Healthcare is not a free market

From the obvious department, amIright? Yes, but not for the reasons you think. Healthcare cannot and never will be a free market. There are several reasons for this that I will elaborate on here.

Healthcare consists of micro-regulation in the form of the reimbursement structure. This is an artifact of two different systems combining to make things worse. First, because the Federal Government is big and has two different programs one for Federal Employees and one of those in need Medicare/Medicaid (I’m combining them here for simplicity), there’s also the VA, but that has much less influence on healthcare. These two programs set the terms on how the government will reimburse or even pay providers for care provided. These are based on Current Procedure Terminology (CPT Codes) and not based upon your diagnosis. Essentially the government sets a price they are willing to pay for a procedure. As one of the largest market players, this influences all of the other payers (IE insurance companies). Many insurance companies use Medicare payment rates to set their own, which drives down the cost of a procedure to the point, in many cases, where it’s below the cost of the actual care. This drive providers to select more expensive and more procedures in many cases to make up the short fall. This payment model also makes it hard for new procedure methodologies to be adopted as they may not be paid for.

Healthcare is a network economy – nearly all care happens close to home. This is why groups like the ACLU argue that driving more than an hour for an abortion is an unnecessary burden on women. Because of the proximity of the majority of care (10.2 miles) this creates a local network of care based on the original provider a patient sees. When you receive a referral, there are a few different routes this can go, best doctor the the referrer knows, another doctor in the same clinic, or in the same care network (such as UPMC in Pittsburgh or Kaiser Permanente in CA). This drives an incentive to send patients within the network leading to mutual referrals or money staying within that care network even if there are better doctors for that specific patient outside of that care network. In addition to the Doctor’s network there is, of course, your insurer’s network which may be in direct conflict with the professional network that your provider has.

Imbalances of knowledge – in typical free markets there’s an assumption that everyone has the same amount of knowledge. In Healthcare, it is abundantly clear that this isn’t true. Most patients have little to no understanding of their diseases when they are first diagnosed. On the other hand, both their insurer and provider has an extensive knowledge of the disease. This limits how well the patient is able to correctly make decisions about their healthcare. It also pushes reliance to the provider whenever there is a disagreement between insurer and provider. The member can’t effectively participate in those conversations about care. Furthermore, there maybe little penalty to the patient if they fail to follow the prescribed course of care until much later where neither the insurer or provider can enforce a change of behavior to reduce costs for the entire system now through treatment rather than later when there are more complications.

These are but three cases that highlight the lack of free market mechanisms in healthcare. Even in cases where a patient wants to seek the best care it’s typically the patient’s responsibility to pay for it if it’s not with in the insurer’s network. In many cases these clinics can reduce systemic costs through lower point of care and lower likelihood of readmission after care.

Over the course of the next few weeks I will discuss Exchanges and their potential, how healthcare can be made more affordable using process improvement tools and other mechanisms. I plan on writing weekly on healthcare. If you have any topics that interest you please comment and let me know!

Unintended consequences of knowledge management regimes

There are several consequences of the differences between the US (and the west) and China (and other autocracies). First, with one of the major assumptions of neoclassical economics out the window, it calls into question basing economic policy on neoclassical economics. Second, with a monopoly structure for intellectual property several different economic incentives have been created. Finally, the differences in IP management between the countries creates tensions at several different levels. I’ll discuss each of these points in more detail.

First, if one of the major assumptions for economic policy includes non-rival, non-exclusive knowledge, it’s difficult to understand why there isn’t more competition in many markets. However, as we know it’s not really possible for any firm to pick up any sort of technology and start to produce a given product. Because of this difficulty regions and areas tend to become experts at specific types of technologies. However, even in the case of China the freedom of access to IP makes it easier for firms to produce specific products. The problem still lies in the fact that you still need tacit knowledge to actually make the product. A patent is supposed to give you the information you need to produce the technology. However, the actual patents are difficult to read and not likely to be possible

Second, with a monopoly structure in place for intellectual property it gives very different incentives for owners of intellectual property. First, for people who actually produce a product, attacking products that are similar for infringement can be a very lucrative proposition. It prevents other companies from becoming competition. Apple is currently using this tactic to go after Android through Samsung and HTC. With a full monopoly technological progress can actually come to a standstill. An example of this is with Xerox copiers. With the monopoly in place Xerox did not innovate and kept prices extremely high. As soon as their patent ran out the competition came in and almost took all of the market share from Xerox. They introduced lower priced products and a wider more personal product range. Without the monopoly in place other companies could try to move into the market space earlier and drive innovation from the beginning of the market.  Finally, with reduced ownership of IP there will be less patent trolls like Intellectual Ventures.

