dr_analog
razorboy
No bio...
User ID: 583
Re: patient-based medicine. I've been on one of those not-legally-called health insurance plans ("health ministries") for the last few years. It's possibly a scam, but the idea is I go out of pocket for medical care, unless I have a single medical event that costs more than $5000. Then I can file a claim. The premiums are significantly cheaper. I've also never filed a claim.
Basically, life's been pretty interesting as a cash pay patient that can afford to go to the doctor.
For a GP, I do a "Direct Primary Care" model, which is basically like ghetto-concierge medicine. I pay a small fixed amount every month and have a GP that I just email, from my gmail account, if there's an issue. I can even drop by his office sometimes for concerns. Sometimes they reply in a few hours, sometimes it takes 2 weeks. So far I still vastly prefer this to any other doctor I've ever seen.
When I need to get drug prescriptions filled, I check on goodrx.com for coupons. Most drugs are heavily discounted! In fact they're so discounted they're often cheaper than copays are on health insurance plans. I have no idea how this market works but for the most part I'm paying less. (Hot exciting drugs usually don't have coupons though)
For things like imaging, I call around town and get quotes ahead of time. Prices vary wildly, and I do not understand why. An MRI is an MRI is an MRI right? If I go to the place that quotes 1/5th as much for an MRI as another place, is the actual quality of the MRI that gets sent to my doctor just that much shittier? Or what? Nobody says anything about it.
Another example: the imaging lab in town offers DEXA scans. They're booked months out and it takes like an hour to get one done. But there's also a bro science gym about an hour away that does DEXA scans without a prescription. They do it in 7 minutes and I can get one this week if I want to. Is there any quality difference? No idea, but my doctor will accept the bro science gym's report just the same.
For emergency care I try to go to the urgent care in town. They charge a $175 flat fee. Sometimes if I have something particularly gnarly they'll send me to the ER anyway, and then the ER does basically nothing different from what the urgent care was too squeamish to do and they'll bill me $4000. Which they'll discount to $1900 if I pay cash. I don't really have the stomach to tell them to go ahead and send it to collections if they don't want to accept 15 cents on the dollar, but maybe one day I will.
So, I haven't had the misfortune of spending a week in the hospital to really test out how my health ministry would handle that. But other people say it goes fine. They're apparently pretty adept at negotiating $100k bills down to $25k and then paying that.
This whole experience has convinced me the medical system is basically a casino
- everyone quotes you their aspirational price (a friend calls it their "fraud price")
- the insurer never, ever pays the aspirational price, and instead reimburses a fraction of it, and most of the time the provider just accepts it
- if you are cash pay, the providers often caves if you say you refuse to pay this, sometimes accepting even less than an insurer would reimburse them
- sometimes, the provider thinks they could stick the insurer with a really high fee service, but if the insurer refuses to pay outright they just tell you the patient to forget about it. wat!
- so, who pays this fraud price? people with a momentary lapse in coverage or random possibly erroneous AI-driven denial who don't want to deal, or just price insensitive people who are too proud to haggle; sometimes the provider or pharmacist is all too happy to try to convince you to pay the aspirational price with a straight face
All of this is either really re-assuring or really disturbing. But yeah, I do think having an insurer in the mix emboldens providers to increase prices.
Therapeutic culture has somehow managed to turn 3/4th of ordinary human experience into trauma, while at the same time creating a culture hyper focused on feelings and especially negative feelings as facts. If I were to try to cure depression and anxiety I’d spend more time trying to get the person to understand that bad things happen to everybody, that you’ll get better with time, and that focusing on how broken you feel just makes things worse. And until you start living despite the hurt and the “trauma” (which unless you’re fleeing a literal war zone or horrific abuse, is probably something fairly normal to human life) you just aren’t going to heal.
Hard agree.
I think most problems in America are not so hard to solve. We’re just losing our ability to knuckle down and actually do the work. We’re the people looking for ways around having to do work. We want gamification of education, because why should we study, it’s boring and feels like work. We don’t want to count calories and macros and stick to a healthy diet because it’s not as exciting as deep fried raviolis and white sauce pasta. We don’t want to exercise. Instead we’re looking for quick fixes.
Hard disagree. While there's more room for gluttony now, and fat acceptance movements certainly don't help, I don't believe the people of today are fat while our people of the 1970s were thin because the people in the 1970s worked harder at being thin.
Also I'm pretty sure never-becoming-obese-and-staying-thin is a lot easier than becomes-obese-and-now-must-become-thin.
