domain:philippelemoine.com
Throwaway05
12hr ago
I can tell you that in my personal practice I try and be cost aware when possible but that a number of practical concerns come first. For one my job is to get people better, not spare their wallet, the threat of litigation makes it extremely hard to deviate from that even when both the patient and myself want to.
In some situations it appropriate (or required, most often with homeless people) to be more careful about this but I can't always do so. A classic example is inhalers, insurance change what they cover all the time, if I don't know your specific insurance plan well....it's just going to be wrong some of the time, even if I do know the insurance. Hospitals have invested in tools like e-prescribing which help with this.....but all kinds of negative effects of those things have also been generated.
One of those is that I am highly limited in what I can do. The hospital owns most physicians right now because of increased costs like EMRs we do what they say. Some times that involves practicing on our license essentially. It also frequently means things like me signing away my right to bill the hospital just does it for me based off of what I charted.
When it comes to inpatient medicine ultimately I'm going to be like "I'm sorry you are going to get a fuck off huge bill and I have no control over it and depending on your insurance that may or may not be a problem." I am also incentivized to not think about it too much to avoid burn out.
For outpatient medicine usually it's a stripped down professional fee that I have no influence over and a medication bill that I can try and save you money on.
I don't really know what percent of patients have co-insurance, and as you demonstrated and like I said I don't think about co-insurance at all most of the time. This is because legally and practically it has nothing to do with me, that's what the regulatory and legal environment have decided.
Usually when this kind of thing comes up it's "put the doctors on it" but the hospital and insurance company are in charge!
MadMonzer
Pedo! Pedo! Pedo! Out! Out! Out!
12hr ago
And they are already notionally aiming for $7000 tickets, which is 1/2 the inflation-adjusted price of Concorde.
That is what I mean by a 2x improvement. Slightly less than half the inflation-adjusted price, for a marginally worse product (Mach 1.7 vs Mach 2.0). Still a niche product for rich people - the marketing spin is that the fare is competitive with business class, but airlines don't sell many full-fare business class tickets at the moment* - the average fare actually paid needs to go up a lot relative to subsonic business class for the economics to work out.
* As well as the usual discounted fares, the big volume business travel customers (mostly banks and consultancies) all have negotiated rebate schemes which means that the revenue to the airline is less than the face value of the ticket.
Throwaway05
12hr ago
You know, the American edge of this kinda stuff runs into a few issues. One is our legitimate exceptionalism, we are the superpower, we don't usually need to make compromises. That's not a completely terrible approach and for long enough that most of the people alive in the country have only experienced that....it worked.
It limits our facility with actually going through this process however.
Part of it is that people know that something can be shaved off without impairing patient care. This is probably right but nobody knows (or agrees) what it is.
Then you have American specific attributes - we are pussies when it comes to pain for instance, we are more willing to seek and use care, we are too independent, and so on.
Low societal temperament to say "yeah let some mee-maws go down if it saves a few hundred million dollars."
But yes you are right that this conversation is happening just less transparently, and at the same time if you came over here I think you'd be shocked at how much we through at things.
Is it good that we'll code a clearly dead kid for 90 minutes? Is it good that we will give homeless crack cocaine Fred the standard of care 12 times a month when he presents with psychiatric issues caused by his recreational polypharmacy?
I don't know.
I am however at times horrified and at times proud.
faceh
12hr ago
Too easy to game by making predictions about things that no one cares about, and are easier to gauge.
You know, this is a valid point. "my calibration is perfect when it comes to predicting coin flips, dice rolls, and card turns!"
That's the benefit to a somewhat adversarial system, you're forced to actually pick something that someone reasonably disagrees with you about and cares enough about to take on some risk. so it must be more meaningful.
but I think one can learn not to take it thay way.
I'm pretty close to that. I'm actually getting a little flippant about tossing out bets, even if I'm not too interested in the topic.