Third, the IP management is causing issues between firms and the Chinese government. The firms do not want to give up their IP because it’s how they are able to make their money. Some of these technologies are so easy to copy it’s impossible to make a profit without protection. In theory pharmaceuticals should be perfectly copyable based on the chemical properties of the drug. If the pharmaceutical companies didn’t have a chance to recoup the investment on a drug (500 million – 1 billion per drug) there would be no innovation. The differences present problems for trade and agreements between countries. The US and China have had serious disagreements over how IP should be managed.

Basically, the differences in how IP is understood impacts a countries policies economically and in trade. It is important to understand exactly what’s going on with these issues. Our governments are pushing for different levels of control over IP both in patents and other forms of copyright. As some one interested in policy, it’s important to understand what types of policies we should be pushing for. I don’t think there’s any true right answer for the IP problem. In different situations policies should be adjusted. We cannot have a stagnant IP regime when technologies are evolving as fast as they are.

Are democracies or autocracies better with technology Management?

According to neoclassical economics knowledge is a non-rival (I can use it without preventing you from using it) and non-exclusive (available to everyone) resource. This has two impacts on their economic theory. First, the actual impact of research and development is excluded from economic growth and is ignored. Second, that any company should be able to pick up and produce any technology. Both of these points are relatively ridiculous. For two reasons. First, we know that research leads to the formation of new companies. Second we know that most companies cannot produce any product and many companies that produce products outside their expertise fail at it.

From a neoclassical perspective democracies are terrible at sharing knowledge and technologies. Democracies have a slew of laws that regulate access to technology form monopolies for specific technologies if they have something called a patent. Additionally, there are other contracts that can get in the way of sharing of knowledge in a way that is neoclassical. Non-disclosure agreements and non-compete clauses. If you aren’t allowed to discuss a specific technology with other people, it prevents knowledge from spreading and being shared to other companies. If you aren’t allowed to compete within the same industry after you leave a company, it prevents you from using that knowledge in a positive way at another firm.

These laws have been put into place in our democracies to ensure proper protection of technologies for firms. It’s designed to prevent the spreading of tacit knowledge from company A to company B. As a company this is incredibly desirable. Without these protections some research would be worthless to conduct. Knowledge spill-overs would cause prices to fall to cost or lower as firms compete for market share. It’s great for consumers, but bad for firms.

So what happens in China? Well according to Make it in America, China requires many firms to hand over their Intellectual Property to the Chinese state. What ends up happening after this is that the Chinese government sells the information or gives the information to one or more Chinese company. These companies tend to be made up of former employees at the company that made the product before. This allows tacit knowledge transfer to the firm and a fast ramp to compete directly with the inventor of the technology. The knowledge is freer in China than it is in the US because of this. This increases competition and may be impacting the cost of goods like solar panels.

In a way this type of behavior forces companies to compete based on the actual costs of the technology. This is what is expected in the neoclassical theory. All prices will eventually drop to the marginal cost of a product with near zero profits for the producing company. In a perverse way, this is a “freer” market than ours because it comes closer to the non-rival non-exclusive knowledge base.

In my next blog, I’ll discuss this topic more.

China, Technology and creativity

Sorry I’ve been away for so long. I’ve been hanging out with my Awesome wife! She gave a talk in Ireland, which I went to for most of a week. It was a good time. She then came here to Eindhoven for a week and had an interview. So that’s why I haven’t been updating. Sorry faithful readers.

At a party on Saturday, I got into a fairly active discussion with 4 PhDs and myself. They are all engineering PhDs, so they understand research and how technology works rather well. We got into a discussion on if China was going to actually really over take the US in scientific research. I said I think it’s likely, but there were many arguments against that likelihood. I didn’t really get to finish my argument on why it’s possible. So, I’m going to do that now.

