as few as 4-5 years out of high school with some courses. That’s to me the definition of not knowing what you don’t know. I’m a critical care paramedic who has corrected many NPs on fairly fundamental learning.
I’ve found that nurses with significant field experience do very well, but there are plenty of courses who will “zero to hero” you fresh out of high school.
Meanwhile, PAs go through a program near as rigorous as medical school and have to have physician supervision while NPs are not subject to oversight.
Doctors begin delivering clinical care in year 3 of med school. You're doing a sleight of hand with this "out of high school" thing; doctors are also educated "out of high school", the difference between the two roles is 1-2 years before clinical practice, and NPs tend to practice supervised for longer periods of time than doctors.
And, obviously, NPs cover a smaller range of conditions than doctors.
There's accelerated pre-med too! My point is: it's all "out of high school". High school has nothing to do with any of this, but you mean to attach that term to NPs, as if they were in home ec last week. No, that's not at all how it works.
Sorry, this is fundamentally incorrect. To the point I can only assume you’ve made up every other thing you’ve said. Though I’m fascinated by a paramedic having opinions on someone else’s medical training.
The world would be better if we had less strident opinions on things we know we don’t know anything about.
If you want to be pedantic, then everyone has oversight through medical licensing boards, including physicians.
But if you mean "supervising physician"? Then let's see:
* Alaska - Full Practice Authority (NPs can perform the full scope of practice without a supervising or collaborating physician.
* Arizona - Full Practice Authority (NPs can perform the full scope of practice without a supervising or collaborating physician.
* Colorado - Full Practice Authority (NPs can perform the full scope of practice without a supervising or collaborating physician.
We're six states in, and half have no requirement for an NP to have any supervision from a physician.
Let's keep going though:
Connecticut, Delaware, DC, Florida, Guam, Hawaii, Idaho... zero supervision required. At this point I couldn't be bothered going through the list. This list, from the AAFP telling physicians about their responsibilities in supervising NPs state by state: https://www.aafp.org/family-physician/practice-and-career/ma...
So to put that back on you, explain my fundamental incorrectness.
And again, if you're talking about DOH oversight, then that seems a little disingenuous, as even the Chief of Medicine at a Level 1 Trauma Center practices under that insight.
I'm very well aware of the limitations of my scope of practice. That's why I operate under online and offline protocols. But hey, maybe I should have done another year or two of school so I could have a "full scope of practice without any need for a supervising physician". Not sure the ad hominem has any relevance.
Okay but what does that have to do with enshittification, as defined by Cory Doctorow, which refers to the decline in quality of online platforms and services over time, often driven by the pursuit of increased profits. This degradation is characterized by a shift in focus from user experience to maximizing revenue, typically through tactics like increased advertising, higher costs, or changes that favor business customers at the expense of users.
Or do you just like how the word has shit in the middle of it and are using it incorrectly?
> The fact that a neologism is sometimes decoupled from its theoretical underpinnings and is used colloquially is a feature, not a bug. Many people apply the term "enshittification" very loosely indeed, to mean "something that is bad," without bothering to learn – or apply – the theoretical framework. This is good. This is what it means for a term to enter the lexicon: it takes on a life of its own. If 10,000,000 people use "enshittification" loosely and inspire 10% of their number to look up the longer, more theoretical work I've done on it, that is one million normies who have been sucked into a discourse that used to live exclusively in the world of the most wonkish and obscure practitioners. The only way to maintain a precise, theoretically grounded use of a term is to confine its usage to a small group of largely irrelevant insiders. Policing the use of "enshittification" is worse than a self-limiting move – it would be a self-inflicted wound.
lol damn well I can't argue with the man who created the term! Still, it seems anti-intellectual to want words to have specific meaning and nuance and flavor, and for people to want to be able to have a common dictionary in order to have elevated discourse.
In the days before the Internet, there was only space for a 30 second soundbite and that was the level of discourse. These days, we have Twitter and Substack, so there's slightly more nuance available to us (only slightly), and I'd like to think the "normies", as you put it, are smarter than you think, and are capable of nuance.
To be clear here, as the person who originally used the term in this thread, in light of your grandstanding about "anti-intellectualism" - I did use the term for its general connotations, not just to mean "bad".
