domain:academic.oup.com
Throwaway05
4hr ago
I didn't mean your specific situation, apologies if it came across that way.
In this case, there is a pre-negotiated master charge list
Those numbers should still have been negotiated with some bullshit juju thought right?
One of the crazy things
Ahh shit, I meant to also blame providers in my post and may not have. Yes it's not uncommon to see someone and have them go "oh I can't handle that" and send you to the ED. A good chunk of that is absolutely to shift liability and is inappropriate but common. Biggest issue is when you say something unrelated to a specialist. Tell your endocrinologist that you checked your blood pressure at home and it was 160 over something and they'll send you to the ED even if that isn't quite appropriate. Another common problem is increasing specialization leading to specialists not knowing as much outside their field and PCPs being limited in what they can do and know (especially with midlevels). Lastly you have legitimately complicated shit, I don't really do peds at all IIRC from med school people are super fucking careful with kids that young. I think an urgent care would probably also sent you to the ED especially if ultrasound was standard of care.
Incidentally peds providers get paid way way way way way less than adult medicine.
If our child was on telemetry
It sounds like you were paying for hospital level of resources and in ye olden days your kid would have been admitted but now instead it can be managed conservatively outpatient - but you need inpatient level equipment (the ultrasound). One of those weird gaps.
Ultrasound is in a weird spot because it's evolving from a "nobody in the ED to can do this" to "we are starting to train everyone from day one to do this because its safe and cheap" but we are in the middle of that process. Wouldn't be shocked if in 5-10 years most PCP offices were doing it.
hydroacetylene
4hr ago
I know Texas state reps are happy to(have their staffers) research obscure state regulatory issues for constituents who call complaining about it, at least if you are a precinct chair in the same party.
I would suggest reaching out to local republican Apparatchiks to ask state legislators if they can find the regulation.
urquan
Hold! What you are doing to us is wrong! Why do you do this thing?
4hr ago
I've never actually watched either Stargate or Battlestar!
My parents are boomers, so they watched Star Trek and The Next Generation when they aired, and especially saw the films when they started coming out. Talking to them about movies is an interesting experience: they remember a time when movie theaters were everywhere, and going to see a movie was almost an everyday occurance. My dad talks about how when Star Wars came out in 1977, he saw it several times before it left theaters.
So I grew up on watching Star Wars films with my parents, we'd pull the lounge chair into the center of the living room and I'd curl up with my dad and watch the OT. When the prequels came out, we watched those too, but my favorite was Empire, obviously. When I was a little older we started watching Star Trek too, I remember liking Star Trek 1 and I was surprised when I got older and found out everyone hates it. But I also was obsessed with the Voyager probes as a child, so I guess it hit the spot for me.
Star Trek and Star Wars have always been the most mainstream of the space franchises, so I grew up with them as normal popcorn movies that my parents liked. Now, if you start talking to my mom about Lord of the Rings, that's where you'll start finding the nerdiness.
So part of this is that I grew up on a bit of an older wave of nostalgia, and I don't know what the Xer and Millennial parents of my cohort raised their kids on.
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.
Yep.
I think its less awkward when its actually a norm, but sometimes it does get used as a backhanded way to 'beat' someone by claiming "hah, you don't actually believe [thing] unless you put money on it!" Sometimes there's just too much uncertainty or the terms are inherently poorly-defined, even if the belief is tightly-held.
But that said, man, when you know there's some status hanging in the balance (i.e. if you 'lose' a few bets people might keep using that to undermine your arguments in the future), even if you're perfectly calibrated (i.e. you win your 50% bets 50% of the time) a couple losses in a row can make you feel like you're losing face.
Prediction markets offer a decent alternative because it makes the situation less directly adversarial. I would kill for there to be a way to publish your own positions in a way that others can verify and take positions 'against' yours, without it locking both of you into "one must win, the other must lose" proposition.
dev
4hr ago
The hospital negotiates with the insurance by saying X and the insurance says 1/4X and then the hospital says 1/2X and that's what the insurance decides to pay.