I actually made 50 bucks on Kalshi yesterday betting that Starship wouldn't launch, on the logic that if it didn't launch, I would be sad, and money would cheer me up some.
Throwaway05
12hr ago
I try and keep in mind that (in the U.S. for sure) the PUBLIC HEALTH apparatus absolutely did some shady business and doctors were complicit. This killed a ton of trust.
MRNA vaccines had legit concerns when they were being forced on everyone and I knew plenty of docs (including liberals) who had concerns initially for politics came into it.
Vaccines have always been a tough topic as far back as the Salk/Sabin days lol.
ABigGuy4U
12hr ago
I would count the Line in Saudi Arabia. Many people write it off as another prince’s embarrassing vanity project, but I think it’s the first serious attempt to construct an arcology. A type of semi self contained megastructure that you will probably be hearing a lot about in the near future.
netstack
Texas is freedom land
12hr ago
Wikipedia says it was inspired by the Molotov-Ribbentrop pact, but I’d believe that too.
I really need to read Homage to Catalonia.
MadMonzer
Pedo! Pedo! Pedo! Out! Out! Out!
12hr ago
I also agree with JTarrou - a superordinate political identity like "Christendom" or "Western Civilisation" doesn't need near-universal adherence to matter, just broad popular or broad elite support in the nations it seeks to unite. And political Islam is a functioning superordinate identity group, and the factional splits within it are the main drivers of political violence globally. (Contra Huntington in Clash of Civilisations, the borders of the Islamic world are a lot less bloody than the interior). "Western Civilisation"/"The Free World" remains an important superordinate identity, with globohomo a faction within it. So far we handle our factional conflicts at the ballot box, and everyone except the nuttier fringes of MAGA want to keep it that way.
None of the various religious groups you mention have any desire to be a superordinate identity in this sense. Orthodoxy is in practice a bunch of ethnic churches that hate each other more than they hate outsiders, with the Orthobros being irrelevant. Rad Trads are happy being themselves, and religious Jews explicitly see themselves as a nation state that isn't part of a superordinate group.
ThomasdelVasto
Κύριε, ποίησόν με ὄργανον τῆς ἀγάπης σου
12hr ago
OracleOutlook
Fiat justitia ruat caelum
12hr ago
Interestingly, google-gpt says about 20% of plans have co-insurance.
I think this is a mistake on GPT's part. The majority of plans have 20% co-insurance, meaning the patient pays 20% after the deductible is met. See https://www.healthcare.gov/choose-a-plan/plans-categories/ or even just try to look for an example of a plan without co-insurance.
I asked Gemini, "Is it possible to get a Health Insurance plan without co-insurance?" and the response was:
"Yes, it is possible to find a health insurance plan without co-insurance, but they are not as common."
I followed up with, "What percentage of Americans have a health care policy without co-insurance?" and got:
The available data does not provide a specific percentage of Americans who have a health insurance policy without co-insurance. However, we can infer some information from the general landscape of U.S. health insurance.
Most health insurance plans, particularly those obtained through employers or the Affordable Care Act (ACA) marketplace, include some form of co-insurance as a cost-sharing mechanism.
The types of plans most likely to have little to no co-insurance are:
Medicaid: This is a public program for low-income individuals and families. 1 While cost-sharing can vary by state, many services are covered with a very small copay or no out-of-pocket costs, effectively making it a no-coinsurance plan for most enrollees.
The Uninsured Population and Health Coverage - KFF Source icon www.kff.org
High-Tier ACA Marketplace Plans (Gold and Platinum): These plans have higher premiums but lower deductibles and out-of-pocket costs, and sometimes have a copay structure for a wider range of services, which can reduce or eliminate the need for co-insurance.
Some Medicare Plans: Traditional Medicare has a coinsurance for many services (e.g., 20% for Part B services). However, many beneficiaries enroll in Medicare Advantage or Medigap plans, which can reduce or eliminate this cost-sharing.
