domain:alexepstein.substack.com
ArjinFerman
Tinfoil Gigachad
1hr ago
Doing these necessitates a bunch of complicated questions. Do you refund people if they "use" less? Can you charge them more if they "use" more? Is it fair to charge someone 4k instead of 100 dollars because of an alcholic?
That's just a restatement of your third argument, and it does not show how calculating the price is impossible. These sort of calculations take place in most industries all the time.
If we are going to make everyone pay in and pay out according to who uses it why not just simplify it and make it socialized medicine which is the logical solution?
That was my original question, if you remember, and you asking it makes no sense. For one, socialized healthcare is the opposite of "pay in and pay out according to who uses it". For another, how is the government supposed to allocate the healthcare budget, if calculating the prices is so impossible?
Developing accurate numbers is complicated, time consuming, and expensive and puts hospitals at financial risk due to insurance shenanigans.
Insurance is already calculating the relevant numbers, they can just show them to their customers / the public.
fmac
Ask me about bike lanes
1hr ago
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 use every "more wonders" submod and I find them in a pretty good place, but that's also personal taste.
Supply reducing mods are mandatory, they can be found on the forum
Throwaway05
1hr ago
Ask them the most ridiculous thing they couldn't get covered or documentation change they had to make to get coverage.
Should get some good stories.
TeknOShEeP
1hr ago
This is excellent information, thank you!
OracleOutlook
Fiat justitia ruat caelum
1hr ago
If these numbers are well understood, I wonder if you could buy "procedure insurance" instead of general insurance.
Throwaway05
1hr ago
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.
Psychiatry is a great example of this. Do you prescribe the homeless schizophrenic the best drug or the cheapest one or the one that is easiest to take. These are very often all different medications and have different results.
In a different patient population you might ask the patient to decide what makes sense for them, but the schizophrenic has cognitive deficits from the disease (not counting any other factors like malnutrition and drug use). They can't adequately consent to to complicated cost benefit analysis.
Even highly educated, intelligent, frickin healthcare workers botch this when they are on the receiving end.
So then we have to wonder if the plan is to dictate patients get the cheapest medication not the most effective one....or vice versa.
As you mention it's complicated and ethically difficult.
Tenaz
1hr ago
In LDS theology there are no creatures at all. Everything exists eternally. We don't think God is "caused" somehow or dependent on some greater god for power; he's fully self-existent just as in other Christian theologies. It's just that we are too.
John_Doe_Fletcher
anarcho-heretic, Quokkit guy
1hr ago
I think Hellsing Ultimate has a pretty great dub. Also (and I know some would say this is breaking the ruurus) the dub for Panty and Stocking with Garterbelt fits the "Powerpuff Girls but X rated" style. It's bretty gud.
Throwaway05
1hr ago
One of my attendings in training did an exercise with a patient where the patient was requesting something that was technically appropriate but would cause prior auth difficulties and could be avoided.
It was at the end of the day so he told the patient he would get it approved if the patient sat with us and if the patient left he would be discharged from the practice (deeply unethical but hilarious).
The three of us sat there for something in the 2-3 hour range while the attending argued with insurance, completely unpaid.
It worked.
Was it worth it? No.
Did the insurance win even after they approved the med? Yep.
Throwaway05
1hr ago
I mean I think that happens every time?
"Oh shit that looks bad" here are basic details "oh shit we were wrong."
This one was certainly "worse" (as in looked bad) than most of the others.
I think the dems blew a lot of juice in magnifying Floyd though, and as mentioned all kinds of other pressure cooker stuff was going on.
Throwaway05
1hr ago
Accepting the fixed costs of a quality insurance plan is obviously the best idea.
After that it depends on risk tolerance. A hospital is required to treat you if you show up even if you clearly won't pay you can then deal with medical debt. This is how homeless people function. Obviously not a great idea but you pay nothing (and also get no preventative care).
Speaking of which if you have any medical complexity you need a real plan.
That said if you are otherwise healthy you can try and get a catastrophic plan or other high deductible plan and realize the risks. Again recurring expenses cause problems.
I will draw your attention to direct primary care however which may be viable - you basically pay for a subscription to your PCP. Obviously this has recurring costs but it means you cut out insurance and therefore it can be much cheaper (because dealing with insurance is expensive for your doctor also) and if your PCP is good you won't need much in terms of specialists.
However you need to pay for other types of costs somehow (like hospital care).
Tanista
1hr ago
Yes, this is the stance that conservatives eventually took. Questioning whether the hold was illegal, whether he had fentanyl in his system, whether Floyd was another deadbeat criminal.
I don't think it was the initial reaction. The initial reaction was "ooh, looks bad".
Throwaway05
2hr ago
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.
Doing these necessitates a bunch of complicated questions. Do you refund people if they "use" less? Can you charge them more if they "use" more? Is it fair to charge someone 4k instead of 100 dollars because of an alcholic? If we are going to make everyone pay in and pay out according to who uses it why not just simplify it and make it socialized medicine which is the logical solution?
Developing accurate numbers is complicated, time consuming, and expensive and puts hospitals at financial risk due to insurance shenanigans. If you make it voluntary they'll do it where it makes sense like they do now. If you make it mandatory you need to put a number on how much you are willing to increase healthcare costs to do that and answer some of the questions above with respect to what to do about it when it fucks up.
Tanista
2hr ago
Harry Potter has Hogwarts houses with found families based on character traits ordained by a magical hat. Both are about social institutions that provide the security of structure without the rigidity of oppression, with many stories revolving around how morality and justice override authority.
