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PaperclipPerfector  8d ago (text post)   26321 thread views

Culture War Roundup for the week of December 30, 2024

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There was a wild post on r/RealEstate yesterday. It's already been deleted.

Hello,

I'm a young owner of a few rentals - I got lucky young starting a marketing business that worked.

We've been having some wind here lately and it partly ripped off some siding on the side of my house that's way to high for me to reach with a ladder. I look online and call a dude with good reviews - I think he's a solo gig. He pulls up within an hour of calling him and he's like "Oh, no big deal!". I watch him get out his ladder, get up there, screw these screws into the siding that are literally going into nothing (i think he did it so it looked like he was doing something), he pushed the siding back into the trim, and got down. Literally up there for 2 minutes. He said "Okay I'll go to my truck and get a quote"

He ends up coming back to my door like a half hour later and he claims his service call is $3000 and the screws were $5.

I kind of just look at him and I'm like "hahaha how much do I owe ya?"

Him: "$3005. I accept all forms of payment"

Me: "You're joking right? You told me on the phone your service call was $75."

Him: "We never talked sir. You must have talked to some other siding guy"

Me: "If I talked to someone else, how would you have known to come over right away and do my siding?"

Him: "Uhhh.. I mean.. Like I use a contracting app that gave me this job. My rate is $3000"

Me: "I'll give you $100 just to leave. I'm not doing this, that's crazy"

Him: "Maybe I should call the police. Should we do that?"

Me: "Go right ahead but it's a civil manner"

Him: "This is theft of services. If you don't pay, I'm pressing charges and you're going to jail"

Me: "I can promise you if you keep up this immoral scam like behavior you're going to end up in jail"

Him: "I just got out of prison, no sweat off my brow"

Me: "Doesn't surprise me with that prison tat on your neck"

Him: "Look kid you gonna pay me or not"

Me: "No"

Him: "You'll be hearing from my lawyer kid. Hope mommy and daddy can pay for it"

Me: See ya later!

I'm 25 but look 20. I've had people try to charge me crazy prices for things or take advantage of me but this was nuts and criminal (not literally but you know what i mean - just not right). Why are there people out there like this?

There's obviously a good chance that it's a totally fake story. I'd basically assume that it is. I don't even really care if there's even a 0.1% chance that it's actually true; it doesn't really matter.

Part of the reason why people likely believe that it's fake is that it sounds like absolutely outrageous behavior by the contractor. Something that no one would put up with. Something that would shock the conscience if it actually happened and there was a recording of the interaction or something.

So what's weird is that this is the standard modus operandi in the medical industry. It's just the way things are done. Yes, if you have insurance, then instead of telling you to your face that they're charging a ridiculous made up number after the fact, they tell your insurance provider the same thing. But the basic fact pattern is absolutely the same.

I'm definitely not going to go all Kulak and say that since this routinized obscenity shocks the conscious, everyone needs to start going around murderin'. But it absolutely is a routinized obscenity that should shock the conscience. Perhaps my crazy pills are significantly less potent than his, but they appear to still be crazy pills.

Lawyers can debate the legalese of "consent to treat" forms and what they do and do not allow, but it simply cannot be plausible that we will have a functional medical industry when it is the one and only industry that is allowed to simply refuse to provide you a price prior to authorizing work and then go on to just make up whatever the hell inflated price they want after the fact.

The reason people don't care that much is they are insulated from the cost in most cases (and indeed most of the outrage comes from when those cases breakdown - such as Out of network bills).

I don't really care what the ER charged me, I hit my deductible regardless every year. This principal-agent problem is obviously part of the issue with increasing costs.

The bigger problem though is just that there is a very small portion of the population that is very expensive to treat, and you/your loved ones have a small chance of losing the lottery in any given year and being part of that population. That's why premiums keep going up so much/Medicare solvency is threatened and all that. Someone who goes to the ER a few times a year/has a baby with the accompanying IP stays etc. is still a very small utilizer in the grand scheme of things.

I still think posting an obviously fake rage bate just so story to make your point detracts from an otherwise great post.

Why is it obviously fake? "Do something trivial, then demand outrageous payment with an implicit threat" is a very old but still quite common scam. Tbh I wouldn't believe any particular story on reddit and the back and forth is quite stilted to make OP sound based, but the basic incident doesn't look obviously fake to me.

