domain:nfinf.substack.com
netstack
Texas is freedom land
13hr ago
I would argue that he has been doing this with remarkable consistency since his first term.
But perhaps that messaging is what it takes to win a contract?
The_Nybbler
If you win the rat race you're still a rat. But you're also still a winner.
13hr ago
The useful idea behind prior authorization is that the provider and the insurance company should get together... get their shit together... and figure out what the price is going to be for the patient. And, frankly, that makes sense, especially for items that often have significant variance. It's hard to make hard and fast rules here, but my sense that many insurance companies have a list of items where there is significant variance and so they require prior authorization.
This is fine for a steelman. But in real life the insurance company likes to treat prior authorization like a negotiation. That is, they'll start by just saying "no" regardless of whether the policy covers the thing or not. Then 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.
FlailingAce
13hr ago
I mean in the sense that doesn't match the meaning of 'price'. Conceptually a price is a fixed value that you will pay, not a variable. If you come in my store and ask the price of a sandwich, and I tell you $10, and then when you check out you're expected to pay $15, you would rightfully tell me I lied about the price.
MadMonzer
Pedo! Pedo! Pedo! Out! Out! Out!
13hr ago
Given that Concorde was not close to being transformative, I think Boom would need to be 10x better than Concorde to be transformative with >50% probability, and they seem to be going for 2x.
anon_
13hr ago
Hospitals have a perverse incentive to "upcode" your bill, that is to put down a code for a higher tier/cost, of treatment that you received. This is illegal, but it happens with shocking regularity.
There is also the converse problem -- I am friendly with a lot of doctors and they are all beyond frustrated that they will get an appointment for visit A and patients will expect them to also cover B,C,D and E. This is especially bad at the level of preventative visits turning into issue visits".
They have different approaches. Some will bill higher codes if patients want to talk about something outside the scope. Others will ask them to come back (or do a Telehealth followup). Sometimes they'll just eat it if the patient is quick about it. None of them have an objection to doing those visits, it's just that they aren't reflected in their scheduling or billing.
I expect upcoding is more of a problem than scope-creep, but I wanted to mention it because the symmetry is there.
ArjinFerman
Tinfoil Gigachad
13hr ago
As long as these are reasonably predictable, you can calculate a price.
I don't think that's true at all.
I'm sorry for being pedantic, but how does that mean what I said is "not true at all"? You literally just gave an example of a calculated price. Someone might not now a median from their ass, but you can tell them "just look at the expected value, bro". They can then use that information to compare with other providers.
FlailingAce
13hr ago
Many don't like this but you can't really function in our system without having insurance
If you were to attempt to function in the system without insurance, how would you go about it? Asking for myself.
When I was younger I went uninsured for a few years, and a few more on a catastrophic plan, and happily didn't have any issues. Now I'm older and married and my wife has a lot of worries about not being insured (I currently have full health care coverage from my job but I'm about to leave that career). Conceptually I think 'health insurance' is a misnomer the way it's typically used, that only high cap catastrophic plans actually constitute insurance, and frankly that I'd much prefer saving and investing my money instead of giving it to an insurance company.
However, anecdotally I've heard it's a real pain to get medical care if you show up and say you don't have insurance, and that you'll just pay for everything yourself. So, do you have any advice on how to do that effectively?
netstack
Texas is freedom land
14hr ago
It’s incredible how Orwell wrote something which, no matter one’s political affiliation, candidly describes one’s outgroup.
TowardsPanna
14hr ago
Yup, I played a few games with VP. It's very good. But it's not Civ 5. They basically created a new game with it. Which is fine, lots of people love it, but I actually like un-converted Civ 5 more, despite it having its issues with balance etc. VP nerfs the wonders too much for my liking, and the wars turn into long slogfests and meatgrinders. The AI fights them more skillfully, I'll give them that. But it wasn't necessarily super fun after a while.