I don't have a study for this but I simply don't believe if you take two thin identical twins, force-feed one until they gain 100 pounds, and then challenge them to lose it, if they even succeed, the one that loses 100 pounds will not be the same as the one who never gained in the first place. The one who lost 100 pounds will almost certainly be ravenously hungry for ever. Like 95% chance of this. Maybe higher.
I run 6 days a week, lift weights 3 days a week and intermittent fast from 6pm to 10am. I don't eat "processed" foods either. I've still been gaining weight and DEXA scans confirm that it's actually fat that's being gained.
I've been struggling with obesity since I was a teenager[1]. I had a foothold on it in my 30s in that I was simply overweight and not obese but now it feels out of my control completely. Until...
Personally, I think I just enjoy food more than other people. God I love food. I love eating. It is basically the only thing I really enjoy in life. When I bite into a home made migas taco, the melted cheese, the crunch of the fried tortilla strips*, the creamy avocado, it makes my whole brain light up. I am salivating just writing this.
Have you considered... Semaglutide!? I went on it recently and the effect is pretty interesting. Mostly it's a lot more psychological than "physical", for me, so far. I can feel hungry and be in the kitchen, and feel like snacking, but all of the snacks seem like too much work to get out and eat. So I don't.
Cue meme where person with ADHD does Adderall and they're bewildered at their insane focus and energy and cry that this must be how normal people feel all of the time. But non-ironically.
- And no it did not magically get fucking better living in Europe. The food in America is not uniquely poisonous.
You are very biased in favor of defending the system.
The irony in facing accusations like this is that I irrationally refuse to sign up for any company like UH or Cigna or whatever because I find them too triggering to work with and instead use some low-cost possibly-a-scam health ministry and just pay out of pocket the rest of the time.
I'm also a rare person who has experienced health care in multiple US states, including extreme Cadillac insurance and also Medicaid, and also "socialized medicine" in countries like the UK and Italy. At the end of this I'm generally burned out and annoyed by simplistic rationalizations and explanations.
The system sucks. Everywhere. In the sense that it's run by humans and have to deal with impossible demands and mis-aligned incentives. I don't think simple-minded analyses move the needle in a helpful direction. In fact they're usually wrong and sometimes just get people killed!
Ah yes more censorship of problems and calling everyone bad names and conspiracy theorists
I was not calling for censorship.
That trade-off certainly exists sometimes, but is overdetermined. Under Obamacare they're heavily regulated and their profits are bounded.
- They must pay at least 85% of premiums collected on claims
- The remaining 15% must be used for admin and then profit if any is left over
- They can't just not pay all claims if they collect too few premiums, they have to park capital in the company in case of severe mis-modeling issues, which has opportunity costs
- If they spend less than 85% on claims, they must rebate the pro-rated premium
It's not totally grim of course, they can earn a return on the parked capital and the float on premiums but it does complicate the picture. And they are incentivized to scale.
In the limit they actually prefer "the standard of medical care" to go up[1], because it means premiums go up, because the pie is bigger and the 15% of the bigger pie is more absolute profit.
Nevertheless, these corporations may be big, and profit-seeking, but you would not get rich quick by investing in them.
- Though you can imagine failure modes where medicine becomes more expensive but doesn't improve health outcomes. They're indifferent to that.
dr_analog
razorboy
7d ago
This is what's attractive about those health ministry things that (ironically) aren't allowed to be called "health insurance". Some of them are more like "really big surprise medical bill from casualty events" insurance, and those are way more affordable. They have a high deductible for that and cover nothing else.
Does it mean you have to pay out of pocket for checkups and other routine stuff? Yes. Do you shop around sometime for competitively priced MRIs? Yes. Do you find yourself traveling a bit for providers? Yes. Are you looking for coupons on goodrx.com for prescription meds? Yes. Are your (family) premiums $5,000/year instead of $24,000/year? Absolutely.
If you have a warranty condition, that's on you to cover. Which, you know, is expensive. But so is covering everyone else's when you don't.
dr_analog
razorboy
7d ago
In large part, USA life expectancy is dragged down by non-trivial amount of blacks. If you compare Japanese Americans lifespans vs Japanese in Japan, the latter have it shorter despite "better healthcare".
I guess I know what I'm spending some ChatGPT o1 credits on.
dr_analog
razorboy
7d ago
I've been informed by LLMs that, despite how biblically popular it is, that teenage women are still physically immature and giving birth is higher risk as well.
See also other underclass issues raised separately in replies.
dr_analog
razorboy
8d ago
Sure yes, I guess I'm still just shocked at murder possibly caused by a sub-culture's overzealous interpretation of an Our World in Data graph.
