domain:shapesinthefog.substack.com
dev
4hr 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
4hr 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.
4hr 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
4hr 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
4hr 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.
By forming an orthogonal coalition with other people willing to press the "cooperate" button. "Orthogonal" meaning you cluster around a set of self-consistent values that are split between the current political coalitions. For example, if I had the charisma and moral fortitude, I'd try and pull together a movement that concedes to the left-wing economics of the liberation theology catholics but promotes the right-wing moral culture of the tradcaths. We'd advocate something like an open-borders welfare state, but with brutal enforcement of moral orthodoxy to discourage leeches from coming here. (I'm a morally spineless neoliberal currently, but compromise means being willing to give stuff up.)
ControlsFreak
4hr ago
The problem is that the cost to provide the healthcare, the price the hospital wants to charge the insurance company (and therefore you), the price the hospital actually charges the insurance company, the price the insurance company actually pays, and how much you are on the hook for are all totally different, often completely unrelated to each other, and involve information that other parties don't have.
Adding to @ArjinFerman's response, most of these don't matter.
Your health system can usually functionally guess how much your insurance will want you to pay for something but it's a guess and insurance companies deviate frequently and quite substantially.
You know what you're planning to bill, right? You know what the list price and the negotiated price are, right? You can give that to the patient. If you're doing something where you think there's a substantial chance of a substantial deviation, perhaps inform your patient and consider asking them if they'd like to do a pre-auth to help reduce the uncertainty?
If the insurance company knows exactly how much something costs they'll low ball the hospital
You're slipping back to one of the numbers that aren't relevant and that no one is asking for. We just want what you're going to bill and what you've already negotiated with the insurance company. The insurance company already knows these things. You already know these things.
Smuggled into here is the expectation that the doctor specifically and the healthcare system in general provide information about what another actor (the insurance company) will do.
You don't need that to provide what you're planning to bill and what your negotiated price are. Sure, if you're significantly worried about what this other actor will do, then see above.
Physicians themselves having awareness of some of the specific numbers is possible in an environment like one guy only doing total knees with a few major insurance companies but that doesn't usually happen. Asking us to know
Yup. The "Why should that be the doctor's job?" argument. You know full well that I don't care whose job it is.
Throwaway05
4hr ago
Many don't like this but you can't really function in our system without having insurance and this has been attempted to be enshrined in law.
The reasons for this are many but some things to keep in mind:
-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.
-Insane fuck off cost overruns are more common and possible in medicine than in other areas. Compared with say car insurance - the number of cars on the road worth over a million dollars is incredible small. 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). You can just not drive. Everyone has health and the lack of it - and it can become phenomenally expensive to manage through no fault of your or own or fault of your own. Getting a liver transplant or ECMO is a multi-million dollar endeavor.
Between those three things healthcare does not resemble any other industry. It's probably most similar to national defense in its fundamentally "non-economic" nature and that's why both of those things are usually run by the government.
But We Don't Do That Here.
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.
gattsuru
4hr ago
I haven't had time to play the newer release, but I'll second this from the 1.18 update.
The part I found most addictive is how there's always one next small task to run, usually 'just' a five or ten minute task, and they're almost all pretty engaging. Absolutely will eat several in-game days of 'and I just need to finish this - oh and -'.
100ProofTollBooth
Dumber than a man, but faster than a dog.
4hr ago
I appreciate your framing, sincerely.
What's your take on the other abrahamic "hard" religious groups; Rad Trad catholics / Orthodox "ortho-Bros", and actual zionist and/or messianic Jews?
BahRamYou
4hr ago
OK yeah. Looking into it more, it sounds the makings for a hilariously old school imperialist land squabble. Going by this: https://en.wikipedia.org/wiki/Australian_Antarctic_Territory: "Only four other countries accept Australia's claim to sovereignty, being New Zealand, the United Kingdom, France, and Norway, all of which have territorial claims in Antarctica and mutually accept each other’s claims"
So it's the British Commonwealth, Frand, and Norway vs the entire rest of the world!
Subsidies don't have to lose money if they have a positive multiplier.
They do if the government can't effectively recoup their investment via tax revenue-- which is what happens when money goes to tax-avoiding corporations.