I tried Lekmod too for a few games. It's very good. It's somewhere in-between in terms of how much it changes. Only real downside is they haven't added graphics for all their new civs/leader screens. You get many grey screens during diplomacy. It's mainly a multiplayer focused mod, where I guess you don't see leader screens or something.
I remember having to get an X-ray for an injury a few years ago and not a single person from the hospital or insurance company could give me a straight answer on how much it would cost me out of pocket. This was a procedure with extremely predictable costs and no potential for complications and still, after hours of navigating the insurance company's websites and phone trees, I had to give up. I'm sympathetic to the concept of price transparency generally but when it comes to healthcare I do have some concerns.
I've always wanted to ask those most ardently supportive of socialized healthcare: we have finite resources, where will you draw the line for what medical services we do and do not provide? Does grandma get a $300,000 chemotherapy course for a 60% chance at 2 months of vomiting and brain-fog? In a single payer system, the government has to make those decisions.
I saw my colleagues prescribing suboptimal drugs and thought they weren’t practicing evidence-based medicine. In reality, they were doing something better — practicing patient-based medicine. When people said they couldn’t afford a medication that their insurance didn’t cover, they would prescribe an alternative, even if it wasn’t the best available option.
The cost-benefit landscape is high-dimensional, fuzzy, and rapidly branching with time-delayed consequences. "Informed" consent is a complete misnomer and I have to wonder if given complete price transparency whether healthcare wouldn't completely devolve into a Market for Lemons. For those who want complete price transparency: do you think the populace is equipped to make those decisions for themselves? We have enough snake oil products as is. How long before a price transparent but information asymmetric free market devolves into the same? The current system seems to eliminate the principal-agent problem, giving doctors less incentive to stray from optimizing for standard of care (hopefully one of our resident doctors can comment on whether this is at all an accurate assessment or a complete misinterpretation). The downside is this price-opaque mess. I'm not sure if the alternative is better or worse for society at large. Do you really want hospitals cutting corners and trying to undercut competitors on prices? A/B testing in medicine takes years of expensive and coordinated clinical trials. It's not something as quickly self-correcting as a restaurant going back to more costly ingredients because their customers notice the decline in quality and the consequences aren't as trivial as a bad meal.
anon_
14hr ago
Boom is reasonably likely (2:1 odds) to get commercialized supersonic passenger transport by 2040. I think that will seem like a mere evolutionary change (plane go faster) but, if it succeeds and scales, will be transformative.
100ProofTollBooth
Dumber than a man, but faster than a dog.
14hr ago
Maybe it shouldn't be called "mental health"
That's my point, and that's why I caveated my post with "Tangent"
but what would you prefer for such a reasonable ask?
Nothing. It is, in fact, a reasonable ask. It's not a mental health question. "Patient comfort" sure, "procedural professionalism" whatever.
I don't think it was your intention, but please try to avoid conflating the points I'm making.
ArjinFerman
Tinfoil Gigachad
14hr ago
Ditto for the conversations a couple years back about how the UK Tories were showing everyone what right-wing competence looked like.
I was thinking a lot about that one too.
FlailingAce
14hr ago
Major complications of surgery are 1%-10% depending what we are talking about, certainly orders of magnitude more (yes I know I'm missing some things about car insurance for the sake of simplicity)
As long as these are reasonably predictable, you can calculate a price.
I don't think that's true at all. You can calculate an expected value, but 90%+ of patients won't understand that. If you tell them the price of a procedure is $2000 dollars, but the typical/median price is $1000 and the max is a million, how are they supposed to use that information?
gattsuru
14hr ago
Girl Genius was well-enough regarded in the Hugo set that they had to actively refuse nominations into the start of the Sad Puppies era, and they're still pretty well-regarded among the tumblr set, modulo a few (not wrong!) complaints about the comic's pacing. I'd like to say they've been grandfathered in, but I'd said the same for Lackey and was proven wrong, so I'll guess it's more that even if they're not faster than the bears, they're at least faster than the other guys.
