Disruption of Bureaucracy

This is honestly one of the hardest things I have had to write. It’s about a subject that will change the lives of so many dear and hard working friends. Facing it means admitting the fear and horror is happening, and needs to.

That sounds like a lot of rhetoric, until you realize I mean the world is being forced to change, and it will destroy most of the jobs you know. It also means that the system we have now has major problems, and everyone has been arguing over the wrong things. The entire pill is difficult to take, and the destruction to make it better will not be easy.

A few weeks ago, Jimmy Kimmel talked about the birth of his son. It was a traumatic experience, because the boy was born with a heart defect. Kimmel has money, and was able to pay the cost of millions of dollars for his son to be taken care of. As he talked about it, he explained in tears that he did not want this to happen to anyone. We needed government funding to help people who did not have money.

Before this happened, a very dear friend of mine was in the same hospital, with many of the same staff members at the NICU, because his daughter was born with a heart defect. He and his wife are not rich, and rely on the government to help them pay for this incredible cost to pay for their daughter to live. This particular day, they were removing her, because the money promised by the government had not arrived. There were several phone calls, and tears made, and finally someone signed the right card for her to stay.

After dealing with it, he said that there was a problem. It had been there before President Obama had signed his healthcare law into service, and it was there during, and it would be there after it was gone. The problem was not laws, or the promises made by government. It nearly killed his little girl.

Let it all sink in for a moment. I know it hurts to read. In fact, right after reading my friend’s message, I looked into every book I could find about medical health care to find out why such an awful thing nearly happened, and is likely happening to others. It scares me what I found.

This isn’t the only thing I did either. I work at a medical office, and know several doctors, and how they worry about things. I know the bills they have to pay, and how much the government actually gives out. I can’t give exact details, or links on it, but the people involved are scared.

It gets more insane when I talk to people outside of the medical industry. For example good friends who teach school are scared of changes by the government. Many of the same reasons are given that the medical people would say. There is a lot of anger at the issue, and not knowing what to do about it. Both groups are not evil people, and care a great deal, but somehow the world is changing and destroying what they love.

The books, articles, and other stuff on the subject were pretty boring for the most part, but I did find a few that shed light onto what is going on. The first is by a medical student doing research in the 1960’s. The second is from a technology business researcher who coined the phrase disruption.

The medical student had passed all of his exams and was now doing his medical internship. The hospital was specially designed to help students become doctors, so all sorts of new technology and ideas were available. He would later quit medicine, and use the research techniques he learned to write about insane things like cloning dinosaurs, or long dead ancient ruins being protected by gorillas. Michael Crichton is well known for having whole chapters dedicated to research he had done on the subject with a small disguise. In fact he does this so much, some people thought Jurassic Park was actually happening.

Five Patients is a great work of nonfiction, and a way of looking at his writing before he became famous. It is also a look at what was being expected for the near future of ten years after the book was published. That date of the future was 1980.

In one of the chapters of the book, a woman named Mrs. Thompson is at an airport and feels woozy. She heads to a medical center to be checked up. A nurse is there, and a doctor is on call using television transmissions, and fax machines. The nurse uses the equipment to do simple tests on Mrs. Thompson, as the doctor looked over them at his location. He gave a recommendation, and then Mrs. Thompson went on her way.

The entire scenario was expected to become common, and the equipment itself would become easier and easier to use. Soon a person could do most of the tests, and someone could then tell them what was wrong.

In a later chapter, Crichton interviewed the head of the American Medical Association about what the future held. The comments were that people needed to make the hospital easier for the patient, not the doctor. The incredibly awkward corridors of unknown testing stations was getting insane, and usually made things worse for the patient. He said it wasn’t helping anyone keeping it this way.

These two ideas for the future never happened. We can look directly at how the structure of hospitals and other buildings has not been changed, only expanded to explain this. A common story is how a medical center began with a place for doctors to see patients. New technology was added, so a new part of the building was made. Soon, it became a labyrinth of rooms and specialists. If a doctor wanted tests done, they tell the patient to go to each of these rooms, and then has each specialist report back on what they found.

The next book was released in 2008. The author had released a similar book about the school system that same year. The idea was to show how the use of technology will change the industry. Many of the things mentioned in the book on medical technology, show up in Crichton’s book. The author used his studies on the business term Disruption, to see what was up and coming. He recommended better regulations to help these new technologies move in.