Basically, some of the core arguments against China being able to overtake is us lack of creativity. China is a country of followers, not a country of creative leaders. Another argument was the lack of high quality education and research centers in China. I’ll address the second argument first and then discuss the first argument.

Americans know that we educated a lot of foreigners at our universities, 2008 was an all time high for the number of international students. In fact my roommate at one point explained to me that one of the groups at the University of Texas was comprised entirely of Chinese students. They conduct their meetings and research all in Chinese and, in fact, leave the US speaking worse English than when they arrived. But why are they leaving? The link above notes that there simply aren’t enough H1B Visas or green cards for them all to stay. Effectively we’re throwing out the people we educate. Over time enough good scientists and engineers will be sent back and will start teaching in China. China has big ambitions and has been creating universities as fast as it can. Using an evolutionary perspective, we can see that it’s likely they will continue to create variation and students will be selecting the best universities. One of them is likely to start producing more science and better science than another. This will lead to the best students and best researchers going to that school. One or two could become the Chinese version of MIT, Berkeley or Harvard. I think it’s clear that education won’t hold them back. Eventually, they will have several universities in the top 200 list according to the Times Higher Education ranking.

The second argument is a little tricker to argue against. The Chinese aren’t creative enough to create radical innovations. First, I’m sure that the Chinese I know would object to this blanket statement. However, let’s assume for the moment that’s it’s some what correct. There’s a culture that doesn’t reward creativity and rewards conformity. I can think of two countries that have similar types of culture that have been creative and are excellent centers of research and innovation, Japan and South Korea. Now are they as good as the US at innovation or research, No. However, they have had some great innovations and do great research.

When it comes to patent research there’s something called a Triadic patent. It’s a patent that is filed in the US, Europe and Japan. Europe and Japan have higher standards for patents than the US and are more difficult to acquire. Why does this matter? Well effectively Japan is the only country in Asia that would fit better with the European countries in terms of GDP per capita, protection of IP and research.

Both South Korea and Japan have a few companies that are on the leading edge of their respective fields. Samsung is in a huge number of different areas and is the world leader in many of them. Japan has Nikon, Sony, Toyota and a few other big companies that are on the cutting edge in research, design and innovation. So, I don’t accept the argument that the Chinese couldn’t be creative.

Another point I was trying to make, is that over time as a country becomes the center of manufacturing and incremental innovation on a product, it’s likely that they are going to be able to create the next radical innovation in that field. There are two things that support this. First, in a book by Andrew Liveris, the British CEO of Dow Chemical, there is anecdotal evidence to support bringing manufacturing back to the US along with the R&D that goes with it. The other argument is based on the research of Cesar Hidalgo of MIT that shows through network theory, that to become a leader in technology you have to build your way through a series of other technologies. It helps explain why it’s so hard for countries to pick up creating semiconductors. However, as a country develops the technological capability to work within a type of technology they are likely to create innovation and changes in that technology.

China has effectively been given the ability to manufacture just about everything through outsourcing. They have the technological capabilities to build and design new technologies. China also has the resources devoted to it. They created a five year plan where they are going to invest $1.5 trillion in 7 science sectors. Because of these factors I believe that China is a real threat to US and European leadership in research and technology. For any one to dismiss China because of cultural reasons or technological capabilities is making a mistake and is likely to be surprised in 20 -30 years when China becomes a leader in at least one field, likely more than one.

Ubiquitous free high speed wireless: Society

This is the last post I discussed the impact on the computing industry of ubiquitous high speed free wireless internet. In this post I’ll discuss some of the societal changes. In some ways the societal changes may be smaller, at first, than we’d anticipate.

First, we’ve seen how much people have jumped on playing with their phones in public spaces. I fully expect this trend to continue and in fact to increase. Simple to play games like Angry Birds will become more advanced and will likely look better. People will do more work on their phones and will likely begin using video calls in public. Which will be annoying, but it’s going to happen.

There may be a wave of apps that will try to increase the amount of social interaction of players. This doesn’t mean that we’ll have an increase of in person social interaction, but will likely be an increase of virtual social interaction. Which for some people is significantly better than what would happen otherwise.