I don't know if the full computation has been done, but if you thumb through this fairly large report (free, but email required for guest download link) it's pretty clear that the US has a worse showing in a lot of these causes of death versus a basket of comparable countries. So, the claim doesn't seem easily disposed, at least.
dr_analog
razorboy
8d ago
I mean, is every revolution in history actually just based on vibes? Can otherwise reasonably well off people just flip their shit and start cutting heads off in the streets?
dr_analog
razorboy
8d ago
I have heard this but I don't really know how to tease this out. Also isn't it unfair to only let the US filter out its underclass? Why can't Sweden do that too in this conjecture and really break some records?
dr_analog
razorboy
8d ago
These days the doctors are on the receiving end of class rage though, everyone is mad at us on both the left and the right, thinks our job is easy and easily automated, and wants us to make less money. Thus my long ass rant.
It is pretty astounding to hear that health spending occupies an increasingly larger share of GDP yet doctor compensation is worsening.
That said I do it because I want to help people and I like teaching. It's also interesting as hell. Medicine is hard because it is much poorer define than most knowledge work which means there is a lot of room to learn and research and for your job to stay interesting over the course of your career.
I obviously don't know anything but from the outside it does seem like one of those things where the more you learn and the faster you think on your feet the more good you can do. When, you know, the cases aren't boring and you have to remind the patient yet again that they don't get better unless they actually take the meds as prescribed.
dr_analog
razorboy
8d ago
Can I ask what motivates you to be a doctor? Is it that if you don't rage out and quit by the time you enter your 40s you can start expecting a really sweet lifestyle, if you properly monetize your certifications and experience?
I feel a little guilty that I never went to college and liked computers instead and was clearing $500k/year and retired in my 30s. But at least when a doctor has a garage full of sports cars society nods and says "oh yeah well he's a doctor that's why" whereas I have to do shit like live a low key life and give to EA so I don't trigger class rage.
In his 261 word "manifesto"[1], the UnitedHealthcare CEO assassin cited that the US is 42nd in the world in life expectancy but first in health care spending. Cremieux reviews it in more detail here and makes something similar to the RCA argument that the US spends more because it's wealthier and gets more medical procedures done and offers alternative explanations for why the US has low numbers.
By coincidence, while this CEO shooter drama was going down, I was listening to Peter Attia's podcast where he interviews Saum Sutaria, the CEO of a health care system[2]. He drops the following claim (copied from the show notes):
Life expectancy has improved remarkably. A lot of that has to do with infectious disease and other things. So when we say our life expectancies in the US are paltry, what we’re really asking is, “Why are we 3 years behind everybody else?”. Especially when we’re spending 60-100% more. “Spending the most, we’re not getting the best out. And I think you make a really good point… somewhere between 60 and 75, the equations slip" Somewhere between age 60 and 75, we go from dead last to first (and the lifespan is the best in the developed world) Because the medical system we’ve created that optimizes for access, quality, sophistication, technology, the best drugs, flips It’s actually quite effective at creating longevity from that standpoint We can discuss whether the lifespan is improving with or without the healthspan
He further argues that US life expectancy is reduced by factors like cultural issues: gun violence, car accidents, etc. Indeed, the US has high infant mortality but also high rates of teenage pregnancy, which are risk factors for higher infant mortality. This echoes Crimeiux from earlier.
Anyway, I went about looking for a source for the claim that longevity rankings increase as we age in the US and found one in Ho and Preston (2010)
US life expectancy at birth sucks versus peer countries, and even still sucks around age 40. But as you get into retirement years it reverses, and the US eventually climbs to 4th place among the 18 countries
The paper tries to explain this but mostly doesn't find anything satisfying.
One interpretation (not from the study, mine and perhaps the Tenet Health CEO's) suggests if you don't get murdered, or into a car wreck, or overdose, or kill yourself, or your mom didn't attempt a home birth at age 16, you actually have good survival odds. The best in the world. The health care system can actually help you. That's what that $10k/capita is all about.
There's some obvious alternate explanations too. Maybe those extra ten years of life are when you're stroked out and have a pretty terrible quality of life and it would've actually been great to meet a health care system with a death panel that said "mmmm actually, there's no treatment available for this condition. so sorry" and you could die with dignity and your family (or someone's family, or maybe collectively) could have an extra $400,000.
Whatever this is, I think it's pretty clear that the health care system in the US exists and can deliver results. Whether or not these results translate to best QOL is more murky and we can debate that effectiveness. Either way, that doesn't have the same revolutionary zeal!