In this case, there is a pre-negotiated master charge list with a million cells in by code and by insurer. There must have been negotiation in agreeing to that list, but what we paid was the list price, the insurer did not do any negotiation to lower the chargers. I think this is a newer development, I remember ten years ago or so getting bills where it would say one charge, and then have a lower "this is what your insurer negotiated." But that is not how it worked for this bill. At this point, it looks like the cash pay rates are generally lower than the insurance negotiated rates.
The ED is for if you are dying, if you are not dying you are not supposed to be there, and it is expensive in the way that you'd expect for "this is the place where you are dying."
One of the crazy things is that for a 3mo infant this is not actually how it works. We went to our PCP first, in fact, spent almost 5 hours there before finally getting diagnosed with a UTI...and then they sent us to the ER because our PCP wanted a catheter sample and she did not feel comfortable doing that, so she said we had to go to the ER, that was the only option. Our child did not have a fever, but did have a UTI that needed antibiotics, but the only way to get those antibiotics was an ER visit. From what I have read since then, the type of antibiotics they will prescribe depends on if the UTI is deep in the kidneys, which is why they want to do an ultrasound. We could have easily gone to an urgent care facility during business hours if that was an option, but that was not an option, so instead we spent 6 hours in a packed waiting room which was a hot-box of germy kids.
In the ED nurses have few patients, numerous types of staff you might not even think about are running around constantly (like the lady whose only job is to get people's insurance), people are in and out of your room, labs come back stat, people are constantly checking if you are dying or not. Most patients in the ED are on telemetry, most patients admitted to the hospital aren't. All these things are extremely expensive and a lot of them happen outside of patient understanding and line of sight.
If our child was on telemetry and had people checking in on him constantly that may have justified and expensive level 4 or level 5 charge, but he was not. He was clearly fine and low priority. We were just waiting hours for admission and then after that many hours for for the ultrasound so we could get the antibiotics prescription.
Throwaway05
4hr ago
Pretty normal to essentially charge for "doctor - seeing you, thinking about you, and documenting you" and "things doctor did to you."
However in this case you could alternatively summarize it as "random blender of shit put together in an attempt to get the insurance company to pay enough for the hospital to stay afloat."
Throwaway05
4hr ago
Agree with the other poster and - insurance companies practically practice medicine all the time by deciding what is covered and what isn't, they deny this is the case however "you can still get X thing we just won't pay for it" works very well as a legal smoke screen and in the case of things like malignancy they can absolutely drag their heels and turn your melanoma from a short procedure to life altering or death causing.
FCfromSSC
Nuclear levels of sour
4hr ago
...Has anyone ever heard of attempts to use freezing water to provide mechanical force for metalworking? Making pressings, for example?
hydroacetylene
4hr ago
Health care sharing is a thing. It's worse than real insurance but you're just getting what you pay for there. The one that's solidarity something is better than the one that's samaritan's something. I am not the expert on these things or how they work but there's plenty of people who's main medical expenses are child-related who are very happy with them.
DuplexFields
Ask me how the FairTax proposal works. All four Political Compass quadrants should love it.
4hr ago
What a lot of people never learn is how much the modern imperial states (Fascist Italy, Nazi Germany, FDR’s USA, the Soviet Union and Communist China) resembled each other, differing mostly in how their philosophers describe them and how much (and how often) their governments are perceived to be allowed to violate their citizens’ and enemies’ human rights.
The opposite of libertarian isn’t communism, it’s totalitarianism.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
4hr ago
I think the only person who dislikes the gameplay of HD2 is Cjet, or at least I think he was the person who says it's a grenade chucking sim. He prefers the Starship Troopers game, which is a highly confusing stance! I got my money's worth out of HD2 even though I only played sporadically of late. I also got my money's worth out of ST, if only because he gifted me a copy haha.
