domain:alexepstein.substack.com
dev
24m ago
I'm not objecting to base charge for a level 2 emergency room visit ($700) which should have covered the facilities and the nurse time (which was very little). I'm objecting that they upcoded that to a $2400 charge while then itemizing and also charging for the things that supposedly triggered the upcoding (the doctor's time and the ultrasound).
dev
26m ago
Just looked over my bills. We got itemized $600 for the radiologist, $800 for the emergency room doc. Then on top of that was the $3,300 for the ultrasound itself. Then on top of that was the up-coding of the ER visit from level 2 (which would have been $700) to level 4 which was $2,400. And then there was also another $900 for catheter insertion and $940 for labs. Everything feels over charged ($900 for a two minute catheter insertion..?) but it particularly galls me that they up-coded me from 2 to 4 because of the ultrasound and decision making and then charged us separately for those things.
RoyGBivensAction
Zensunni Scientologist
26m ago
How many run-ins with HR must a man have
before he recognizes the pattern?
The answer my friend
Is blowing in the wind
Starship isn't really made for the moon either.
The last couple years have had several notable tipped landers (more the norm than the exception, almost). That SpaceX plans on landing something that enormous and tall on the moon directly seems to be asking for trouble. It lacks robust mechanisms for lots of things (the LEM had a separate ascent engine partially because of concerns about the descent engine getting damaged on landing --- and a ladder), and honestly the Starship HLS and Artemis mission plans look like something a kindergarten class drew up: single sourcing not one, but two novel heavy lift launch vehicles (see Akin's Law 39, twice over). Build a permanent space station because you'll need to resupply (Gateway), then dock a single-sourced comically large lander that doesn't really need resupply anyway.
RoyGBivensAction
Zensunni Scientologist
36m ago
If fart-sniffing prestige magazines did not spend an inordinate amount of time lavishing praise on people who very conspicuously do not need it, how would we know who’s better than we are?
I do greatly enjoy FdB's outrageous seething.
If someone asks me, “Why do you write?” I can reply by pointing out that it is a very dumb question. Nevertheless, there is an answer. I write because I hate. A lot. Hard. And if someone asks me the inevitable next dumb question, “Why do you write the way you do?” I must answer that I wish to make my hatred acceptable because my hatred is much of me, if not the best part.
Oh no! LDS theology has something in common with Hinduism? That's terrible! Anyways.
If your idea of God is one that can change, then it is one that can be acted on.
Acted on by himself, sure. It's a stretch to say someone capable of changing themselves is not self-existent, and has more to do with the rest of the bundle of Christian theology than with the word "self-existence." It's not that such a being is not self-existent, it's that Christian theology holds that a self-existent being is (for other reasons) incapable of change.
Your idea of God doesn't really explain anything about the world and we are still left with the question of why is there something instead of nothing.
It's more that for both of us, our idea of things that are self-existent explains nothing about why there is something (self-existent being(s)) rather than nothing. This question predates self-existent beings in both cases.
The ontological argument attempts to address this, but I and most others find it unsatisfying, to say the least. Basically just word salad. If existence is a necessary quality of the greatest possible being, is it not also a quality of the most evil possible being? Why is existence only a quality of the greatest possible being?
My point is that LDS teaches something like "God is just like us, just more self-actualized and powerful. Theosis is us leveling up according to the nature we already have that is equal to God's."
Classical Christian thought is more like, "We have a different nature from God's, but He promises Theosis anyways through the marriage of Heaven and Earth in the Person of Jesus Christ. Human nature has now been grafted onto a Divine Person and we are able to participate in the internal life of God through conformity to the perfected human nature of Jesus."
The latter is also how I'd describe LDS theology. We put off the natural man, and put on the divine nature. We don't really believe in "natures" in the classical Christian way, but inasmuch as you can use the word nature we certainly don't share God's nature yet.
God is definitely like us, but more self-actualized and powerful. I don't think any LDS person would say that he's "just" more self-actualized and powerful though. There's a fundamental difference of type, it's just not as fundamental as in classical Christian theology.
I have my complaints with classical Christian theology too, and don't particularly care to litigate them right now. I just think it's pretty silly to say that LDS people see God as like a superhero. It's just not true. It's your way of fitting LDS theology into classical Christian theology, retaining just enough of LDS theology to make it look silly. Frameworks can't fit inside each other, though; you need to address them on their own terms rather than saying "within my framework your framework is wrong." Yes obviously it's wrong by definition if the argument assumes your framework to be true. That's not a productive conversation to have.