Because in that case, that's the government owning a Treasury issued by the government.
Yes, that's the problem. Treasuries are essentially just an investment in the government's future ability to raise revenue, but that comes with the obvious moral hazard that when growth fails to cover the interest, "raise revenue" ends up becoming "raise taxes". I do agree with you on the "managed investments" bit-- and also the competent, professional team bit. With reference to...
I would like to reiterate that the executive branch borderline randomly scooping up equity stakes in flavor of the month companies is not this.
You won't find me arguing in favor of the implementation. Trump is definitely not the president I trust to do this. But the fact of the matter is, the government helicopters loads of money into flavor-of-the-month causes literally all the time, regardless of party or president. So why not set the standard that the government will get equity in return? And with reference to price discovery-- the government committing money into a sector is a truthful signal that the government is interested in promoting it, and that the government will become self-interested in making favorable regulations toward it. Obviously there are moral hazards associated, but price discovery, of all things, is not going to suffer.
fmac
Ask me about bike lanes
4hr ago
Looking at my game files, I don't seem to have any(??). It doesn't even have a Steam workshop.
I can't remember why I bought the game, as you seem to be able to pirate the whole thing.
Maybe I wanted mods but never got around to it because I was enjoying vanilla.
Extended power plant range was on the list of mods I wanted though, kind of cheaty, but it gets tedious.
yofuckreddit
4hr ago
I'll mention that the people I know who raise chickens often complain about the challenges and costs. I wouldn't do it.
For decoration/wallpaper, one thing my parents did was cut out Calvin and Hobbes strips and use them as wallpaper. It was awesome. So: Be creative about what "wallpaper" means.
Building secret compartments in the house of a sort could be cool. Vaults in the drywall, for instance?
I love the concept of building forts etc. as well, huge part of my childhood.
Throwaway05
4hr ago
I would advise people to be extremely careful about this because the rules are frequently revised, confusing, or impenetrable to patients.
Yeah you do see issues with straight up fraudulent charges at times (usually you see this in Medicare when someone gets caught and obliterated by a federal prosecutor) but usually it's completely by the book or mild but justified up-coding. Hospitals have entire departments whose job it is to comb through notes and make sure they extract every dollar from insurance.
Does talking to the patient about their relationship count as brief therapy? What if the psychiatrist uses CBT language you aren't familiar with? Does an ear lavage count as a procedure? Does time based billing refer to purely face to face time or does coordination of care, medication ordering, and documentation count? Can you use MDM as part of your E/M instead of or in addition to time based billing? When was the last time the answers to any of these questions changed?
Doctors often go to workshops that teach them how to bill correctly, yes to up-code but also to make sure they don't accidentally commit fraud by putting something in wrong. It's hard.
If you complain you may get some stuff knocked off but it's very possible you are making an accidental fraudulent complaint and they just don't want to fight about it.
Especially if your insurance is paying, help the health system out dawg.
The doctor is unlikely to find out you did complain but if it's an iterated relationship and you keep doing this you will end up with worse service because they'll get told to clean up their documentation and be careful and it will knock them out of their flow state and likely result in petty inconveniences (ex: more likely to rely to mychart with 'schedule an appointment'").
For OP specifically - I'm obviously a homer for the medical care side of things but you should consider that insurance companies are famous for incorrectly denying things that were provided and even things were provided and billed correctly.
Ultimately the problem is that it's hard to give numbers in general, it's harder to make them accurate, nothing the hospital can do can guarantee the numbers are accurate, they are therefore not very useful in the vast majority of situations and also have a very real cost to deliver to a patient.
I might be a simpleton (it is very likely, in fact), but I don't see how this is any different from any other industry that faces uncertainty (which is all of them), where the prospect of telling the end customer "you don't need to know the price" is typically seen as absurd.
For your case to be persuasive, you'd need to do some comparative analysis, and show how the kinds of uncertainty faced by the medical field is much larger or fundamentally different from, say, car manufacturing or agriculture.
If making the numbers accurate being impossible / comes with costs, how can insurance companies function to begin with? Their existence hinges on having reasonably accurate numbers for these things. If they do have accurate numbers, I don't see how passing them to the customer would generate edtra costs - we have computers these days!