The healthcare industry is obviously not an online platform. And I would say it's being done to "lower costs" rather than "raise profits" (the two are often related, but not the same). But other than these, it strikes me as the same basic dynamic in a different industry. I spelled it out in a different comment:
> 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
The thing with online platforms is that they are new and fresh having been built out of whole cloth by subsidizing investments, allowing for multiple discrete enshittification steps as management focuses on one area after another. Doctorow:
> This is enshittification: surpluses are first directed to users; then, once they're locked in, surpluses go to suppliers; then once they're locked in, the surplus is handed to shareholders and the platform becomes a useless pile of shit.
Whereas the healthcare industry has been turning the screws for years. Now it's just an environment of making things worse wherever new ways to "control costs" can be created.
It's not a question of if you are in the healthcare industry, but rather when you will be in the healthcare industry.
I too am not gainfully employed by the healthcare industry. I have just advocated many times for multiple family members. With the reflective hacker/systems mindset I've become painfully aware of the system's patterns of failure.
> 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.
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"
- The multiple times I've seen a doctor personally step in to grease the system for something way way below their pay grade, because it was the only way to provide appropriate health care
I'm sure I'm forgetting plenty too. Frankly I don't know how one could step into any moderately sized medical provider and not perceive the entrenched corporate government tentacles in every facet.
There are NP mills that will take you from high school, put you through an accelerated RN and prereqs and basically have you as an independent provider in just a few years out of high school (well, 4-5), that’s ridiculous.
You basically can’t or it won't have the same effects because medicine doesn’t really follow the same dynamics as most other markets: the supplier (doctor) has an information asymmetry and thus makes most of the decisions, while the buyer (patient) is not usually the payer (insurance) so aren’t really incentivized to save.
> the supplier (doctor) has an information asymmetry and thus makes most of the decisions, while the buyer (patient) is not usually the payer (insurance) so aren’t really incentivized to save
Counterfactual: patients in India routinely shop around for second opinions and negotiate fees.
Completely fair point. I should have prefaced my statement with US based healthcare system is structured this way. I don't know how the dynamics are in other countries -- though I do suspect it's similar in term of information asymmetry. I imagine doctors everywhere have some pretty advanced and specialized knowledge. I don't know enough about India to know how they overcome this issue or if they do or not.
Fixing a severe shortage is actually likely to have some impact.
For instance, if there's a lot more doctors, the payer may be able to negotiate lower prices. We already have insurance mechanisms that drive patients to the providers that the insurer has negotiated with...
But then you're just shifting the cost somewhere else. The doctors aren't working for free. Someone is paying them. It's just not the patients in the case of free clinics.
In addition, doctors aren't the only cost centers in health care either. Even if they're free, which is sort of already the case or fairly inexpensive for the insured in the US, the overall cost of healthcare will still be high.
Plus if you want completely free clinics (everything from doctors to medicine, etc), then you're not talking about a market solution to the issue, which is completely fair too. No one said you have to use a free market solution for this problem.
My point is that we can't expect a free market to solve this issue. It isn't as simple as supply and demand.
Giving people insurance without actually increasing the supply of doctors or clinics increases the number of people willing and able to seek treatment. It does nothing for lowering costs of said treatment. Per basic economics, that’s shifting the demand curve (i.e., increasing demand).
With no changes to supply that leads to higher prices. So every time the government makes a new program or expands anny existing one that provides insurance coverage, costs for everyone will go up.
In contrast, my proposal for explicitly bringing in doctors and creating clinics increases supply. People who would have gone to see a doctor elsewhere may now choose to go to this new free clinic.
The demand curve itself would not change, though with the lower cost due to the supply curve shift you would have a larger overall market.
This is clearly oversimplified. There’s some second order effects where if primary care market increases, you’ll need more X-rays and CAT scans. So there could be an increase in those prices. But that’s could be solved in the same way too.
I think you’re still missing the point - it’s NOT classic supply and demand because the mechanism by which that works is prices, and in many healthcare markets including the US — the buyer isn’t the payer, and shortages lead to rationing (via wait times) rather than increased prices, so often increasing supply doesn’t change prices even as it increases aggregate costs (because there’s still excess demand and rationing).
For this argument to work you have to believe that decreasing the price of service delivery wouldn't decrease the price of health insurance. Provider costs dominate US national health expenditure, like it's not even close; it's not a full order of magnitude difference but it's close to one.
