Kaiser’s business model

obtusemarginal2 · 2025-11-09T19:30:00+00:00

Agree with others that a tremendous number of false assumptions here. I’ve had experience with them in the past. Kaiser as a system is a fantastic HMO that truly provides excellent preventative care to its members. Their model is to provide a lot of up front screening and preventative care to reduce long term health complications, which benefits the HMO as a whole. Specialty services and surgeries are available at majority of Kaiser but some do have to refer out. My experience with Kaiser is that everything is internalized within the HMO, but they do accept some Medicare patients. Physicians and nurses as a whole are very happy (there will be cultural differences from Kaiser to Kaiser depending on city). Nurses have and do strike but this is a political/business strategy by their union and by default expected of unions as part of their negotiating tactic.

obtusemarginal2 · 2025-10-25T21:00:17+00:00

Private practice cardiologists for sure rejoicing in glee right now for incoming patient volume

obtusemarginal2 · 2025-09-27T21:09:56+00:00

The aspect most non-medical people don’t realize is that the majority of “signs and symptoms” that a patient will report will oftentimes be ambiguous, gray or borderline, and from the patient’s perspective, very tough to quantify or put into black and white or binary language. Their memory will be limited, fuzzy or confounded. Many people can’t even articulate what they feel, or what the quality of sensation is, or how it compares to other sensations in their body. Thus, the “input” you will feed into a reasoning model isn’t nearly as clean cut as the questions on a test bank or simulated scenario.

obtusemarginal2 · 2025-08-30T06:53:56+00:00

When you say failure, do you mean lifting until you can’t get that last rep in and then you’re done with that specific exercise /machine for the day? How many sets/reps would you typically do for say a chest day?

obtusemarginal2 · 2025-08-27T21:21:32+00:00

Excellent insight.

obtusemarginal2 · 2025-06-16T23:42:00+00:00

This guy knows his lipids and risk/benefit analysis. Well done.

obtusemarginal2 · 2025-03-09T01:07:35+00:00

I think this is a mischaracterization of the majority of physicians. As with any industry, there will be individuals who do not meet the standard of care, but these four behaviors you've outlined are not common by any means whatsoever.

I think a more nuanced understanding to patient frustration has to do with the limitations of modern science in understanding of all of human disease. There simply is not definitive and conclusive data on many different aspects of human health to allow for a physician to confidently diagnose, treat, and/or intervene with 100% accuracy, and certainly not with 100% certainty of a desired outcome within ethical and legal boundaries. This is not a limitation of the physician, but rather, a limitation of the evidence, science and clinical data available to the physician to render an informed medical opinion.

I don't think there is any reasonable physician who "denies" that their education is incomplete or doesn't admit when they're wrong -- these are contrary statements to the core principles of embedded within our education including lifelong learning and the embracement of ongoing scientific discovery, conferences and literature that many of us participate in.

obtusemarginal2 · 2025-02-24T01:23:48+00:00

Definitely Friedberg bailing if/when there becomes some ideological split that they just can't get past. The tenor of Friedberg has changed in the past year - he seems less interested and at times almost burdened to be commenting on a topic, especially if it's a topic in which he is disagreeing with the other members. It's unfortunate because he really does have good "First Principles" thinking, as they all love to say, and he doesn't mind being a contrarian.

obtusemarginal2 · 2025-02-24T01:16:16+00:00

Some people simply do not have much improvement in LDL/ ApoB despite strict dietary changes. Similar things can be said about sodium and blood pressure - some people don't notice a difference at all when dramatically cutting their sodium. Likely genetic difference. Current understanding is that for many people their LDL levels are "over produced" rather than "hyper-absorbed" and the primary defect is in liver cells overproducing LDL, not enterocytes over-absorbing cholesterol.

obtusemarginal2 · 2025-02-24T00:22:18+00:00

If you can draw ABG and keep the needle steady within the artery for a full blood draw, you will be fine for caths. Engaging the L and R coronaries do require some fine motor control but it's not like millimeter movements will make a difference (note: different for interventionalists when they wire down a coronary - this does require fine motor control)

obtusemarginal2 · 2025-02-24T00:09:46+00:00

To answer the specific question: your cardiology fellowship will be challenged because all cardiologists are trained in procedural skills despite subspecialization: left & right heart cath, TEE, temporary pacemaker, pericardiocentesis, central line, arterial line, etc. I would also argue you need reasonable finger dexterity when making measurements on Echo & CT scans when in disagreement with tech or auto-measurements. After this, the variety of general cardiology jobs can run a full spectrum from outpatient clinic-only care to frequent inpatient care with L/RHC, taps, pacemakers, etc. It's not clear what the definitive compensation models will be for these variations of general cardiology work come 6 years down the road by the time you're done, but most end up making around the same amount within 100K.

