Matthew Zirwas, MD@MattZirwas
Doctors have been waging a 60-year guerrilla war against the healthcare system on behalf of patients.
How has the healthcare system responded?
600,000 pages of rules with 4 million administrators to enforce them.
That's not a joke. Not made up.
That's my legitimate estimate of how many pages of rules a single doctor in a single state has to work around in order to provide care to one patient.
Receipts attached.
Hospital rules, insurance rules and contracts, Medicare rules, malpractice rules, state medical board rules, to name a few (not nearly all of them).
It'd take 20,000 hours of intense focus - 10 full working years - just to read them.
It's called kludgeocracy. Real term. Real literature.
Mainly applied to the government and yesterday I said the government's kludgeocracy is worse than medicine's kludgeocracy.
I was wrong. Medicine has it worse. Way worse.
There are 3x as many pages of rules for your doctor as are in the entire federal government rulebook (called the CFR).
But for your doctor they're spread over dozens of independent, unrelated entities who don't talk to each other, are actively antagonistic towards each other, and intentionally make them hard to access.
And did I mention they change.
Every month.
And nobody tells your doctor what changed.
On the surface the literature only offers kludgeocracy as a diagnosis with a fatal prognosis.
Think of the medical system as a patient with 6 separate types of stage 4 metastatic kludgeocracy at the same time. And has failed 5 chemo regimens. And is an active alcoholic who continues to smoke 3 packs a day.
Sounds hopeless. Been hopeless.
But kludgeocracy in medicine could be the first disease AI cures.
The main theme that runs through the literature as a solution: identify it, name it, and quantify it.
Make the costs and sources obvious to everyone paying them. Which is every taxpayer, patient and doctor.
In other words, everyone.
That's been impossible. 600,000 pages spread over dozens of layers and entities. Too much for any human to even hold 1% in memory.
And remember, they change.
Every month.
So, that's what's standing between a single patient and the care they need.
But current frontier models are powerful enough to pull it all together so we can all finally see it.
The most important takeaway is that adding anything on top of the existing system to try and make it better can only make it worse.
You cannot fix a kludgeocracy by adding fixes to it, by reforming it.
That's the key insight. The ah-ha moment.
The healthcare system, as it stands, is unfixable.
Unreformable.
Everyone can stop trying. Stop debating. Stop running pilots. Stop designing patches.
So we give up?
No, we start from scratch. And it doesn't have to be pandemonium.
Here's one idea. We pick our 5 least populous states and erase it all.
The Medicare and Medicaid waiver mechanisms to do this already exist and the state legislatures can do most of the rest.
Get a bunch of full-time practicing docs from each state. Full spectrum of specialties and care settings - rural, urban, big hospital, small hospital, outpatient, inpatient, single provider private practice, big group practice, academics and community docs.
Nobody with any real administrative experience in the room, but make sure a few of the docs have some policy or healthcare economics expertise so the group knows what's been tried and doesn't work.
But mostly only full time clinicians (who, by definition, are all also patients) and a frontier model - and give the group in each state a month to design it from the ground up.
How payment works, how hospital policy works, how and if treatment decisions are reviewed, how 'malpractice' works, how competence is measured, how and if private insurance works, what a safety net looks like, how we use AI, all of it.
One rule. Physician compensation has to go down by 20%.
Each jurisdiction does it on its own - no communicating, no collaborating. We want different approaches we can compare.
We implement 5 separate systems, give the experiments a year, see what crashed and burned and prune it, what worked better than expected and spread it to the other jurisdictions.
Iterate for 3 years.
Pie in the sky? Maybe.
But the only other option is let it keep getting worse and wait for it to literally collapse.
i.e. fixing the system is demonstrably impossible.
Look it up. Kludgeocracy.
One option.
Kill it.
Replace it.