But part of the provider cost is driven by the availability of money to pay, which is part of the reason why drug costs are so much higher than in the US. For example, the doctor has no strong incentive to prescribe less costly drugs since they don't pay. The patient don't know any better and aren't the payers either. The insurance has some control over what they will pay for and how much but except for some cutting edge treatments, it is very hard for them to say no. This is part of the reason why insulin in the US is so expensive and why drug companies advertise to doctors and patients, etc.
I think in countries where the health care costs aren't as astronomically high as the US there is some form of government intervention to distort the market. And the original post is more or less arguing for a market distortion that doesn't rely on simple price signals to bring costs under control. But that is very different than what has happened in Denver's housing market.
Drug costs are also a small percentage of the national health expenditure, which is dominated by procedures delivered in hospitals and outpatient clinics. I don't accept the logic you're using for drugs, but we don't reach that question until we figure out why the single largest health expenditure in the United States has no impact on health insurance costs, which are the primary way Americans interface with the health insurance system.
If that expenditure does impact health insurance costs, then the rebuttal given above about increasing the supply of doctors not improving affordability fails.
If you google [National Health Expenditure spreadsheet], there's an annual spreadsheet that has includes an incredible amount of detail about where we spend money, broken down in a variety of different ways.
> For this argument to work you have to believe that decreasing the price of service delivery wouldn't decrease the price of health insurance.
I think we are talking past each other. My argument is not that lower prices for medical services wouldn’t lead to lower insurance costs. My argument is specifically that increasing supply doesn’t necessarily lead to lower prices for medical services. It would be quite a finding if US cities with more doctors per capita have cheaper medical services but if anything the opposite is true
It has, but in an accidental way, in a, "Shit happens," sort of way, not in a, "My parents looked at me, decided I was faulty, and never gave me a chance," sort of way.
This is much more akin to the old practice of leaving babies to die by exposure if they seemed sickly/weak, which still turns my stomach.
I think it would even be a different thing to me if we were screening sperm and ova for their genes and only combining the best sets than screening the embryos.
> Does anyone else think the fact that companies hire superfluous employees (i.e. bullshit jobs) is actually fantastic?
I do.
It's much more important that people live a dignified life and be able to feed their families than "increasing shareholder value" or whatever.
I'm a person that would be hypothetically supportive of something like DOGE cuts, but I'd rather have people earning a living even with Soviet-style make work jobs than unemployed. I don't desire to live in a cutthroat "competitive" society where only "talent" can live a dignified life. I don't know if that's "wealth distribution" or socialism or whatever; I don't really care, nor make claim it's some airtight political philosophy.
> It's much more important that people live a dignified life and be able to feed their families than "increasing shareholder value" or whatever.
its just my intuition, but talking to many people around me, i get the feeling like this is why people on both "left" and "right" are in a lot of ways (for lack of a better word) irate at the system as a whole... if thats true, i doubt ai will improve the situation for either...
I think the more optimistic interpretation would be that companies eliminating bullshit jobs would provide signal on which jobs aren’t bullshit, and then individuals and the job prep/education systems could align to this.
That’s very optimistic! I don’t fully agree with it, but I certainly know some very intelligent people that I wish were contributing more to the world than they do as a pawn in a game of corporate chess.
First, let me say I'm glad the FTC is going after monopolies. True capitalism requires competition, not massive corporations.
That said, I feel like going after Big Tech is a massive misuse of resources. Not because it's not a monopoly (it is), but because there's a far more important monopoly that should be broken up: healthcare insurance.
Something like 7 corporations dominate 70% of the healthcare insurance market. The AMA had a study last year that concluded these insurance companies are charging monopoly pricing.
This is why Americans are paying astronomical prices for healthcare.
This is IMO by far the most pressing issue. Yet the FTC is seemingly spending all its time going after Big Tech, which has a comparatively lower impact on the quality of everyday Americans' lives.
I don't really see how that's possible. They are prevented by law from charging more than 25% on top of what they pay out to medical providers. The problem is the providers who are represented by the AMA.
This relies entirely on market concentration and doesn't even bother to address the legal cap on premiums enacted in the ACA. I expected it to be trash because it is written by people who have every incentive to try to blame insurance companies and I was correct.