I didn't see anything the insurance denied. Altogether, our insurance and ourselves paid $8,500 $9k for an ER visit that involved a six hour wait in a crowded waiting room, then a brief consultation with the doctor, a catheter insertion and lab tests, and an ultrasound. The bill seems totally unreasonable to me, there is no way I can get that amount by calculating their costs from first principles. They had to be overcharging me above costs in order to pad their overall revenue.
MotteInTheEye
43m ago
Nice job getting people to commit to specific predictions. Even though it's super awkward, this is my favorite norm of the rationalist community, because you don't realize how reluctant people are to make specific, testable predictions until working out the terms of the bet forces them to.
It will be interesting to see whether you win all of them or not, and personally I have updated a bit towards your view of Musk and his companies being more grounded than I thought.
I don't know if I'm being clear but my specific and very minor gripe is that ICD has codes for everything under the sun but not a code for a physician phone consult (which would cover the time and hassle?) Or is there one and it wasn't used here?
Edit for clarity: This wasn't Out of Pocket, I had insurance. Not every insurance has a Co Pay system, even when you do have a "Co Pay" on the card you still get billed for more than the co pay later on, I've noticed this on your comments a few times over the years but you seem to have always had really good insurance and don't know what the average experience is like.
ArjinFerman
Tinfoil Gigachad
48m ago
I don't think this is accurate. Insurance knows how much it costs to insure someone in aggregate and where to set their premiums.
Do you think when you're buying a hot dog at a stand, they're charging you the price of that particular hot dog, or the aggregated price within a particular time-window that the stand owner is operating in?
I'm still hopeful for SpaceX to at least make operations on the moon more feasible, though I'm skeptical of making a real go at Mars colonization, especially as Elon's star has fallen so far recently.
Starship isn't really made for the moon either. Their best bet is high-throughput LEO transport, but I don't think they'll get it to work for that either.
It's a bit off topic, but I doubt there'll be a better place to post it any time soon. I had a bet about Starship going to orbit with two other posters. It was driving me crazy because I couldn't find it for the life of me, and I was starting to think I got pulled into the Berenstien universe, but I finally managed to find the relevant comments, so I thought I'll post them as a reminder, and to make future reference easier:
- It turns out that I just won my bet with @slothlikesamwise.
- I have 1.5 years to go for my bet with @TheDag
- I thought I had one with @self_made_human, but it turns out I just coaxed some predictions out of him. We've breezed through his 50% confidence interval one, just passed his 70% interval, and have one year left to resolve his 90% interval prediction.
self_made_human
śāśvataṃ jīva athavā yudhyamāno mṛtyuṃ āpnuhi
54m ago
Definitely, but they're less common than is the case for Skyrim. Most Rimworld mods tend to play well together, but I have a taste for massive overhauls.
I don't personally use mod packs, at most, I check compatibility for some of the more comprehensive mods like Combat Extended. However, the best that comes to mind are usually the themed collections made by Mr. Samuel Streamer, he's got dozens of playthroughs up, and each one has a link and setup guide. Do you want Starwars flavored Rimworld? Medieval? Post-apocalyptic? There's a series for you.
You will (and definitely should acquire anyway) the RimPy mod manager. It can import mod lists, handle load orders, note many incompatible mod combinations and will make life a lot easier. The vanilla mod manager, while not useless, is lacking in comparison.
Throwaway05
56m ago
Modern U.S. healthcare is probably more adversarial than you think because of the role of insurance companies that will try and refuse expensive things.
This doesn't work well for a million reasons (including Pharma basically paying the insurance company to only accept certain med requests). But supposedly we have these systems in place including with Medicare/Medicaid (sort of).
The problem is that nobody agrees what is an appropriate use of these things and in America that's going to be impossible.
Even if you can get agreement on what kinds of things are worth it........every last person is going to disagree when it's their turn to be told no, especially when it's no....you'll die now.
With respect to fraud it does happen but it's rarer than you think, calling out Medicare fraud is actually incredibly profitable for the whistleblower. Which is neat and stops a lot of bad stuff.
The government has also come under fire in the last few years for faking fraud because they had a quota system.
Skill issue tbh, I never had an RNG problem. I found that keeping a list of tasks and theories loosely sorted by likelihood, and playing each run flexibly with "I'll start out going for X but will pursue something else if that's where the rolls go", I was never bottlenecked to grinding on a single theory until very late in the game (much later than you would have gotten by your description), and almost every run moved at least something forward.
And by that point
But then again I just loved the basic drafting game and would take any excuse for another run. This would probably still be GOTY for me just for the main gameplay loop without most of the stuff beyond the first credits-roll.
Throwaway05
1hr ago
For context I have Idiopathic Thrombocytopenia and I think my OB wanted to ask how to titrate Prednisone.