If you've wasted enough time on the internet you can smell these fake stories a mile away. The word choice alone tells everyone it is fake. Perhaps having english as a first language helps in this respect.

Believing this is like believing facebook forwards from grandma. Some other motte posters have already posted good breakdowns of why this is fake ragebait. It is 100% a fake story. I would bet everything own on that.

Lawyers can debate the legalese of "consent to treat" forms and what they do and do not allow, but it simply cannot be plausible that we will have a functional medical industry when it is the one and only industry that is allowed to simply refuse to provide you a price prior to authorizing work and then go on to just make up whatever the hell inflated price they want after the fact.

I can tell you offhand what pretty much every single treatment and consultation in the NHS will cost you out of pocket: Zilch.

(Let's ignore taxes for a moment)

Even in India, it would be highly irregular for a doctor or private hospital to not give you an estimate for care, let alone consultations. You're quoted the rough cost of surgery, meds, an ICU bed, if not with perfect accuracy, to within a reasonable margin. At the very least, we can tell you if it's going to be very expensive.

This seems to be an uniquely American dysfunction.

In india it's never been a "rough cost" for me. It's an exact cost as a nice round and memorable figure - e.g. 80k rs. I have never been charged a rupee more than the quoted figure.

That's true if I get out 3 days early or complications make me stay an extra week or whatever. The hospital treats it as their job to amortize these costs over multiple patients because it is unreasonable to expect patients to predict and guess this stuff in advance. Also, in india, if they changed the price afterwards I just wouldn't pay and they'd be screwed.

This being reddit, I'm guessing that contractor/landlord interaction was completely made up as a parable to illustrate some point about landlords being parasitic/rent being too high.

This is a classic scam for Irish traveller gypsies to pull. You do a shoddy repair job then guilt or intimidate the owner into paying up before moving on to the next town.

It's well known in Ireland, I've seen news articles about this same thing happening in France and Australia and Youtube has some recent American tv news clips linking them with violent crimes and some direct recordings of travellers arguing with police etc so it looks like they've started causing trouble in the US now.

How do irish travellers make it to the US?

They travel!

I'd be surprised if they last very long here though. We lack the long term structures of intense racism, respect for family structures that combine to produce gypsy culture.

There's definitely roma in the US living their traditional con artist lives. Don't know about Irish travellers.

The same way their eastern european counterparts do- bleeding heart pinkos think a well-deserved reputation for being scum of the earth entitles you to come live in the US.

Post about specific groups, not general groups, wherever possible.

Knock it off with "bleeding heart pinkos" and "scum of the earth." If you want to critique immigration advocates or Irish travelers in a more effortful way, you must make the effort, not just drop your boo-labels.

You've been warned about this a lot. You have a mix of warnings for low-effort random racial slurs and ad hominems, and occasional AAQCs, so you can clearly write well when you choose to, but much of the time you don't care. You've mostly gotten short tempbans because you're overall a fairly good contributor, but you aren't going to be allowed to keep doing this with impunity.

There aren’t that many under-40 (non-Russian, non-Jewish) Eastern Europeans in the US. A few people in tech, some diversity visa winners, some affluent students, some limited family reunification, but the numbers aren’t big.

Gypsies in America came from somewhere.

Sure, I thought most were Roma though rather than Irish travellers.

Yes, I've never seen any travellers, but ziganos are fairly recognizable in a way travellers aren't- dress like arabs with distinctly could be Indian could be south Slav features, talk fast, pretend to be Hispanic a lot, etc. The same behavior from travellers just comes off as normal white scumbags.

They're not travellers, but fully 20% of my irish relatives are just coming off US travel bans for visa overstays in their twenties (Most of them got 10-15 year bans). It was (probably still is) incredibly common to just take a holiday to the US and not come back home for 4 or 5 years.

They all have Irish or British passports so the old school method of booking a holiday and never coming back probably still works.

Some of them just hop across the wall on the US-Mexico border, and there are scattered news stories of Irish people smuggling rings 1, 2.

Some of them have been in America for generations and have become very rich through life insurance scams.

Interesting, thanks.