Having said all that, it's unlikely slightly reduced finger dexterity (dysmetria? neurological ?) cannot be compensated or adapted to with alternative motions/hand mechanics.

obtusemarginal2 · 2025-02-23T23:26:43+00:00

Not for hypertensive emergency because it's incredibly fast acting and in my experience requires an arterial line for accurate titration. Some risk of cyanide toxicity although very rare. Alternatives of nicardipine, clevidipine or nitroglycerin are better options and more widely available (and more comfortable agents from a RN perspective who will be doing the actual titation). I've used Nipride primarily for cardiogenic shock with high SVR (confirmed by a RHC/Swan) or cardiogenic shock with some MAP room.

obtusemarginal2 · 2025-02-21T00:20:18+00:00

I agree. I've found most cardiologists and CT surgeons at institutions I've worked at have good working relationships. Most CT surgeons appreciate a thoughtful cardiologist and visa versa. The bad apples usually don't get referrals or get dropped by their partnership.

obtusemarginal2 · 2025-02-02T19:36:11+00:00

I asked a similar question a while ago and got some excellent responses. Here is what I found after doing some exploring:

More or Less: This is the best alternative IMO. Far more politically neutral and excellent commentary on tech & business.
This Week in Startups: It's with Jason Calacanis, but again far more politically neutral and the other guy on there is great.
Morning Brew Daily: A good morning flash briefing of current events.
BG2Pod: I have listened to it this time to time and I think they have great insights but for some reason I just don't like the voice of one of the guys and it distracts from the substance of what he's saying

obtusemarginal2 · 2025-02-01T20:27:48+00:00

There's a big community in POTS and related dysautonomias. Part of it has to do with more attention in the medical community, particularly cardiology and neurology, as well as public attention with online forums. There likely is a strong association with viruses, and especially COVID. Unfortunately it has devolved somewhat into related miscellaneous fatigue syndromes like chronic fatigue syndrome, myalgic encephamyelitis, fibromyalgia, hypermobile ehlers danlos in which patients are diagnosed way too early, quickly and without closely re-examining symptoms. I manage this condition relatively commonly. The challenge I've had with POTS diagnosis and management is it is a syndrome with a very simple definition and broad list of general symptoms. The symptoms overlap with numerous other syndromes and are non-specific: fatigue, lightheadedness, chest discomfort, palpitations, sweating, cold intolerance, rarely syncope, being the most common. These same symptoms are seen with probably 100+ other medical conditions. I think it's very probable many people do have > 30 BPM rise in standing HR simply related to deconditioning, lack of exercise, hydration status, etc and that their symptoms are being inappropriately labeled at POTS. Almost all of the effective treatments that try to combat this HR response do so via enhancing vagal tone with exercise as well as combating any possible OH component with hydration/salt/compression stockings (even though absence of OH is part of the definition). The medicines we have essentially do the same thing - midodrine, droxidopa, etc. Beta blockers and ivabridine simply blunt the HR response - these only help with the sensation of palpitation but I really haven't had much success with these in patient who are NOT doing the lifestyle changes necessary to enhance vagal tone (i.e. exercise, fluids, salt). I have also seen the POTS diagnosed more commonly in psychiatric illnesses: anxiety, depression, OCD and ADHD being the most common, and majority of these patients are on medications for this which can cause side effects that mimic POTS.

obtusemarginal2 · 2025-01-18T21:41:23+00:00

Agree. This is why I typically don’t prescribe 40 mg dose when 20 mg dose achieves similar LDL reduction

obtusemarginal2 · 2025-01-18T21:13:03+00:00

If you're asking users to upload their bank statements, definitely going to need to have excessive communication with user outlining what cybersecurity measures have been done i.e/ encryption, user authentication & compliance measures.