Yeah my suspicion is this is one of those weird situations where the OB legitimately needed help and wanted to make sure the hematologist got paid for their expertise. They may even have done you a solid by not making you go to a random doctor's office unnecessarily since this was OP.
What was supposed to happen was that the doctor was supposed to review your chart (probably did), see you (clearly no), and write a note (maybe?).
Not seeing you and saying they did is fraud but it's also okay sometimes. Does the delirious or sedated patient really need to see the psychiatrist to give an agitation rec? No.
Unfortunately physicians do a lot of unreimbursed work (like providing education to colleagues) and attempts to get some credit for this can be sketchy or fraudulent without actually being bad behavior.
Obviously in your case you may have appreciated the chance to ask the doc questions but most people would be excited if offered "hey let me just call this guy instead of scheduling you an extra appointment somewhere else" but it's technically not allowed.
Sometimes what we can vs cant bill for is stupid as hell (for instance: dealing with insurance!).
Since the hematologist would have accepted legal liability they def wanted to make sure they got paid and because most people's bill turn into a 20 dollar copay it doesn't get looked at closely.
Personally I think this is sketchy but fair, for those who think otherwise consider the side effects of formalizing things and reducing flexibility.
VoxelVexillologist
Multidimensional Radical Centrist
1hr ago
Or Desert Bus.
chooky
1hr ago
You're right, my bad. I think I just remember watching countless book reports of Greenwitch in 5th grade, which was popular due to its low page count.
VoxelVexillologist
Multidimensional Radical Centrist
1hr ago
You can teamkill and there are no guardrails against it.
Some of the most fun moments I've had with friends in HD2 involve hilarious team kills. From the accidental "Uh oh, got sniped and dropped the orbital bombardment on our present position" to the intentional "Why does someone always call a bombardment on our extract point as they get in the chopper, sometimes hitting stragglers?"
Throwaway05
1hr ago
Insurance is already calculating the relevant numbers, they can just show them to their customers / the public.
I don't think this is accurate. Insurance knows how much it costs to insure someone in aggregate and where to set their premiums.
They do not know how much stuff actually costs a hospital in aggregate (they attempt to guess and knowledge of this is extremely valuable to the insurance company and extremely detrimental to the hospital). They know what the hospital claims the stuff costs them in aggregate. Often the hospital doesn't know how much it really costs because even though they can add up everything they spent money on it is incredibly difficult to breakout what was spent on what because how do you account for things like admin costs. Do you spread them equally over all departments? Do you try and track what department those admin were spent working on (expensive, hard). How do you account for all the salaried people taking on extra work for no additional pay like physician committee work. Hospital employee a lot of people, a lot of types of people, many places will account for things differently than each other.
All of that is the aggregate stuff.
Nobody knows how much many types of individual things are going to cost a specific patient because the error bars are so large. You also have stuff like "this patient is ready for a downgrade to rehab but the insurance company isn't approving the prior auth because it is Labor Day. Does that suck? Yes. Does it need to get paid for by somebody? Yes. Is the insurance going to pay for it? Usually. Is that hard to calculate when giving cost estimates? Yep.
Sometimes the insurance company is increasing the costs for no reason other than their own inefficiency!
In short medical billing is hideously complicated and doesn't work like anything else and that should be trivially obvious because of what healthcare is necessitates that it not function like other economic activity.
Attempts to criticize or change it should necessitate some Chesterton's fence type thinking.
VoxelVexillologist
Multidimensional Radical Centrist
1hr ago
I have long thought that modern medicine could use a bit of an adversarial model on whether specific treatments are strictly necessary. Briefly, doctors are incentivized, at least slightly, to treat patients that may or may not benefit from the treatment. As examples, I'd point to the occasional fraud charges brought on accounting of billing Medicare or Medicaid for unnecessary services, and occasional horror stories of long chains of medications for symptoms of other medications for an original prescription from three doctors ago that has never been reconsidered.
As a weak contrast, I've heard stories from more centrally run health systems where "have tried seeing if it gets better on its own?" was a much more common question. Not for all situations, but "wait 12 weeks to see a doctor" comes across similarly, if not direct medical advice.
That said, I don't think modern health insurance is a good adversarial system. But maybe we do save a few unnecessary procedures (and presumably put hurdles on ones that are necessary).
Probably they reviewed your chart and provided legitimate advice but didn't want to see you because it didn't alter management or was grossly inconvenient. Now they've done something and have legal liability so the hospital will insist they bill and it is somewhat legit. Radiologist and pathologist don't come to see you.