Clayton Christensen has become famous for his introduction of the term Disruption and how it is used. It basically means a new technology comes in, and is not good enough for the average user of a similar more used product. So, the creators sell it to smaller groups that may need it. Slowly the technology improves, and takes over where the original competitor was.

Cars were expensive, and unuseful when they were first introduced. They were literally on fire to move forward, and barely had enough torque to go as fast as a horse. Eventually they were improved, and people figured out how to sell them to the lower people instead of as a cool but useless thing for the rich. This eventually led to everyone owning a car. The horse is now something very few people have, or use.

Going back to Crichton’s book, he was showing how the new technology was replacing the old ideas. The nurse in the airport with a doctor checking things is somewhat expensive, but cheaper than having the doctor there. Not only that, he could be a doctor at several airports without many problems. The cost is way lower, and for people that wouldn’t expect to be customers. This same facility was described by Christensen.

These two books are 38 years apart, and talking about the same problems. Why are they still there? Did the technology stall? Who was causing this?

The answer isn’t complicated, and is happening in a much wider circle than just the medical industry. To show what I mean, I will show what has happened in a small section of the world of doctors, nurses, and prescriptions. Then I will show how one industry was changed. After that, how others are being changed because of this as well.

My bill paying job is working at my parent’s optical. The equipment used has not really changed in the 30 years since my Dad became a doctor. If you have glasses, you know the routine of looking at a chart, and reading it with one eye or the other. Which is better, one or two?

That entire routine is so well known, because it hasn’t really changed in decades. When my Dad was getting his Doctorate degree, they were using the techniques in the 1980’s. I was used as a patient, though I bet I wasn’t very good for it at four years of age. I was more interested in going to the park, or working the cool buttons on the chair.

The devices have gotten better, but never improved. IE, the chair you know so well used to have a leg pump to move you up, and another to bring you down. Now it’s a foot button, and that idea was introduced while Dad got his degree.

This means most of the technology you use now hasn’t improved. The Optometrists know this, and are trying to move up to other technologies, but it isn’t always working. The truth be told, the exam you know is not going away by natural means.

What you don’t know is that Optometrists are unable to work in specific areas, by law. Ophthalmologists actually went to the government, and canvassed to not let optometrists do those things. Optometrists were slowly gaining ground, using new devices, and getting into the fields of the higher up ophthalmologists. Even today, the conventions for Optometrists promote using this new equipment.

This isn’t actually new equipment either. One of the biggest cool things in my Dad’s office has a computer that runs Windows 98, and needs an old ATI graphics card. The device itself really doesn’t improve, but there are ones that connect to newer computers. The technology is old, and in all honesty, most of the training is not to use it, but that it needs to be used. Which means the doctor has to rely on someone else to do the tests.

To do this the doctor has to rely on an optician to run the equipment, and figure the technology out. Which means the same scenario as the hospital, the doctor is waiting for a test done by someone else.

The equipment is usually not covered by insurance providers, unless it is actually needed. Since the doctor doesn’t understand it, he can’t figure out if the device is needed. Which means he has an expensive piece of equipment, that isn’t being paid for.

This is true throughout the medical industry. There are technologies to do the things you want to do. There are medics in several airports who have equipment to check the basics, or resuscitate people. They have to fill out paperwork though. Sometimes on paper. If you want a Star Trek style tricorder, there are a couple options, but they don’t seem to be spreading. You can have it, but somehow the doctors and staff are not using it.

One of the problems is that most routine things are done by a common system. Check the vitals, check the symptoms, and it is likely this. If it is more difficult, the routine includes tests outside of that range, but they are looking for common things. The more likely problem is the common one. Although Doctors are trained to know about all sorts of diseases, if they don’t deal with it, they only know about it in theory. If it was a rare disease, it would be difficult to test for, because everyone is following a routine.

Even if you were to tell a doctor about a disease, and have them test for it, they would likely say the patient does not have it. They would have tests done, but no one involved would know how to test for it.