((Fair on the het bit; especially given the fandom, it is unusual that the closest thing to an in-universe mention of a gay pairing in Girl Genius has been joking references to Othar/Gil. There was one M/M bit in one of the old XXXenophile, but it was actively less erotic than one where a guy's brain had been transplanted into a dog. Given conventions of the convention circuits of the 1990s (where there was a much stricter wall between gay and straight than today) and the amount of F/F the series had, I was never sure whether this was just down to the Foglio's audience, but it probably does point to Kaja not being a fujoshi.))
FCfromSSC
Nuclear levels of sour
14hr ago
With this latest capitulation, I've thought about doing a bit of a gentle retrospective over the various long-running fan debates here on the motte over whether or not The New Stuff was or wasn't a good idea. Most of those conversations died off as most of the old-timer Blues left, but it seems now the writing is pretty much on the wall.
Ditto for the conversations a couple years back about how the UK Tories were showing everyone what right-wing competence looked like.
Azeltir
14hr ago
I think the author is making a somewhat more reasonable point than "we shouldn't have to worry about the bill" - it's that they shouldn't be having such a worry added on last-minute to the existing worries of a surgery! Maybe it shouldn't be called "mental health", but what would you prefer for such a reasonable ask?
sarker
It isn't happening, and if it is, it's a bad thing
14hr ago
It's totally unrealistic. Not once did the player character need to take a shit despite the length of the journey.
100ProofTollBooth
Dumber than a man, but faster than a dog.
14hr ago
So, in an unexpected instance of "the system works" would this imply that the frequent flyer hypochondriac who asks the doctor dozens of follow up questions, thereby turning a 15 min consultation into a 45 minute one, will actually end up paying (either directly, or via their insurer) more?
Hospitals have entire departments whose job it is to comb through notes.
Fuck. That. Noise. So, an army of functionaries use their best judgement to try to translate a doctor's notes into one or more of a series of codes to reconstruct the exact service provided? I thought lawyers billing me in 15 minute increments was bullshit. After the fact reconstruction of what happened layered with overly hierarchical categorization is a new level of theft.
dev
14hr ago
An issue that made be angry recently was that my kid's emergency room stay was upcoded from level 2 to level 4 because they wanted to take an ultrasound, which meant an extra $2k in charge, but then they charged be separately $3k for the ultrasound and $1k for the doctor's time. I asked, why is it level 4 when we weren't urgent, it took us 6 hours to be admitted? The answer is that the guidelines say that level 4 is when "more complex decision making is required" or a diagnostic test like an ultrasound is required, which is what they did. OK, but then you charged us separately for the ultrasound and the doctor's time, so you are essentially double-counting. The bot-like tier 1 billing support person did not understand this argument though, and since I already had paid the bill I had no leverage.
ArjinFerman
Tinfoil Gigachad
14hr ago
Medical care is one of the most inelastic things arounds. If you need something or you will die that's a pretty good thought experiment for what perfect inelasticity looks like. For things that are less inelastic (primary care appointments say) usually not doing it is the actuarially wrong decision and demand should be more inelastic.
Patient's aren't the ones paying. Insurance pays. "Randomly" your insurance or the health system or some weird combination of laws and policies screws you. The government tries to close these but it turns out to be really hard to do for a variety of reasons.
Those sound like arguments for price transparency, not arguments for the impossibility of determining pricing to the end consumer.
Your chance of crashing into one of those cars and somehow being on the hook is one in a million. Major complications of surgery are 1%-10% depending what we are talking about, certainly orders of magnitude more (yes I know I'm missing some things about car insurance for the sake of simplicity)
As long as these are reasonably predictable, you can calculate a price. The specific issue you're talking about might mean that the price is higher, not that it's impossible to give an accurate number.
Also - now insurance companies can use fancy computers and actuarial tables to even things out and stay functional but if you tried to do this directly with health system you may end up with something like: "hey this thing should cost 100 dollars but instead it costs 4000 because that guy over their refuses to stop drinking soda and vodka instead of water." People get pissed by that in the U.S.
