Operation Occupy Wall Street

[Timex]

Because why? Efficiencies of scale would make the whole thing too cheap?

Not everything gets cheaper and more efficient when they get larger.

[CLWheeljack]

Not everything gets cheaper and more efficient when they get larger.

Typically for health cost purposes, bigger is better though. Larger risk pool, etc.

Timex, I don't want you to think I ignored your last post. I read it in full, and I think we're pretty much in agreement. There's a lot of really interesting points of discussion within it, but a lot of those are different conversations entirely. I think the largest point of contention is the magnitude of the impact of Singapore's political system on their health care system vs. other factors, which is a potentially interesting question, even if we all agree that other factors are as important if not moreso.

In any case, I always appreciate defusing P&R conversations with civility, and appreciate the time you took to write that out.

[Timex]

Typically for health cost purposes, bigger is better though. Larger risk pool, etc.

Well, it's only better for some things.
Really, it's only better for one thing.. which is that you can leverage more buying power against providers to request better prices.

However, in most other regards, bigger is worse in that the increasing size necessitates more management and bureacracy, which eventually grows to the point where it requires management of the management, etc.

Also, as previously pointed out, when you move to large systems which stretch across large regions, you start to have problems making rules that match up with the local needs of different regions. It's hard to make a one-size-fits-all management for those types of situations.

[CLWheeljack]

That all depends on how it's structured, doesn't it? I don't know much about management theory, but couldn't a single bureaucracy be in theory more efficient than multiple smaller ones?

It seems like structure could solve issues with regional needs as well. You have some level of approval at the top level, but the individual regions then make decisions about what to offer. In theory, it could be more efficient because rather than each region, say, testing a treatment themselves, once it's approved in one region it can be deployed in all of them, if that region decides it needs it.

Note that I'm not disagreeing, I think the scale, especially at orders of magnitude like the US vs. Singapore is a huge problem. But, I'm not sure if it's theoretically insurmountable, or just impractical.

[Tortilla]

However, in most other regards, bigger is worse in that the increasing size necessitates more management and bureacracy, which eventually grows to the point where it requires management of the management, etc.

Also, as previously pointed out, when you move to large systems which stretch across large regions, you start to have problems making rules that match up with the local needs of different regions. It's hard to make a one-size-fits-all management for those types of situations.

There's certainly some truth that nationwide programs in big nations have complexities that smaller programs wouldn't, but they also have efficiencies of scale that smaller programs wouldn't. I'm still not buying into the idea that ideas that work on a small scale can't be made to work on a large scale.

[Tin Wisdom]

That all depends on how it's structured, doesn't it? I don't know much about management theory, but couldn't a single bureaucracy be in theory more efficient than multiple smaller ones?

It can be, but it also tends to push everything towards the middle, meaning that edge and specialty cases get shoved into "one size fits all" solutions. If it's designed to be nimble, the leadership of such a system can adapt on the fly, but as any system gets larger it becomes much harder to maintain that degree of nimbleness without starting to decentralize and make regional or departmental "sub commands". With medicine in particular, you can't afford to sacrifice effectiveness for efficiency.

But I think what we're talking about here [Singapore v. whatever] is that a system custom-designed for one tiny geographic area with a very dense population would probably not work on a country-wide level.

In the case of Singapore's model, they can centralize stores of medicine; create "hub-and-spoke" models of hospitals and clinics that feed in and out of one another; and standardize on doctors' certifications and tests, down to requiring that everyone take their certifications in the exact same room (if they so chose... which I assume they do not).

Such a model may work quite well in, say, Chicago and the surrounding counties, but it would probably be a disaster in rural Illinois where the low population levels and large distances between population clusters would cause such a system to collapse under its own weight.

Regional differences in medicine are pretty important too. Singapore's system probably doesn't worry too much about how to treat frostbite, but a national system (especially one that covers a large swath of territory) needs to be able to care for frostbite victims and sunstroke victim at the same time. Such a system would have to pre-stage drugs for frostbite everywhere, but focus them more in the areas where they'll be needed without driving up the cost in the areas where they are not needed. Not impossible, but also not something that Singapore's model needs to worry about.