What you also don’t know is the background stuff behind your medical visit. Every time you do anything at a doctor’s office, they bill your insurance. The first thing done is checking to see if the exam is even covered, and how much you get for various items. Making sure the office actually gets paid takes up a lot of time, and may even be longer than your visit. The best part is never knowing how much will actually be paid. The insurance company may say one thing, but the check may be different. This means long phone calls listening to hold music. The office worker is literally waiting to find out if a paper is signed, or if something is already approved. This means the office can be paid for the job.

That same wait is what nearly killed my friend’s daughter. They were literally waiting for a piece of paper to show approval, for the hospital to be paid.

Right now hospitals and medical care centers are not making enough to pay for everything needed. They can see hundreds of people in a week, and not know if insurance or other forms of payment, including government, will actually happen. This creates a problem, because the equipment they have is expensive. The push is for even more expensive equipment, even if the technology itself isn’t as much of an improvement as it is being promoted. Like the optometrists, other doctors rely on technicians, and others to do most of the tests, and then they give the final results.

This is the reason why it many attempts at government intervention seem to be a problem. As an example, Optometrists in Washington were paid a specific amount for every visit, pair of glasses and so forth. The state decided to expand coverage, but did not have the budget to do so. The next best solution used was to pay the doctors and medical facilities less. An eye exam went from $160 to $70 in a few years. Then, to make sure the doctors were doing everything correctly, the state government required safety measures, and checks that the doctors were doing what they said they were doing. Equipment had to meet requirements, programs had to be doing things correctly. Many facilities were running out of money, even though they were seeing more people. Obviously those are not the real numbers, that may be against the law to tell you, but they are close enough.

Let’s look a different field that has just gone into a major change. Clayton Christensen, who wrote the book on medical technology and disruption earlier in this essay, says that Uber is not disruptive. Most websites do not understand because they see the sudden success, but not the details. The people who caught onto the new taxi service were ordinary, the time for the disruption was too fast. Disruption has a system to it, and it starts at a niche nobody likes and goes up. Something was being disrupted, but it wasn’t Taxi services. Uber did not disrupt the business, the phone disrupted the bureaucracy the taxi companies worked within.

The taxi company would hire the people, relay who has what area, how much should be charge, maintain the car driven, and even what their hours were. The Taxi driver had to pass several tests, and go through rigorous training to find the best route, drive safely, and be courteous. They have a routine, and follow it. What you do is order a taxi, and then the company arranges everything, and the taxi driver follows up. The entire thing from your side is very simple, but the parts you don’t see are fairly complex.

There are also requirements the Taxi drivers must follow. Some of these are brought out to make working conditions better for the drivers. Others are make sure the passengers are safe. It is difficult to maintain a car’s cleanliness, keep it working, and also arrive at a safe amount of time to a place.

Uber did not change what you did. You ordered a taxi, got people who said they would do it, and then you took one of them. Both you and the driver are arranging things directly, and the phone simply makes it possible to do that. Using GPS, the driver doesn’t need to know where every place is. Passengers can grade their driver, and drivers can warn others about difficult clients. The hours are chosen by the driver, and where they are willing to go. Each thing can now be done using phones without the need for a large bureaucracy to help you with it. The taxi company itself is not needed. This means the bureaucracy is no longer a part of the conversation, and is thus what is being disrupted.

Like Optometrists slowly moving up into the Ophthalmologists field, people are demanding the government stop such changes. They cite how Taxi drivers are better trained, and have a system for doing this. The livelihoods of everyone working at these businesses will be gone. The bureaucracy will be lost.

The word bureaucracy itself means office work. Bureau means desk in French. The first person who coined it was complaining about how much of his country was being run by people simply who signed papers for a living. It became a rallying cry during the French Revolution. Personally, I wished they also made sure it was easier to spell as well, but sort of smile imagining some guy who never turned his paperwork in on time being beheaded.

The officer workers are being disrupted. Computers have been famously taking jobs for a while now. As a video person, I had to be trained in using sophisticated equipment, many items I still don’t really understand. However, with technology today, a person can do a live video with graphics, and everything with a computer. They can then edit it quickly enough, -preview render time is still horrible-, and all of this doesn’t take a great deal of training.

With how well phones work today, you can take a video, do screen shots of things, edit items, and other stuff before you even get to the computer. It can be uploaded live, and have everything you need. An entire TV Studio worth of equipment is no longer needed, the professionals who ran that studio are now out of a job.