While we can't provide a precise number, it's safe to say that a vast majority of Americans with health insurance are enrolled in plans that include co-insurance. Plans without it are available but are less common and typically come with higher monthly premiums.
I think it does matter, because it's not solely insurance deciding how much the patient pays. How the hospital codes and the choices the doctor makes regarding patient care has a direct, visible consequence on how much the patient pays. It is interesting to see that doctors might not realize that.
nomenym
12hr ago
Britain should settle Antarctica
I think civil war is actually more likely.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
12hr ago
I am regularly dismayed by the Motte's average epistemics when it comes to things like vaccination. Some of the takes I've seen post-covid had me pulling at my hair.
The mRNA vaccines? The ongoing moratorium on government funds for the same? Where does the stupidity end?
The rest of the world is not devoid of competent doctors or statisticians, the COVID vaccines are highly imperfect and not that important for young, healthy adults or children. There is no concerted effort to suppress a spree of cardiac myopathies or weird clotting/autoimmune disorders that needs buy-in from the governments of the other 7.5 billion people on this globe. When promising cures for things like aggressive pancreatic cancers are caught in the cross-fire, I am tempted to order a gun, or, in this country, a sharp gardening implement.
the males are smart and the females are dumb breeding machines
Not at all, and not what I said. The females are, in this phase, about as smart as the males. They just have less pressure to use those smarts — for the time being. Sit tight!
Actually your reaction is kind of humorously on-brand for the chapter, if I'm reading it right. Did you detect, here, the edges of an idea which might hurt your social status were you to accept it?
It may help to remember that I'm describing a last common ancestor (LCA) which would map to something like 6-7 MYA, not modern humans. And, having studied this fairly intensively, the situation I'm describing is pretty much the current best mainstream academic hypothesis as to how they behaved. (If you'd like to know more, probably start with asking an LLM and it can direct you to where all of this is in the literature.)
Partly this is inferred from observing modern chimps, gorillas, and so on, and working backward. No strict harem system where one guy gets all the sex, but coalitional, with close allies also getting substantial preferential mating access. And, most interestingly to me, lack of female identification with the coalition in question. Instead, females ranging where they please and associating with the local males until moving on. But now I'm just repeating myself.
Point being that there's plenty of time for the situation to change between then and now, which is rather the topic of next week's chapter.
But laughter is good medicine.
self_made_human
amaratvaṃ prāpnuhi, athavā yatamāno mṛtyum āpnuhi
12hr ago
Does grandma get a three hundred thousand dollar chemotherapy course for a sixty percent chance at two months of vomiting and brain-fog?
This is a powerful objection because it feels like an unanswerable dilemma. It conjures the image of a cold, centralized bureaucracy, a "death panel," weighing a beloved grandmother's life against a line item in a budget. The implication is that any system forced to make such a choice is morally monstrous, and that your current system, for all its faults, avoids this grim calculus.
But this assumes the alternative to an explicit line is no line at all. In reality, the American system draws lines constantly. The line is your FICO score. It is the fine print of your employer’s chosen insurance plan. It is the difference between an in-network and out-of-network hospital. You don't get to avoid the decision about grandma’s chemo, you simply outsource it to an opaque web/distributed network of insurance adjusters, hospital billing departments, and personal bankruptcy lawyers. I presume that, at some point, someone with an MD will have opinions on the matter.
The interesting thing is that the dreaded explicit system is not a hypothetical construct from a dystopian novel. It is a real, functioning, and remarkably mundane bureaucracy in places like the United Kingdom. The NHS confronts the line-drawing problem head on, not with a panel of grim-faced commissars, but with a legion of actuaries and medical ethicists, and yes, actual medical doctors at an institution called NICE, the National Institute for Health and Care Excellence.
NICE's primary tool is something called the Quality-Adjusted Life Year, or QALY. It is a straightforward, if necessarily imperfect, metric. One year of perfect health is one QALY. A year lived with a condition that reduces your quality of life by half is half a QALY. NICE then calculates the cost of a given treatment per QALY gained. As a general rule, a treatment that costs between twenty and thirty thousand pounds per QALY is considered cost-effective.