I'd love to join in, assuming there's room!
hydroacetylene
4hr ago
Your best bet when dealing with medical bills Act Like a Dot Indian. 'I'm not paying that, it is too much'. They'll knock it down eventually.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
4hr ago
Say what you will about the British government, they have a unified, highly legible design for all their official websites. When I was filling up my DS-160 for a US visa, I was struck by how positively antiquated it was in comparison.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
4hr ago
Aight, I let it through. But you should probably put the submission statement in the body of the post, probably easier to parse once people start commenting. You can do both that and include a link without issue.
hydroacetylene
4hr ago
I mean, you can always cartelize healthcare providers and insurance companies and leave them aligned, together against the patient.
Throwaway05
4hr ago
Okay so two things going on here:
-
The funny numbers bit. The system is designed around everyone having insurance. The numbers on a bill a not random but can essentially be thought of as random. The hospital negotiates with the insurance by saying X and the insurance says 1/4X and then the hospital says 1/2X and that's what the insurance decides to pay. It's stupid but it is the system, the numbers are funny on purpose. If you don't have insurance you get absolutely obliterated but you can usually negotiate with the hospital because they know the numbers are funny, but "you have insurance" and "this weird shit happens" is how society and government have decided to run this bullshit so that's the way it is.
-
The ED is for if you are dying, if you are not dying you are not supposed to be there, and it is expensive in the way that you'd expect for "this is the place where you are dying."
Unpacking this is complicated and it results in a mix of things that are the fault of various patients and things that aren't, but for the most part the ED is more expensive, complicated, and a higher level of care than actually being in the hospital. On a hospital floor things happen slowly - you might have a handful of nurses on a step down floor, your doctor might see you once at the beginning of the day. In the ED nurses have few patients, numerous types of staff you might not even think about are running around constantly (like the lady whose only job is to get people's insurance), people are in and out of your room, labs come back stat, people are constantly checking if you are dying or not. Most patients in the ED are on telemetry, most patients admitted to the hospital aren't. All these things are extremely expensive and a lot of them happen outside of patient understanding and line of sight. The ED is more like an ICU. This is part of why patients being boarded in the ED is such a catastrophe.
In any case the ED is designed such the majority of patient's are pre-triaged. You are "supposed" to go to your PCP first, or people to call your PCP's answering service. Most people used to do that while the modern model was being developed but they don't anymore. Many people use the ED as a PCP, go get obvious "wait and see" things checked out, don't use common sense, and so on. Other people can't really be blamed because they have a sensible complaint and don't triage because they aren't medical people, or because it's hard to get a PCP these days or one with a good answering service. But the system isn't designed for this. Add in other things like homeless and illegal immigrants don't or can't pay and you've got a mess.
Part of this is specifically American - in other countries people use PCP as designed more, or are more comfortable with waiting, but that isn't how we are. Step-down EDs or the equivalent have been triaged but they hard because if you fuck it up you'll get sued to hell (another American problem).
Additionally emergency care doesn't reimburse well from private or government insurance so one has an incentive to build out and staff EDs to match the volume they are getting.
The last piece is the professional fee aspect - you are paying for someone with a lot of training to figure out how safely they can do the minimum on you. Ideally we diagnose without any testing, give you the minimum of interventions, and use our brain power to rule everything that could kill you or be going wrong with your body.
Because we are on the hook if anything goes wrong! But we also don't want to give you an expensive full body scan that will give you cancer in thirty years.
NPs have much lower professional fees but they also scan and test people much more and cause more bad outcomes and unnecessary complications.
You pay ED physicians so much for them to safely do nothing, which is weird as hell but is what the ED is designed for.
hydroacetylene
4hr ago
These are not Christendom. Christendom is an earthly kingdom(or group of kingdoms/republics) dedicated to expanding Christianity in a generally aligned way. It's possible, but a bit of a stretch, to point to some fringey parts(Francoist Spain, South Vietnam under the Ngo family) of the general US sphere in the cold war as the last vestiges of Christendom. But Christendom today is either dead or limited to Liechtenstein. It is, specifically, a state, operating like a normal state.
netstack
Texas is freedom land
4hr ago
More than one, certainly.
I do not believe that the kind of society I describe will necessarily arrive, but I believe (allowing, of course, for the fact that the book is a satire) that something resembling it could arrive...[it is] a show...[of the] perversions to which a centralised economy is liable and which have already been partly realisable in communism and fascism.