That could be an argument against price transparency, but not an argument for the impossibility of providing accurate numbers. Even then, this point can be argued against, it's not like it's unheard of for regulators to tell companies which factors they're allowed to take into account when making their calculations.
100ProofTollBooth
Dumber than a man, but faster than a dog.
14hr ago
Given that presurgery mental health is surely part of the institution’s concern
Tangent here.
Not only no, but fuck no. To this.
The quick little slip of "mental health" here is an exemplar of how insidious current perspectives are on the topic.
When (normie) people hear the term "mental health" they automatically connect it to images of depression, bipolar, maybe even schizorphrenia, along with PTSD etc. A "mental health crisis" might even conjure desperate scenes of attempted suicide or some full blown panic attack that necessitates the men in white coats arriving.
Whatever the specific circumstance, we're dealing with a disorder of some kind. Perhaps mood related, perhaps cognitively related, perhaps something more broadly endocrine (note: there are some cases of neurological issues, but I always roll my eyes when people use the term "brain chemistry" as it is both horribly imprecise and, more to the point, they're usually talking about the endocrine system as opposed to a brain (as in the grey matter, not the concept of mind) specific neurological problem")
These things are called disorders because they represent an unexpected and maladaptive response to normal life circumstances. Depression; "I have a good job, an active social life, stay in shape, and don't abuse any substances. I'm horribly sad all of the time. What do?", Bipolar disorder: "I have a good job, an active social life, stay in shape, and don't abuse any substances. But these mood swings are causing me to drink, miss work, not go to the gym, and alienate myself from people. What do?", Schizophrenia: "The Jew Aliens keep reading my brainwaves without my permission. What do?" (Okay, I had fun with that last one).
What the NYT author describes is categorically not a "mental health" issue. Getting an unexpected and alarming piece of mail should cause some level of distress. If you're totally incapable of dealing with that distress, my first response would be to question general maturity and life capability. A second would be to look at your specific life circumstances at the time to see if there's a charitable reason why you might be in a bad position to deal with such an occurrence. Only much, much later would I start to think, "Well, maybe this guy has an awful mental health disorder which makes it hard for him to deal with ... things happening and mail."
"Mental health" is not a species wide mission to prevent bad feelings from happening. Especially when the given circumstances would naturally provoke negative feelings. But this is yet another wonderful biproduct of the culture war; bad feelings have become pathologized as a) horribly disturbing and never to be expected b) worthy of full and unquestioning accommodation by ALL others and c) probably both someone else's fault and responsibility to deal with.
The author slips all of this in, easy as you please, by asserting that of course his health care provider obviously considers "mental health" to be as high a priority as sterile operating room conditions and well trained staff.
dev
14hr ago
Consider code 97161, "pt eval low complex 20 min." That is, a healthcare provider spent between 0 and 20 minutes in the room with the patient, providing an evaluation of a low complexity issue.
Is this "20 min" just the time the doctor is in the room with the patient, or does it include total doctor time for the appointment (including time spent looking at readings, time spent consulting with the nurses or their assistants, time spent writing up notes and doing paper work)? I've seen bills where it comes across as "30 minute appointment" even when the doctor spent 5 minutes with me, but then I do see the doctor wrote up a bunch of notes and so there clearly was time spent outside of the room with me.
ControlsFreak
14hr ago
prior auth reform
I am sad that you won't see this, because I am genuinely curious to find out what you mean by this. Like, it could mean anything. We could reform it in a way that is even pretty painful for insurers. Could make it basically mandatory for many of the things (at least anything that has some minimal level of denials happening), and require insurers to respond within certain timelines, electronically or whatever. Then, you'd have less uncertainty about what they'll want to do, and you'll have good information to give to your patients. I kiiiinda think that this isn't what you have in mind, and yeah, am just super curious.
But is it a "polar bear hunting" joke?
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