I'll run the numbers on grandma, even if I already know the answer. A $300,000 treatment (roughly £240,000) for a 60% chance at two months (0.16 years) of very low-quality life (let's generously say 0.2 QALYs) results in a cost per QALY that is astronomically high. The answer from the system is a clear, predictable no. Conversely, a treatment with the same price tag for a teenager that offers a high chance of fifty more years of healthy life would be approved without a second thought. The system is explicitly utilitarian. It prioritizes maximizing the total amount of healthy life across the population. It can and will spend millions on a child, but it will counsel a family against a futile and painful intervention for a demented octogenarian. This isn't some big secret either. I have had such discussions with dozens of families, and not a single one has had a problem with it, or withdrawn their relative to go elsewhere, as they are at full liberty to do.
For those who find this calculus unsettling (I do not know why the standard approach to handling scarce resources unsettles anyone) the system provides an escape hatch. The existence of the NHS does not preclude private medicine. The wealthy, or anyone with good private insurance, can opt out of the public queue and pay for the treatment the state has denied. You can, in effect, disagree with the state’s valuation of a life year and substitute your own. The state provides a robust, free baseline for ninety-nine percent of situations, while allowing a private market for those who want more. A similar model exists in India, a country with far fewer resources than the United States (citation available on request) which manages to provide basic care for free while supporting a thriving private sector.
The American conversation on this topic often seems stuck in a state of arrested development, terrified by the philosophical specter of a problem that other Anglosphere nations have long since downgraded to a matter of accounting. The "death panel" is not a uniquely socialist horror. It is an inescapable feature of any system that deals with scarce resources, which is to say, any system in the real world. Not even the most charitably inclined soul will spend the entirety of their nation's GDP on the cancer treatment of even the most photogenic child. Their parents might empty their bank account and go into debt to do so, but that's simultaneously their right while also not entitling them to demand infinite resources from the rest of us. The Pope might claim that all lives are priceless, but you don't see him pawning off the Vatican's paintings or his Pope Mobile to do so.
ArjinFerman
Tinfoil Gigachad
13hr ago
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!"
I understand the reluctance to put money on the table, but it doesn't have to be this way, gentlemen's bets are a thing as well. The feeling of losing face might be a bigger issue, but I think one can learn not to take it thay way.
even if you're perfectly calibrated
Meh, I'm kind of sour on the rationalist idea of calibration. Too easy to game by making predictions about things that no one cares about, and are easier to gauge.
Throwaway05
13hr ago
you will cause new cancers once you scale to hundreds of thousands of people.
Ugh this is one of the biggest issues with large scale medical interventions like vaccines. Yes your vaccine can be perfectly safe for plenty of sigma but if you give it billions of people some weird shit is going to happen!!!!
RoyGBivensAction
Zensunni Scientologist
13hr ago
Where can I read more about this? None of the related articles have anything to say on the subject.
Various critics were deriding FDR as fascist within his first year in office, yet that NIRA article mentions none of it. Herbert Hoover was a prominent critic and wrote 2 anti-New Deal books in 1934 and 1936 specifically pointing out the parallels.
In the part about critics from the left:
Richard Hofstadter noted that critics from the left believed "that the NRA was a clear imitation of Mussolini's corporate state".[35]
There is this line in the criticism of FDR article:
John P. Diggins found only superficial similarities between the New Deal and Italian fascism. However, Diggins produced some quotations indicating that Roosevelt was interested in fascist economic programs and admired Mussolini.[49]
Footnote 49:
Early in 1933, Roosevelt told a White House correspondent: "I don't mind telling you in confidence that I am keeping in fairly close touch with that admirable Italian gentleman". In June 1933, Roosevelt wrote to Ambassador Breckinridge Long in Italy about Mussolini: "There seems no question that he is really interested in what we are doing and I am much interested and deeply impressed by what he has accomplished and by his evidenced honest purpose of restoring Italy and to prevent general European trouble". John P. Diggins. Mussolini and Fascism: The View from America (1972). Princeton University Press. pp. 279–281.