I think that the ubiquitous internet will have a mixed impact on the ability to do work. As it is a lot of people already spend a great deal of time working from home off the clock. This will likely increase, but I think there will be a trade off. As people will, hopefully, be able to work while commuting more easily on trains and buses. People will begin to work in more places like cafes compared to the amount that currently do.

There will be other changes as new devices and applications are created to take advantage of the high speed internet. Many of these changes will happen as these devices are developed.

I would like to be completely optimistic that the greater the amount of internet will lead to a larger amount of user created content. That the increase of wireless internet will increase personal engagement in political and social activities, but I don’t think it will. I think that there will be a small increase because there will be a larger number of people that weren’t able to do it before are able to do it.

I think that a high percentage of engagement in social networks, content creation and other types of engagement will take some time to occur. I think it’s because of a mind set. A lot of people have no desire to become involved in these types of things. I would like to imagine that these changes will happen over night. However they will not. People will need time to understand how to exploit this infrastructure. It will take time for unique social experiments to develop using the network. Some people will understand immediately how to create new tools for the new environment, but it will take many established firms time to fully exploit it.

It will also take people time to adapt to the change. It’s not obvious in what ways the average user will exploit this technology. In many ways it will just increase the amount of general web browsing going on, in other ways video viewing will increase as well.

In this series I’ve looked at how our government, business, computer and social environments will change based on ubiquitous free wireless internet. It will have immediate changes and longer term changes that currently fall into the realm of science fiction. Device makers and app developers will have a new world to exploit because of increases in computing power locally and remotely. Creating novel methods of using this power is what will drive the next phase in our economy.

Ubiquitous free high speed wireless: Computing

In my last two blogs, Government and Business, I’ve discussed some of the impacts on our society of ubiquitous high speed wireless internet. In this post I’ll look at the future of the computing industry. I think that this industry will go one of two ways, or perhaps both at the same time. The first route is obvious and is already happening, the second route will probably begin as a backlash to the first route.

The obvious route is cloud computing. As I’ve said we’re already going down this route. The best example of the speed of this transformation is the Amazon Kindle Fire (all three different links). Basically, we will be using less powerful, but still growing in abilities, equipment and pushing the more processor intensive applications out onto a server in the cloud. This will most likely be owned by some private organization. Amazon’s Fire is a great example of this because it provides the ability to browse websites at a much faster rate than what’s allowed under current network speeds. Even with high speed internet this may continue because it’ll fit the website to your screen and make it even faster than over the high speed network.

However, many people are skeptical of cloud computing. There is a sense of a loss of ownership. You become locked in to a specific firm to provide the required services. End User license agreements change frequently and your true ownership of the data and information you place on their servers can change unexpectedly and in ways that aren’t in the favor of the users. Additionally, it’s been acknowledged by both Google and Microsoft that all data in their cloud servers are subject to the US Patriot Act. This raises privacy concerns for the EU and firms using cloud services.

I think that these concerns will drive another type of cloud computing. I think it’ll be something like a personal cloud. It will be similar to working with both a desktop and a laptop at the same time and remoting into the desktop from the laptop, but it will be done seamlessly and transparently. The ownership of the data will be clearly yours and the power will effectively take a phone or low power table and turn it into a fully powered desktop computer. This way the cloud won’t be out there and will be easily controlled by the end user. You don’t have to worry about the Patriot Act or a company going under, changing rates and other issues like that.

Both of these changes will create disruptive changes within the computing industry. The Kindle Fire is on the cutting edge of this. I fully expect Amazon to create additional applications that will run on the Amazon cloud system. There’s no reason not to expect this. It will shift how apps are developed. It will also change who is in the game of creating computers. Dell, for example, will continue to have a major hold over both servers and personal computers, however as we move away from laptops to tablets and phones over time Dell is going to fail in this market. They have been unsuccessful at every attempt to enter these markets. There will be a shift in the players in the market.

These systems will only work with ubiquitous internet connection. They will become more effective as the network speed and capacity increases. Users will become more willing to use the systems as the reliability of the systems increase.

In my opinion these changes will fundamentally change the way that we look at computers. The way we interact with computers and how we feel about the usage of computers. Today they are everywhere, but in the next few years I expect them to become more prevalent as we are able to offload high power demanding applications off of our phones and onto powerful servers.

In my next blog I’ll discuss some overall societal changes.