They probably travel there…. Ok I will show myself the way out

It's pretty clearly a troll post.

It has a couple nice features that make it well-calibrated for engagement.

#1) It gives off a #thathappened vibe. It's just so obviously fake. People can feel smart when they expose it.

#2) It buries the lede. Wait, this guy is 25 and has several properties. He got "lucky" in marketing? So this means he's either a scammer or has money from daddy. Again, this allows internet sleuths something to latch onto and post about.

My favorite form of burying the lede is posts that start with "Me (30m) and my girlfriend (22f)" and then, later on, reveal "when we first started dating 7 years ago...".

I hope you enjoy these helpful hints for getting engagement on your own short fiction on Reddit. I've been considering doing it myself lately. Not sure why. Seems fun.

I've been considering doing it myself lately. Not sure why. Seems fun.

It may be fun for some but if it's not obviously fake then it gratuitously damages social trust by adding to readers' expectations of bad behavior from others. I wish people wouldn't write these.

Damaging people's social trust in Reddit would be doing them a huge favor.

Damaging people's social trust in Reddit would be doing them a huge favor.

It would, but @Incanto's point is not that it's social trust in Reddit that's being damaged, but social trust in people in general. People read a fake story about a cruel or unjust landlord on reddit and slowly grow to believe that landlords are more likely than not to do them wrong, that all landlords are bad, that landlording is evil, that private property should be banned, that the means of production should be redistributed...

The point has also been made about those radio shows (i.e. "Ryan's Roses") where people are caught cheating on their partners, who call in -- they're fake but did damage to the public's trust in relationship fidelity and therefore in relationships in general. The same is true for /r/relationshipadvice and /r/aita.

I don't think Reddit (at least most parts of it) are redeemable.

The only way to interact with an extremist propaganda factory is to mock it. I want Reddit to die and be replaced with something better.

The end result of this is /r/FuckLuigiMangione: an entirely invented drama op that exists purely for lulz.

I won't deny it's given me some belly laughs, but I don't see how it could be good for society. It's not even hurting Reddit: it's volunteer engagement farming that gives them more opportunities to display ads.

The end result of this is /r/FuckLuigiMangione

What's the point of that subreddit? To poke fun at the people who like Luigi, or the people who hate Luigi? It just doesn't make sense to me.

But in general, this is my least favorite aspect of the internet: real discussions boiled down to trolling and why-are-you-so-serious-about-serious-issue type loserdom. The people who care the least shouldn't always win. But nether should the people who care the most always win.

I guess I just see it as another area where the internet destroys authentic connection. If you bring up a serious issue with a real-life friend, you can have an actual discussion about it and maybe learn something. But outside of a few places on the internet, like here, it's lulz vs activism all the way down. Real talk with people who are concerned but not trying to sell you something is rarely possible.

What's the point of that subreddit?

Dramatards hit it big with the abortion bounty hunters thing, and have been chasing that high ever since.

What's the point of that subreddit? To poke fun at the people who like Luigi, or the people who hate Luigi? It just doesn't make sense to me.

Chaos. It's literally an op by rDrama to make people on Reddit of every "side" post angry comments to share and laugh at them.

Stop going on Reddit. Seriously.

It's like complaining about porn recommendations on Porn Hub. You are telling on yourself.

Medicine is worse than that. There was some bureaucratic confusion about whether insurance would be available for my kid's routine visit. I asked at the front desk what it would cost, assuming a normal visit with no complications, in case I couldn't apply insurance. She didn't know. I asked her who would. Didn't know that either. Tried calling the billing department, no answer. Looked up the billing information the hospital is required to publish by state law. The 'common' bills they showed did not include checkups. So basically, I could wait months for a different appointment or I could tell them I was willing to pay whatever price they asked after the fact. It worked out.

Vets, dentists, and the Surgery Center of Oklahoma can all quote prices. Medicine could too. I always thought the rightwing's Obamacare should've been: hospitals have to have transparent pricing and insurance companies can only say to the customer, "We'll cough up X money for your procedure based on your prognosis. We'll incentivize you to spend less than X. You can pay more than X if you make up the difference. You are allowed to spend that money at any hospital." The government can maintain a crappy website that lets you do price compare, with the assumption that Amazon or Walmart would make the actual working website.

