domain:shapesinthefog.substack.com
Throwaway05
3hr 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
3hr ago
Or Desert Bus.
chooky
3hr 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
3hr 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
3hr 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
3hr 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.
3hr 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
3hr 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
3hr 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.
TitaniumButterfly
3hr ago
"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.
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.
ArjinFerman
Tinfoil Gigachad
3hr 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
3hr 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
4hr 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
4hr ago
This is excellent information, thank you!
OracleOutlook
Fiat justitia ruat caelum
4hr ago
If these numbers are well understood, I wonder if you could buy "procedure insurance" instead of general insurance.
Throwaway05
4hr 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
4hr 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
4hr 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
4hr 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
4hr 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
4hr 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).
The supposed "RNG problem" is a skill issue tbqh. I found that keeping a list of tasks and theories loosely sorted by likelihood, and playing each run flexibly with "I'll start out aiming 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 pointyou should have certain RNG-biasing unlocks, reliably abundant rerolls, and be able to draft ~whatever you want most runs
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.
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