Coming up for air here, and approaching the #assassinbae story from a different angle, at what point can we consider misinformation surrounding this life expectancy vs health expenditure chart as stochastic terrorism? I don't know a single left-of-center person who has more than 2 brain cells to rub together who doesn't allude to this as Exhibit A in every discussion about how corrupt the US health care system clearly is[3]. And it's arguably wrong. And it's now getting people murdered. It's not quite as psychotic and singular as Alex Jones, but it's definitely something sinister. Maybe even more dangerous if it's the start of a trend.
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people are beating him up for writing such a short and lame manifesto but he might not have intended it as a manifesto, more of a confession
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guessing this is the last we're going to hear from a CEO of a health care system for quite awhile, so this was well timed
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which isn't to say it can't be corrupt, just, again, the health care system failing to save people from high rates of car accident deaths and also for maybe keeping grandpa alive because their family doesn't want them to die is not exactly a stinging indictment of health care itself
dr_analog
razorboy
10d ago
It doesn't make financial sense, but they just do it anyway because anyone with actual business acumen wants to shoot themselves dealing with medical horseshit and avoids it.
And if they do have business acume, someone shoots them! Heyoo!
dr_analog
razorboy
10d ago
Nobody pays for said admin time directly, and the doctor would choose not take United but we are almost all employed now and have no choice. Instead that doctor quits, goes part time, burns out and retires early or whatever. Doesn't show up in the balance sheet but is a bad outcome.
It shows up on the balance sheet somewhere, no?
Somewhere up the chain of command is the person paying the cost of doctors (and the risks of burning them out) and who is also making the decision on whether or not to accept UHC. And that person often says "yes UHC but no Medicaid"
Unless we take as a given that the entire system is dysfunctional, and making exclusively bad choices, and implosion is imminent, I think this means UHC is actually good. Or, well, UHC is bad, but less bad than Medicaid.
dr_analog
razorboy
11d ago
Yes I understand why the general public is mad, and bloodthirsty, and titillated.
I am in the minority because I also have the curse of basic education in economics and also have worked in a different financial services industry that was widely hated, but from the inside it was clear that most of the hatred was based on magical thinking and ignorance.
They might actually be evil! But my default is to not trust these narratives.
dr_analog
razorboy
11d ago
The bigger problem is that they are often below cost. You'll have to forgive me on the numbers because it's been a few years since I looked this up, but it's something like Medicaid pays .8, Medicare pays .85, and private pays 1.1-1.2 times cost.
[...]
If you see a doctor who is willingly taking Medicaid/Medicare (usually they are taking it because they are employees of a health system and the system takes it, often because of government funding or legal requirements) that means they are deliberately taking a pay cut to help people (which happens a lot because of martyr complexes) or have some way they are abusing the system (which can actually be legal and fairly harmless but isn't always).
I can see how in a certain system of ethics it's bad that UHC denies claims so aggressively. But in another system of ethics the fact that you can run a health care provider business taking UHC but not if you take Medicaid says something important, as well.
dr_analog
razorboy
11d ago
This is true, and I'd be interested to see how claim denial rates line up with a given FY cycle. They could be just vastly incompetent, making all of their customers hate them for no reason by being unable to predict claim demand, even with the vast swaths of data they have.
I am very curious about this as well.
Though comparing claims denial rates between insurance companies isn't useful without more context? It's true Kaiser has a denial rate of 7%, but aren't they famously (though not exclusively) an HMO? 7% seems low, if you ignore the fact that (pulling this out of my ass) 99% of medical providers are not allowed.
dr_analog
razorboy
11d ago
yes, if you completely disavow your work you can salvage it
still not an appealing call to join the industry!
dr_analog
razorboy
11d ago
okay fine we do not yet live in a Cyberpunk dystopia, my claim is withdrawn
dr_analog
razorboy
11d ago
mmm, got it, kamikazee quadcopters: when you want the enemy to know it was you
dr_analog
razorboy
11d ago
Thinking about this for one minute: you can have an accomplice. One person watches for the target to show up and gives the signal. The other launches the drone from a hotel room window. Escape with nobody having any clue what either of you looks like.
Also if your intent is to cause terror you'd want to show that anybody could be a potential terrorist.
I think having the VIP's head blow up and the only advance warning was a buzzing sound for one second beforehand would cause a lot of terror. Every security detail is woefully unprepared for this.
I have done zero seconds of research on this but my money is on mass hysteria / hallucination event
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