Looked up the billing information the hospital is required to publish by state law. The 'common' bills they showed did not include checkups.

Checkouts aren't performed by a hospital, they are outpatient. So of course it wouldn't be there.

Hospitals where I am do outpatient services.

A big problem with medicine, along with other notoriously expensive professional services like law, is that knowing which specific actions to take is part of the service. One can't provide a remotely accurate quote without having already performed the services requested. A checkup for a 10-year-old boy with no medical conditions is a very different service from a checkup for a 58-year-old woman with twelve medications and diabetes.

It's also true for contractors and mechanics as well.

True story, I had a leak above my kitchen, called a plumber who told me that the pan under our utility closet (yay for 2nd floor HVAC/water heater), quoted to replace it. Gets halfway through replacing it, find a bunch of rotted boards underneath and says we really should do those too and that will be whatever-extra$. Dude was 100% honest and his price was, while not cheap, near enough the median charged in the area for that kind of thing.

It happens -- I don't understand why people would expect medicine to be any different. There are a lot of things where both knowing specifically what to do and encountering wild variations in the actual scope of work are routine. A surgery could go well or the patient could crump and be in the ICU for 3 days recovering.

I don't understand why people would expect medicine to be any different.

You had said:

[a plumber...] quoted to replace it

The medical industry currently is different. They refuse to do this part. At all. You can make it not any different. You just have to start giving some quotes/estimates. It's not all that hard; even a plumber can do it. Why can't you? Do we need to tack on some plumber school at the end of medical school or something?

There is a world of difference between a quote and an estimate.

Both can be used in the appropriate time/place. Your plumber didn't seem to have any problems with a quote and then a revision for additional work.

I think that the original poster would be satisfied with a rough estimate for a checkup of the demographic of their kid, with the understanding that this is the money they are committing to pay, not the money it will cost to cure the kid of all ills. If at some point the checkup discovers the need for additional medical procedures, the doctor can simply quote their prices and ask if he should perform them, or if they would like to shop around more.

I mean, there can be procedures where they go "we cut you open, check what is wrong and try to fix it, and depending on what is wrong, this is going to cost you more or less", but even then they could state the costs of the hypothetical treatment options beforehand, with the patient opting in or out of specific treatments.

I mean, there can be procedures where they go "we cut you open, check what is wrong and try to fix it, and depending on what is wrong, this is going to cost you more or less", but even then they could state the costs of the hypothetical treatment options beforehand, with the patient opting in or out of specific treatments.

This works for a basic "checkup" type thing which is bounded, but in a "cut you open" situation, the higher end of the spectrum is "your vitals suddenly collapse and you have to be taken to the ICU for a week, that will be $300K". Nearly every surgery would have to have this as one of the possibilities.

Moreover, that's not one a patient could be realistically given an opt-out from -- they can't just leave you to die.

Absolutely correct. The correct lens to look at this through is informed consent. Patients must be reasonably informed of the known costs/risks/benefits of medical procedures at the point when they give consent. Prices are part of costs, so they need to be reasonably informed of them when they give consent.

Of course, when they're lights out and cut open and something happens, there is no opportunity to inform them of the medical costs/risks/benefits, so we reasonably say that in such situations, it is acceptable to proceed anyway. All you need to do is import the exact same considerations to the question of when you can skip informing them of pricing information. If you feel ethically comfortable not getting informed consent for the medical costs/risks/benefits, sure, go ahead. Otherwise, when you're informing them to a reasonable extent about the medical costs/risks/benefits, you also need to inform them to a reasonable extent about prices. Just tell them what you're planning and what you know about that plan.

Oh definitely. I think that's fine.

I think the other bit is that up-front, the estimate for any surgery with anesthesia is going to be "it's unlikely but as we discussed there are risks in anesthesia and so in the worst case you nearly die and it's gonna be $300K".

Sounds fine to me! Maybe not even strictly necessary to put numbers to all the things. Again, it's just informed consent, just like medical costs/risks/benefits. You can say that there are risks in anesthesia, that unknown complications can happen, and if they do, you'll do what you can (where the actions and price are yet unknown). However, in some cases, where it's a "routine" complication, you can advise a little better. One doctor in these forums suggested that there are some procedures where they know that something happens about 1% of the time, that they plan for it, that they know what they're going to do if that happens (e.g., "If we see X, we're going to remove Y also"). In those cases where you have reasonably known specifics with reasonably known, planned actions, what you do is inform the patient. You can likewise inform them with reasonable information about likely costs of that relatively-known event and following actions. I think people would be perfectly happy with that.