This is probably what happened but shouldn't there be an ICD code for that? It just seemed sketchy that they insisted I saw the Hematologist in person, as described it sounded like a office visit (this wasn't in an in-patient context, charge was a few weeks before admission for delivery). Hematologist should be paid if my OB asked a question, and I trust my OB to only ask good questions, but presumably the cost is less for a phone call vs. going into an office, paying office staff, paying for the examination room, etc?
For context I have Idiopathic Thrombocytopenia and I think my OB wanted to ask how to titrate Prednisone.
The_Nybbler
If you win the rat race you're still a rat. But you're also still a winner.
1hr ago
Consider the case without the pre-auth. Services are rendered, a bill exists that shall be paid, one way or another. Nothing really stops the insurance company from just saying "no" regardless of whether the policy covers the thing or not... at which point, either the provider will argue with them, or the provider will say that the insurance company said "no" and leave the patient to argue with them if they care to. (Otherwise, of course, they must pay the bill themselves.) But now, all of this happens after the fact. What have we improved?
Without pre-auth, the patient has gotten the treatment and now "someone" is going to get stuck with the bill. With pre-auth, the patient can be denied treatment. Both of these are bad outcomes of course, but which is worse depends on the urgency of the treatment. When the insurance company lodges a (specious) objection to cancer surgery, their negotiation tactic could literally kill the patient. Also without pre-auth, the patient has more leverage; it's the provider who is on the hook if nothing is done, and the provider has lots more skill dealing with the insurance company. With pre-auth, the patient is just stuck it the provider won't dispute it and they can't deal with the company themselves. They have zero leverage dealing with the insurance company, since they're not the customer.
OracleOutlook
Fiat justitia ruat caelum
1hr ago
Kind of like Hinduism?
To be fully self-existent in Classical Christianity means to be fully actual, with 0 potential for change. If your idea of God is one that can change, then it is one that can be acted on. There is an explanation for why your God is in the current state instead of another state. This explanation pre-exists your God. Your idea of God doesn't really explain anything about the world and we are still left with the question of why is there something instead of nothing. Which is fine, it's something that the Greeks and other Pagans accepted and lived virtuous lives according to their customs for generations. It's not terribly satisfying to me, just like it wasn't satisfying to Plato and Aristotle. But it's not going to cause a huge cognitive dissonance on its own.
My point is that LDS teaches something like "God is just like us, just more self-actualized and powerful. Theosis is us leveling up according to the nature we already have that is equal to God's."
Classical Christian thought is more like, "We have a different nature from God's, but He promises Theosis anyways through the marriage of Heaven and Earth in the Person of Jesus Christ. Human nature has now been grafted onto a Divine Person and we are able to participate in the internal life of God through conformity to the perfected human nature of Jesus."
Throwaway05
1hr ago
You do see this kind of behavior sometimes and it can be extremely sketchy/represent illegal behavior or it can be ".....fine" or outright "okay."
Be curious if the hematologist dropped a note on you.
Examples of each:
-A kickback program of some kind. They are rare but they still (theoretically) exist.* Typically in shady for-profit health systems. Hematologist didn't do anything useful and didn't see you.
-An annoying consult or weird consult interaction. OB asks the hematologist something. Maybe it was a stupid question, maybe it wasn't. Maybe they dropped a note on your chart maybe they didn't. Now it gets weird. Do they go see you? They might be doing coverage in another city. Did the OB say they talked to you even though they were supposed to just ask a non patient specific question? Did they actually review your chart?
Probably they reviewed your chart and provided legitimate advice but didn't want to see you because it didn't alter management or was grossly inconvenient. Now they've done something and have legal liability so the hospital will insist they bill and it is somewhat legit. Radiologist and pathologist don't come to see you.
-They did actually see you. This is most common (we inpatient at least). Stop by at 4am and make a token effort to make you up? Oh you are in the bathroom, I'll come back later? These are obviously annoying as hell as a patient but depending on the interaction it may meet standard of care (especially for consultants that may not need to see your or talk to you). I promise you whoever did this is actually doing work somewhere or otherwise engaged in fruitful activity.
Of course it could be total nonsense and someone actually scheduled an appointment accidentally.
*I've worked/trained at some places where I've had concerns but never been approached or had any actual evidence.
I don't know what your heuristics are. If it's a game you would like, it's absolutely worth $30. It's a masterpiece in almost the traditional sense (one very competent guy polished it for 8 years, it's a completely realized coherent vision), the pinnacle of most of the genres it's attached to, and very fun.
Probably 15-20 hours to beat the part of the game that most people will stop at (and clearly have enjoyed thoroughly), and 100+ hours to optionally go beyond that if you still don't want to put it down.
The "Blue Prince/Blueprints" homophone is deliberate.
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