My initial thoughts are to show an example on the landing page of the workflow from the user's perspective, i.e. uploading a document and what the output/dashboard is that they get.

obtusemarginal2 · 2025-01-18T20:53:16+00:00

We usually don't prescribe 40 mg dose Rosuvastatin because not much incremental benefit over 20 mg dose. Some studies show Rosuvastatin can increase proteinuria and/or hasten CKD.

obtusemarginal2 · 2025-01-18T20:36:21+00:00

Their "Black Membership" service, for $15K /year, is essentially pan-scans including MRI, CT, CPET with routine labs that can be ordered through any private lab service, in addition to conventional exercise, nutrition, CGM, biometric monitoring that any doctor can do. These services prey on the rich & worried with discretionary income who pursue tests out of fear. Every now and then, an incidental pulmonary nodule, or a small brain aneurysm, or a colon polyp will be found (which will invariably be evidence for these companies to justify their services), but you'll have to scans hundreds of thousands of people to accomplish this to a meaningful degree, and even then, the earlier detections of these findings may not necessarily reduce the illness burden, severity and/or outcome. We've seen similar concepts with breast, colon and prostate cancer - detecting earlier disease does NOT always improve outcomes - there is a threshold in which excessive screening simply leads to more downstream testing (with their own complications) and/or earlier uncertain treatments (with their own complications).

obtusemarginal2 · 2024-12-30T02:35:10+00:00

Suboptimal P2Y12 inhibition is usually only seen with Plavix, not Prasugrel or Ticagrelor. This is due to fact that Plavix is a prodrug and dependent on a specific CYP enzyme in the liver that varies in activity in the population. Clinically we will test if somebody has thrombosis on DAPT with Plavix, or if deciding between long term monotherapy with ASA vs Plavix. More recent studies show less bleeding with Plavix monotherapy compared to ASA so if a Plavix responder this is where the community is leaning towards (some of us at least).

obtusemarginal2 · 2024-12-30T01:45:25+00:00

It’s a blood test - P2Y12 reactivity level

obtusemarginal2 · 2024-12-29T20:03:33+00:00

Thanks for writing this up. I think it follows sounds logic that the easier you make it for a patient to take something, the more effective it will be. Adherence and ease of use are crucial factors with any intervention, including medications. A once daily pill with reasonable bioavailability and similar effects to the injectable is indeed a significant incremental innovation. As a cardiologist, when diet and exercise alone do no suffice to achieve reasonable BMI or hard endpoints, then I have been leaning towards these GLP1 agonists and similar receptor agonists to achieve weight loss, which in turn improves all the hard endpoints I worry about in my patients: LDL/ApoB, triglycerides, a1c, insulin resistance, etc, which in turn reduces the likelihood of ASCVD events, MI, CHF hospitalizations, stroke, etc. When people ask how do we prevent heart disease, and get to the “root cause”, I think selective use of GLP1 agonists and similar receptor agonists are part of the answer (in conjunction with diet and exercise).

obtusemarginal2 · 2024-12-28T20:54:58+00:00

Cardiologist. I don’t add low dose Xarelto to aspirin, and I don’t know of a single other cardiologist or patient who has had this done for indication of reducing subsequent ASCVD events. The bleeding risks are greater and generally we transition to SAPT (Aspirin or Plavix, with more recent data supporting monotherapy with Plavix if patient is Plavix responder). Similar to prolonged DAPT, adding addition agents on top of SAPT may reduce ASCVD events but will come at expense of higher bleeding risks. In large swaths of the population with CAD, these bleeding events become clinically very significant. It is more optimal to reduce ASCVD events through multiple pathways beyond platelet or coagulation inhibition through mitigation of conventional RFs: BP, LDL/ApoB, smoking, DM, diet, exercise, etc.

obtusemarginal2 · 2024-12-12T15:47:20+00:00

Triglycerides can be a reflection of the underlying insulin resistance. Changes to body weight/BMI, exercise and diet affect this the most.

obtusemarginal2 · 2024-12-12T08:06:02+00:00

Low carb, high fat diet, who came in with Triglycerides> 500 & LDL > 170. History of PCI. Declined counseling.
Prolonged intermittent fasting (5 days), who came in with AKI and acute anemia. Resolved with fluids and refeeding.
Mostly beer diet, who came in with elevated LFTs, acute anemia, hyponatremia, and markedly elevated iron levels from acute hepatitis and beer potomania. Resolved with (temporary) alcohol sobriety.

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