It's basically sports teams for nerds as well.
But also after a long period of miss after miss, even my geeky friends aren’t into Star Trek. I know more fans of The Phantom Menace than The Next Generation. I remember when I took IT classes and the instructor was appalled when I was the only one in the class who copped to liking Trek. Nerd culture has changed.
Interesting that this applies to me, despite not really being a central example of a nerd (bounced between Africa and the UK and came to America relatively late) . I never really had "my" Star Trek show, I did catch some episodes and Nemesis (which didn't help) but I was more of a Star Wars/Stargate and then Battlestar kid. My impression was that I simply fell through the cracks between major ST shows but I checked and Enterprise was airing right up until the time of BSG's first season and Voyager and SG-1 overlapped so those shows were out there.
Might just be a change in values or people tiring of it? Stargate was milscifi without the utopianism.Battlestar was self-consciously made by former Star Trek writers to avoid problems they thought Trek had (and to be much darker in a post-9/11 world). Just as Sci-Fi Channel took BSG and Stargate out back and shot them when they were seen as outdated. I thought it was absolute folly but they may have been overcorrecting due to past experience.
ControlsFreak
2hr ago
I don't think I'm being naive enough to say that the providers and insurers will sing kumbaya and everything will get happily approved perfectly as it should be. As evidenced by the doctor's comments elsewhere in this thread, both parties take every single interaction as a chance to negotiate and improve their take. If anyone has an idea to fix this, I'm all ears. But I'm certainly not counting on it.
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?
Instead, the only choice I think we have much hope of making is whether they have to hash out their beef before or after patients have to make decisions that could bankrupt themselves because of the crossfire. I'm certainly open to ideas for reforming pre-auths, so that they get that hashed out before patients have to make these decisions. Time limits, whatever. Any ideas for how to do any better?
Throwaway05
2hr ago
I wrote up a response a few different ways but ultimately I couldn't write something satisfying without a lot of follow-up questions so I'll just point out that usually the reason why things are weird and complicated is because the insurance company refused to pay for something common sense so the hospital had to do some equally weird shit in response.
ArjinFerman
Tinfoil Gigachad
2hr ago
I dunno. There's stuff you can pin on any authoritarian regime, but it clearly resembles some ideologies more than others. I think it had a pretty specific inspiration as well.
Which is why you'd charge me the expected price to begin with, and deal with the variables yourself, maybe adjusting the prices every couple months as the situation calls for it.
You definitely would not tell me how it's impossible to calculate the price of a sandwich, because maybe the fridge breaks down that week and you might need to buy a new one.
Throwaway05
2hr ago
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
Depending on your perspective it's either far better or worse than you imagine.
The physician's note was historically designed as a record of medical decision making on a patient and we are still primarily trained in this task. However they are now used as a record for billing, a record for legal ass covering, delivered to patients, used for cross staff communication, and as repository of information for research purposes.
As there is the greatest financial interest in doing so you more often see time and effort spent on maximizing billing but it's totally reasonable.
If I see a patient with high blood pressure I'm going to write something like "yo this patient has hypertension get some amlodipine in here stat."
Then the insurance goes oh we aren't going to pay because you didn't establish this patient has hypertension. What do you mean their blood pressure is high and its been high for 20 years and the last doctor had them on amlodipine.
Nope no hypertension.
(Billing staff: psst doc write primary hypertension)
.....Primary hypertension.
OH WHY DIDNT YOU SAY SO HERE HAVE SOME MONEY.
The classic for a long time was the Review of Systems which is sort of deprecated now but had resulted in tens of thousands of doctors being trained that if they didnt ask about renal, dermatologic and reproductive symptoms they couldn't get paid for this trauma patient whose arm fell off.
"The patient was anesthetized!!!!!" "Well just write 'patient declined to answer seven times.'"
It's not charging you for every 15 minutes of time like a lawyer its struggling to get paid for stuff we clearly did.
Yes some fraud and abused exists but essentially every physician has to be constantly thinking "what humps do I jump through to get paid for the basic standard of care thing I did."
Quantumfreakonomics
2hr ago
OK, but then you charged us separately for the ultrasound and the doctor's time, so you are essentially double-counting.
What about the nurses’ time? What about the time spent in the facilities? What about liability risk? The time spent by the doctor is not the only institutional decision-makinng cost that the hospital incurred.
anon_
2hr ago
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.
I haven't seen your details, but the complex issue could be the ED physician and the extra doctor's time was probably the radiologist. It's not double counting.
OracleOutlook
Fiat justitia ruat caelum
2hr ago
I remember once being billed for a 1 hour visit with a hematologist I never saw in person - my OB consulted with them. When I asked billing they replied, "That's because you saw the hematologist." No matter what I said, they kept insisting I had an in person visit with a hematologist, even had a specific date/time I supposedly saw him (though the visit did not show up in OneChart, hmmm?.) Eventually gave up because it was "only" 200 or so after insurance and I was dealing with the other hospital billing issues of being billed by the visiting hospitalist OB in a completely different system and it going to collections before I got a whiff of the charge.
IMO this is society's brain on women.
But seriously. I've been told over and over again (by women) that their feelings are their truth. I've also observed many times that they tend to expect everyone else to treat their feelings as a priority and rarely seem interested in taking responsibility for managing those feelings or taking initiative to behave in such a way as to get better outcomes.
How many run-ins with HR must a man have before he recognizes the pattern?
I'm not trying to be incendiary or run afoul of the rules here but from where I'm standing this is just blatantly, obviously what's going on.
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