Dude hated the Soviet Union; he was also pretty unhappy with getting bombed for years.
magicalkittycat
4hr ago
Why political revenge narratives don't make sense to me.
It essentially implies the difference between the right wing and left wing argument about things are about morals and not about the effectiveness of policy or economic ideas for the good of our country and our citizens. If "your rules fairly" includes doing things that you think are stupid, inefficient, counter-productive and extra prone to corruption then doing it back would be strange.
Presumably if you hold an idea like "smaller governments are generally better for a country's growth" or "the state taking ownership in companies leads to bad incentives" or "free speech benefits the country's citizens and the country as a whole" then it would make little sense to abandon them once you've taken power if you want the best for the nation.
After all if you care about the country, I would assume you want good and effective policy. If you see the left's policy ideas as bad and harmful to our future, it's not a great idea to join in on the self-harm. Unless you're a traitor and hate the country, you would be pushing for what you think is the best policy. Now people might disagree on what is best for growth, what is best for the people, and what is best for the country but we should expect them to pursue their ideas in the same way if they care about America, towards ideas they think are good.
This is part of why principled groups can stay principled so easily. An organization like FIRE truly believes that free speech is beneficial. Suppression and censorship when their side is in power would be traitorous to the good of the country in their mind, even if done out of a desire for revenge. A person like Scott Lincicome of CATO truly believes that government taking equity of private enterprise is bad policy, and thus it's easy for him to critique it.
They aren't "turning the other cheek", they just actually believe in the words they say and the ideas they promote. They want good policy (or at least policy they think is good) for the benefit of the country. Sometimes you can see this in politicians, like how Bernie Sanders supports the plan to take equity in Intel. He believes government ownership of corporations is good for the country so he supports it even when the "enemy" does it. I think he's a stupid socialist but it's consistent with what I expect from a true believer. And you see with libertarian Republicans like Ron Paul, Justin Amash and Thomas Massie criticizing the Intel buy.
Counter to this, the "revenge" narrative comes off like the advocates never believed the words they were saying. It suggests their stated beliefs don't reflect what they think is good for the future of the US, but rather personal feelings and signaling to their in-group community. If they changed their minds it would be understandable, but if that's the case then the revenge narrative is unnecessary to begin with, they can now argue on the merits.
OracleOutlook
Fiat justitia ruat caelum
4hr ago
Oh no! LDS theology has something in common with Hinduism? That's terrible! Anyways.
This wasn't meant as an insult. Hinduism has a pretty strong philosophical system. It was phrased as a question because I'd be interested if you saw parallels yourself.
I don't typically argue the Ontological argument because we no longer have the necessary (ha!) shared philosophical background to make the argument sound coherent.
Just the cosmological or rational argument will make the case just as well. I'm not going to go through the whole exercise now in my own words, but I pretty much agree with all said here. (extract from Chapter 3 of Brian Davies' "The Reality of God and the Problem of Evil")
If I were to try to distill it into a single comment instead of a chapter of a book, I would say it like this: "God's nature is that which does not need an explanation to exist. It is necessary that there is something that does not need to be acted on, and God is what that thing is. One of the attributes of God's nature is that it contains its existence."
Then perhaps I would give an analogy - "Everything in the world changes when acted upon. The existence of any one state of being depends on actions taken upon its predecessor. It's like a line of people who have the direction to only raise their hand if the person next to them raises their hand first. It doesn't matter if that line is infinite, unless there is someone who always had their hands raised, no hands will go up. Nothing will happen. God is that which already had its hands raised - whose nature isn't 'raise hands when something else raises hands' but who's nature is 'hands are raised by default.'"
And then we can extrapolate based on that other logical traits such a thing would also possess. But I'm expressing this as hypothetical as I have 0 desire to debate God's existence on the Motte.
But mostly, I was wondering if the world-view of LDS has to do with why LDS authors are becoming more popular and the world-view of Catholics has to do why Catholic authors were more popular in the 20th century.