I haven't read the book by Diggins, but it sounds interesting.
This article by Codevilla talks about it some, but he doesn't cite sources.
ArjinFerman
Tinfoil Gigachad
13hr ago
even my 90% CI is unmet, can I interest you in a $10 giftcard from Amazon or equivalent? That would be from me to you, no need to pay if I'm right.
That's a very nice gesture, but it feels a bit unfair when it's one-sided.
I don't think anyone else would be crazy enough to imagine catching skyscrapers with chopsticks, and pull that off too.
That, admittedly, was pretty damn cool. Luckily for me no one was soliciting bets on that one, because honestly, I thought thr idea is absurd, and would have walked right into taking the "not gonna happen" side
But that aside, it's the recovery of the second stage that is more likely to do them in. They're not even doing it for the Falcon 9, Starship is probably exponentoally more difficult.
Throwaway05
13hr ago
Laziness or ineptitude is certainly a cause at times but "I don't want to lose my livelihood" is a potent motivator.
ED pan-scanning is functionally "standard of care" because using your training effectively is going to result in a few miss or near misses at some point and it is much safer to hide behind the donut of truth.
When laziness and safety line up it's really hard to alter behavior.
However there is something to be said for "we are the richest country why can't we have the most expensive care and avoid making certain kinds of mistakes."
I don't think people realize the trade offs we are making and it's certainly worth a discussion but we rarely do that.
HereAndGone
13hr ago
Yeah, it's tough for men. But for women, it's not attention as "here you are as a person", it's "here's boobs on legs". Visibility, sure, but might as well be invisibility. Some women work that angle, but when you're fourteen and growing into womanly features this kind of "every male from fourteen to forty is looking at my tits" is not the boon it might appear.
HereAndGone
13hr ago
She got everything handed to her on a plate (and, um, if she's Lil' Ms Genius, how come she's not back in Wakanda doing high high high level super science?) and still complained. Disparu went a bit too hard on the series, but he's not wrong: she bitches about what good is a degree, it'll only get her (a really good high-paying doing science) job, then she's all shocked Pikachu face! when they go "okay then, you don't want a second chance, you're expelled".
She's aware right from the start that the Hood and gang are a bunch of criminals, there's no "oh well maybe they're just misunderstood, maybe they're actual urban revolutionaries". Nope, she jumped straight at "violence? crime? murder? for money? gimme gimme gimme!"
That "am I supposed to know who you are?" line to Mephistopheles isn't as smart as she thinks, because now if she's messing around with magic, she better know who is who in that world. But of course this is Riri Williams, Know-It-All Brat, and she can't be bothered to learn anything because she already knows it all. Tony Stark, when faced with the fallout of what he's been building all along, decides to go the hero route. Riri goes straight to "I don't wanna work, I want free stuff, I want money, if I have to commit crime and sell my soul to the Devil, no problem".
Tony Stark was Tony Stark from the start, he was being shown around as a kid genius from the age of four. That's not the family weapons industry at work there. And yeah, box of scraps in a cave, as against Riri being handed the tech from the start and then stealing it because she's incapable of producing her own.
That's not "more interesting" as character arc, that's straight up "she's dumb and evil".
Tenaz
13hr ago
Don't they?
Not per capita, as far as I can tell.
I see the idea of God "by definition" as an artifact of Gnosticism. He can't just be God, he has to be, not only the greatest possible being, but the greatest conceivable being, or he's not God.