And if it's all really so arbitrary, is there any point to this system? Would anyone really notice if the whole healthcare system got nationalized, with Stalin's reanimated corpse in charge?
quiet_NaN
5hr ago
Well, it is claimed territory. In fact, much of it is also claimed by Argentina and Chile. And China and the US do not have any claims and are unlikely to just play along.
For all practical purposes, the British claim is as valuable as if North Korea claimed half of the Pacific as their territorial waters.
SubstantialFrivolity
I'm not even supposed to be here today
5hr ago
Same, except the game came out when I was in college and your post made me feel old. But like you, I tried playing WoW classic and it just wasn't the same. The game was (mostly) the same of course, but my frame of reference was different and it had a much different feel as a result. I ultimately didn't stick with it, though I did have fun for a while (and my wife said I was "bellowing with joy" when I got my first green drop in Elwynn Forest, lol).
ControlsFreak
5hr ago
I read the article as criticizing both the provider and the insurance company, rightfully. They never once put the blame for "dropping the ball" solely on one party or the other. I don't either. Both parts of the industry need to get over the ridiculous idea that prices don't matter to patients and do better at informing them prior to decisions. It is mostly the gestalt sense that prices don't matter and that there's no point in informing patients that causes both of these players to fail so miserably.
It is unfortunate that the author didn't tell us much more about UHC's perspective on the matter. That might have given some choice quotes to make my point further that they're not getting it, either. But we did get choice quotes from MSK which very clearly and directly make my point.
Throwaway05
5hr ago
I mean I think the article is accidentally a great example - they didn't actually need to know and numbers, it got covered, no?
They did end up running around sweating because the insurance company decided to be an asshole, which is what they do. Physicians complain about prior auth abuse all the time, and United is one of the worst. Basically they just try and refuse enough and slow things down enough that at times patients and doctors will give up and go with sub optimal management.
Quality price transparency doesn't help in those sort of situations and will likely help insurance company's beat on health systems.
It's also extremely expensive, you'd have to hire a lot more staff, and since people always expect physicians to know these things you'd probably have to cut clinical supply.
You could certainly change the system via regulation but that has its own costs and there are easier targets to reduce patient angst like prior auth reform.
For a more paternalistic and therefore likely less popular take - the system is incredibly complicated and even people who are subject matter experts in it get shit wrong quite a bit. Injecting patients into the mix would just add to the confusion, expense, and angst.
fmac
Ask me about bike lanes
5hr ago
Does Rimworld have curated mod packs a la Wabbajack for Skyrim? My patience to manage mods has a strongly inverse correlation with my age lol
fmac
Ask me about bike lanes
5hr ago
Definitely play vanilla first just so you get a sense of what the game is like, just enough that you can win fights against evenly matched up fleets up until mid-game so you don't suck and don't get overwhelmed
Then get into mods and it'll be less overwhelming
I hate vanilla purists though, I recommend getting QoL and UI mods immediately
quiet_NaN
5hr ago
The UK's claim to a slice of Antarctica is worth about as much as if they claimed a crater of the moon instead.
Nobody wants to live in Antarctica. I would rather raise kids on a container ship.
This means that the normal process of the rule-based international order, where local polities organize however they like and get recognized as states (which is already flimsy in the case of Greenland with its 0.028 persons per square kilometer) will not have a good solution to this.
The traditional solution to solve conflicting territorial claims is, of course, war. Happily, Antarctica, being south of the Tropic of Cancer, is far outside NATO territory. So if the Brits want to wage war against China or Argentina in some god-forsaken desert of ice and desolation, let them.
Alternatively, the nations of Earth might jointly decide to exploit the resources of Antarctica, but in that case I would expect a reshuffling of territories. China is not going to accept that it does not get a slice based on some claims frozen by a treaty 60 years ago. Nor is the US, certainly not under 47.
fmac
Ask me about bike lanes
5hr ago
Genuinely I have no idea
I'm willing to be the first to cooperate vs defect as I believe in the power of human win/win coordination
But I am a single human with 0 political power
Honestly I'm mildly a doomer about all of this, I just refuse to say "fuck it" and embrace the zero sum game
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?
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.
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