All of this is getting into what is a common situation in hospitals, but is relatively rare for individual patients and in terms of total patient interactions with medical billing. It's kind of an edge case, though it is important to put some thought into. I think people would be pretty fine with a variety of practices concerning informed consent in these edge cases if the industry started getting the basics done on the much more vast world of much more numerous, much simpler services.

This is also true for HVAC work and plumbing. Estimates are a normal part of dealing with these trades.

I think the example cuts the other way -- those trades will give you an estimate but it's by no means binding if unexpected things come up.

To some extent you can just tell the guy to leave in the middle of the job, but that would leave you with a non-functional system, not really an option in medicine.

by no means binding if unexpected things come up

Literally no one is asking for this. They still give you the estimate, anyway, with what they do know. You can do at least that much, too. You can be better than a shitty, druggy, probably criminal contractor.

The checkup itself is pretty routine. If they get referred to a specialist or have to take a test or a vaccine that incurs a separate charge. But surely a base rate for the visit is easy to figure and most added services should be easy to look up as well.

It seems that every time people complain about medicine or law, someone (usually in the industry) will say something like "No, you see it is very very complicated. Our current system is perfect, or, barring that, it's literally impossible to change".

But I don't believe that change is impossible. I believe that there is a lack of political will and that entrenched interest groups have rigged the system for their benefit.

Price transparency is not impossible. But the medical industry won't do it unless they are forced to.

Insurance companies are working on this - ie I've seen presentations about trying to build variable copays into an app so someone trying to go to an urgent care or ER can go to one the company has contracted with at a cheaper rate.

Do those differences show up with different billing codes when you send them over to insurance? If so, how is that difference expressed in the content of the billing codes?

Mechanics have no trouble telling you what it will cost to take a look at your car. They'll post their hourly rate and let you know that if it's just [X] they'll figure it out pretty quick, but it might take [Y] hours if it winds up being the transmission instead. Ask a physician what their hourly rate is for diagnostic services and you will be likely to receive much less transparency and possibly a look of indignance that you'd be so gauche as to reduce their priestly actions to mere labor.

I'll once again note that various excuses about how a treating physician probably can't really know what things cost ring hollow for anyone with a decent veterinarian. That end of things is admittedly a newish experience for me, but when I take my dog to the vet and he presents treatment options, I can inquire what they cost and his reply is, "about [$X], but I can get the exact number for you if you want". That physicians cannot do this for much narrower ranges of practice indicates an incentive structure for not knowing what things cost.

Lawyers can debate...

I genuinely believe this is the part that triggers so many people to feel the way they do about Luigi. Guys like Brian Thompson make tens of millions of dollars and if anyone has a problem with it, they can get their lawyers to take it up with his lawyers, who will all make a shitload of money arguing with each other, lying for hire and making arguments that no one actually believes and that most laymen can't even understand. I'm surprised that others are surprised that profitable Kafka rituals occasionally trigger rage.

Here is an idea: simply allow veterinarians to treat humans.

The human has to be competent and sign a waver that they are aware that the vet's malpractice insurance will only cover a certain amount, so the patient is SOOL if something goes wrong big time.

TMK while canine and feline(the vast majority of veterinarians are trained for these two things and not other animals) biochemistry is pretty similar to people's, with slight differences(eg allergies, dietary requirements), their anatomy is... not.

Lawyers can debate...

I genuinely believe this is the part that triggers so many people to feel the way they do about Luigi.

Or Dick the Butcher from Henry VI, Part 2, who spoke the famous line "The first thing we do, let's kill all the lawyers." in Act IV, Scene 2.

To me, the complaint is very clearly with the doctor (or practice/hospital -whatever), not the executive! So I'm not sure why this would make people admire Luigi.

The doctor doesn't want to fuck you over, neither does the hospital or practice. The health insurance executive however, wants nothing else but to fuck you over.