Let’s go back to the medical industry. There are several regulations, requirements, insurance forms, and other things that have to be done to make sure the facility is allowed to work. To give you an idea, my entire job is to make sure paperwork is signed, and filled out, and then I scan all of it for each patient. This way anyone who asks will have a paper trail following every item sold, or medical care given. We then have to make sure everything is kept safe in case someone tries to get that information.

There are codes for every single item that must be recorded, and shown that it was done properly. A single error, and a glasses order has to be redone, or an eye rechecked. If we don’t do this, insurance companies, the IRS, and others can fine us for a lot of money.

Get this, one of the requirements is that things be sent by FAX. I don’t know the reasons why, but even the hint of a patient’s information being lost, or falling into the wrong hands is too much. I know of medical complexes that use the mail system to send information, because the FAX machine isn’t trusted. This is not a small facility either.

With this level of techno illiteracy, regulation, and demands for expensive equipment you can see the same things the Taxi company had, which were no longer needed by Uber.

Almost every doctor I know, understands this. They freak out at every announcement of a website or app that may take away business. For example, there was a kickstarter for an eye exam using a smartphone. It may be inaccurate now, and only cover a small amount of people, but it can improve and take away that entire exam you know so well. You can then take your prescription and order glasses online. The entire facility I work at is now gone. The paperwork for it is entirely in the database, and it was cheaper for you to use. Now imagine my Dad seeing this, when he knows how precarious the optometric business is already.

The bureaucracy is what keeps many medical facilities afloat. If we could scan you using a cheap item you bought at a store, and then send the results back, think about all the people who would lose a job. The imagine forums, and other places to check for symptoms. At some point doctors will lose out.

It actually gets bigger. My sister has a very rare body disorder. Her skull and neck don’t connect correctly. At one point she could twist her head backwards enough to see behind her. We called it the owl. She had terrible problems, and most doctors didn’t even understand it. Since the doctor didn’t understand, they had tests done, which did nothing because the problems didn’t fall under normal things you would look for. But the doctor was being held back because his training was only in these things, and if he didn’t do tests he could be sued.

Quite often the doctors would say it was all in her head. This is true, its right at the back where the neck and stuff should be acting in a specific way. I’ve been in the room with doctors who yelled at her because they didn’t understand her problems, and she was looking at the results on her own. I nearly applied a lateral impact to the lower mental foramen, causing a fracture and dislocation in the posterior condyle and angle.

To figure out what was going on, websites, and forums were used to look at her tests, and figure out what was going on. Just getting to the needed tests was difficult, and then getting the information, not just the technicians statement, was harder. Many of the tests could have shown important things, but we never got to see them. Eventually she was able to get enough MRI’s, to see the disconnect between her neck and spine.

She had surgery, but the cost was nearly a million dollars for everything since it was so new. The only surgeon who did it was in New York. The insurance only paid for some, because it was outside of how they ran their bureaucracy. The hospitals and many others had to step in to help her, because literally the insurance backed out after the surgery. There was government aid as well, which we are all thankful for.

If that sounds like what happened to my friend and his little girl, I would agree. As you can see, the problem really isn’t the ability to pay for things, it’s something much more difficult. The framework of medical care is based on a bureaucracy that is being disrupted. It scares doctors because they may not be needed when the technology arrives at their field. At the moment, low level stuff like Optometrists are being taken down. It also covers people with rare diseases and problems because the doctors are not trained to take care of it. At the same time, whole medical facilities, technicians, staff, and background people like me are having to work overtime to make enough and follow the rules the various other bureaucracies demand.

The technology itself should have changed things years ago. The problem is none of the professionals knew how to use it, and the government wants to control it. This slowed things down a great deal. Things predicted from the 1970’s didn’t happen, and even obvious suggestions from 2008 seem to be ignored. Because of this, the changes happening are harsher than they would have been. Instead of a change, we have a crash happening in front of us. Since it is a disruptive force, it is going after the routine things first, and will eventually somehow cover surgeries. By then the system will be completely different. Between then and now is a scary time.

As my friend said, the problem was with us before Obamacare, it is still there with it, and it will be there when the laws are gone. It was a problem with how the system was set up, not on who was paying or how. Hopefully the coming change will make it easier for everyone, but I honestly worry about the good people like doctors, nurses, technicians, and paperworkers who will lose their jobs during this crash.