If you disagree, let me ask you:
Say everything in the Old Testament and New happened pretty much exactly as described. God is perfectly good and loving, he is omnipotent, he is eternal, etc. BUT say he's not the un-caused cause. Say that instead, there was some proto-cause that created God and then blipped out of existence, because that's just how reality happened to happen. Would you, upon learning this from God himself, continue to be Christian, or object that, essentially, your definition of God is greater than God himself, and the God who stands before you is not worthy of your worship because he falls short of your definition?
In the past when I have asked Catholics this question, they have answered that no, that omnipotent being would not be God. It astounds me. It tells me that Catholics, at least the type likely to frequent places like this, are more concerned with Platonism and heady intellectual arguments than with reality.
I call this Gnosticism but it's probably more accurately called Platonism. But I hope you can see where the confusion comes from:
As one of the Gnostic texts, the Secret Book of John, describes him, God is
illimitable, since there is nothing before it to limit it, unfathomable, since there is nothing before it to fathom it, immeasurable, since there was nothing before it to measure it, invisible, since nothing has seen it, eternal, since it exists eternally, unutterable, since nothing could comprehend it to utter it, unnamable, since there is nothing before it to give it a name.[5]
Since Gnosticism’s God was too perfect to ever have any reason to do anything, he didn’t create anything – not even Heaven.
What drives me insane is how many of these multi-thousand-dollar fuck-ups are the result of someone not on the hook for the bill (sometimes the doctor, sometimes the patient) choosing the vastly more expensive option just because it’s slightly more convenient. This guy gets told to take his infant to the emergency room for a UTI because hey, why not? Insurance will pay for it.
You can see why insurance companies turn into money-grubbing assholes.
This is a fake example because I'm not a doctor but very easy to imagine something similar playing out.
Oh no, you're bang on target. I'd know, being both because I'm a doctor and because my dad has a heart condition that behaves more or less exactly like this. It would likely be cheaper to get a brand new heart than attempt to cure it with medication.
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.
Depends a great deal on the costs and benefits of the prevention and maintenance! Screening not only costs money, but if it involves, say, ionizing radiation, you will cause new cancers once you scale to hundreds of thousands of people. NICE in the UK does painstaking evaluations, and insurance companies definitely have their own systems, if not nearly as open to scrutiny. It is difficult to make a blanket statement, in some cases, it genuinely is better to wait for a disease to manifest before acting on it.
I thought Musk was making a joke. If I fight the Absurdity Heuristic hard enough I can see how much sense it makes, but until they started mounting the tower arms I still thought maybe it was a joke.
Counterintuitively, no. You'd think that "bigger is harder" in engineering as a general rule, but there are exceptions. The control problem that lets Falcon 9 land within meters and Starship get caught within centimeters is one. Surviving atmospheric entry is another - it helps to be as big and "fluffy" (high surface area to mass ratio) as possible, so you start decelerating sooner and slow down higher and peak at a lower heat flux. Size also lets Starship get away with using steel - previous steel rocket stages needed to be "balloon tanks", pressure-stabilized because of their thinness, but Starship is so huge that even "thin" relative to that is thick enough to worry less about buckling, and they get far more thermal resilience "for free".
Reuse is; recovery they could definitely do. They've already managed to bring three ships to a soft powered splashdown (albeit just barely, that first time) after atmospheric entry, despite one of the three being a "let's try stripping the heat shield way down and see what breaks first" test. I can't imagine any of those were in shape to launch again (or would have been even if they were caught rather than splashed down), but being able to do even a brief short main engine relight right on cue for the splashdown is a pretty good step in the right direction.
The biggest catch is that, even if they technically manage upper stage reuse, they need cheap reuse, with at least a few flights per ship, to make this worth all the effort. Space-Shuttle-style "if we go over everything with a microscope then we can launch this again next year" won't cut it.
In terms of Artemis, though, what's most likely to do them in is the schedule. They're not going to make 2027 for Artemis 3, and if they don't even get an unmanned lunar landing test by then, Congress is fickle enough to put HLS Starship (or the whole Artemis program) in the waste bin next to Constellation.
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