I think, based on your responses to me, that you agree that there is a difference between the two attitudes towards reality. Catholics believe in things like Natures, and LDS does not. Catholics believe that we are creatures, LDS do not. There are other differences that perhaps we could work together on narrowing down. .
These difference might help explain why the rest of modern society likes the fictional contributions of the LDS more than devout Catholics in the past 20 years. It's not due to Catholics becoming less intellectual (look at the make up of the Judiciary.) It's not due to Catholics no longer writing. But LDS writers have been making blockbuster hits and that probably says something more about changes in society than changes in LDS or Catholic doctrine.
Catholic theology would not agree with "we pull off the natural man" but perhaps you define natural man as something like Catholic's conception of Original Sin or something. Cross-denomination communication is hard.
gafpromise
5hr ago
But what's considered life saving? Say a person has a condition that is chronic and deteriorates their heart over time. Untreated, it will lead to heart failure but this could take years. Treatment is an insanely expensive medication or some kind of invasive procedure that has to be done periodically. Insurance, in its arcane wisdom, decides they don't want to pay for it. Eventually the person ends up in the ER with a heart attack. The heart attack is treated but not the underlying condition. The patient is just sent home. This is a fake example because I'm not a doctor but very easy to imagine something similar playing out. The medication treatment is not "life saving" because the patient was able to live for years without it, therefore it clearly was not that vital, right?
When you think about it, it's similar to the debate about covering "preventative" measures, including counseling on diet and exercise. Some people think it's absurd, but I would argue that by not covering preventative and maintenance types of treatments early on, they're creating much more serious problems down the road.
roystgnr
5hr ago
The LEM descent engine was aimed straight down and was only around ten feet above the soil its exhaust kicked up when the contact probe cut it off. The HLS Starship's current solution (though Musk still wants to try direct Raptor landings eventually) is to do its final descent with mid-body RCS-sized engines, a hundred feet up and angled outward. There's still the possibility of plume recirculation from those kicking a chunk of regolith in a bad direction, but even if something hits a main engine they only need one out of three still working at that point.
It's still crazy to only do a single unmanned landing+ascent test before putting people on it, though. We're not racing the Soviets this time, we can afford to "lose" the race to China, and the combination of "SpaceX has pretty great software for precision vertical landings of rockets without a human pilot" with "SpaceX will be landing on unprepared soil for the first time and often takes a few tries to get a new solution right" really suggests we wait a little longer before adding humans.
Technically we're not single-sourcing the lander anymore; Blue Moon is supposed to be ready in time for Artemis V circa 2030. In theory they're launching an unmanned test of the smaller Mk1 version of it next year. I wouldn't be surprised if the schedules slip further, though, whether or not the slippage is "Elon time" bad.
MaiqTheTrue
Renrijra Krin
5hr ago
I'd like to steelman the idea of prior authorization by rolling it into my own perspective that I've been trying to sustain over time.
The fundamental principle is that prices matter to patients. This statement simultaneously seems trivial and is also quite profound in context of the medical industry. There are doctors even here on The Motte who have sworn up and down that prices don't matter, but frankly, they're just wrong about this. This NYT piece reinforces this basic principle, though it does not state it quite so forthrightly.
That is, the story of the article is that, two days before the planned surgery, the author and his wife.
Price matters, but it’s really hard to put a price on survival. And even with transparency in pricing, there’s no way to know the difference between “cheaper but just as good” and “cheaper because it’s dangerously substandard care/medicine.” And it’s likewise difficult to tell when something that sounds trivial isn’t. It’s a lot of information asymmetry that the patient can have a really hard time understanding. And in some cases a high price can be taken for a sign of quality.
Throwaway05
5hr ago
I think we need to go back to basics - it seems trivial to me that healthcare doesn't function as a market and doesn't work like other non-governmental activities. I provided a few examples of this in my replies.
If we can't get on the same page about that I'm not sure we'll be able to talk productively.
If you believe that state ownership of private enterprise is a good thing for the nation then you don't need to talk about "the other side" to begin with, you can justify it off the merits of state ownership.
If you don't believe it's a good thing for the nation, then why would you want the country to harm itself?
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