In my experience, hospitals are more than happy to screw over patients in billing as long as they don't complain too much after the fact. Surprise out-of-network anaesthesiologists used to be common (now prohibited), and I've seen hospitals try to tack on not-covered-by-insurance fees that show up much later and weren't disclosed in advance (not that they ever give straightforward billing answers in advance). Yeah, they'll "kindly" remove or waive those if you call and complain a bunch (probably marking it down as "charity"), but it's really annoying and not always worth my billing rate.

Yeah, they'll "kindly" remove or waive those if you call and complain a bunch (probably marking it down as "charity"), but it's really annoying and not always worth my billing rate.

IME you are significantly overstating how much of a hassle it is to get your hospital bill adjusted.

There are scum bags everywhere, for sure, but the perverse incentives start with the insurance companies. You can't pull a surprise out of network anaesthesiologist out of your pocket if there aren't any networks. It's the insurance companies who ban pharmacies and doctors from talking about the price of medication and offering cheaper alternatives. And it was insurance companies who instituted the policy of denying every claim first and forcing patients to pull teeth getting their claim covered.

It's the insurance companies who ban pharmacies and doctors from talking about the price of medication and offering cheaper alternatives.

This claim simply does not pass the smell test.

It's the insurance companies who ban pharmacies and doctors from talking about the price of medication and offering cheaper alternatives.

Can you provide citation/further reading on this? A brief search actually turned up basically the opposite complaint (in multiple articles that were clearly founded on pro-doctor propaganda advocacy), so I'm definitely interested if the surface internet has it all wrong and no one has been talking about these secret bans.

You're right (well, the opposite complaint would be that doctors and pharmacies are banning insurance companies from offering cheaper alternatives, but I think I get what you mean) I merged two problems in my head - the three big pbms (all owned by insurance companies) refusing to stock certain brands making it either expensive or impossible for doctors to prescribe them and insurance companies banning doctors from telling patients they could get their meds cheaper without using insurance.

the opposite complaint would be that doctors and pharmacies are banning insurance companies from offering cheaper alternatives, but I think I get what you mean

I chuckled. But anyway, what I meant (as you probably know) is the insurance company banning doctors/pharmacies from using more expensive alternatives. Dubbed "step therapy" or "fail first", the insurance companies were saying that you had to have the patient try a cheaper alternative first, and only if/when that didn't work would they cover the more expensive drug. I'm sure there are nuanced arguments on both sides of this, and I don't have a dog in that fight. Probably sometimes one approach is good; probably sometimes the other approach is good. Not worth getting involved from the outside.

insurance companies banning doctors from telling patients they could get their meds cheaper without using insurance.

I agree that lack of price transparency here was a problem. At a cursory look, I would agree with the goals of the Patient Right to Know Drug Prices Act that they cite, which fixed this problem. All we need to do is take that same name, swap in "Medical Services" for "Drug" in the title, and perhaps we can work out a text that can fix more of this price transparency nightmare.

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The insurance companies want cheap alternatives. It's doctors and pharma companies who run advertising for big pharma, patients then demand treatments that are extremely expensive, then insurance has to pay for it.

Hold up, are you saying doctors want patients to spend more money on meds?

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I've expressed before that veterinary care has a lot of medicine, especially the business side, figured out better than humans.

Insurance, for the most part, really is for the big stuff that can't be anticipated, and is priced as such. It's $60 a month to insure my 14 year old beagle with 50% coinsurance. It doesn't cover the cost of exams or checkups. It does cover things like surgeries and cancer treatment.

I once used it for a spine surgery. The total cost was about $7,000, quoted upfront. I paid about $3,500 and the insurance covered the other half. This would have been well into hundreds of thousands of dollars if performed on a human.

I was able to have conversations via email, not through some dumb HIPAA compliant portal.

That most dogs are uninsured probably keeps costs down, as does that typically pet insurance has a higher coinsurance figure than human insurance. There's an unavoidable principal-agent problem that we exacerbate with regulations that practically remove all incentive for people to price shop.

Why did you get insurance with a co-pay of 50%?

Insurance is good if it prevents improbable but huge payments. It has a negative expectation value on your net worth, but should have a positive expectation value on the logarithm of your net worth (presumably defined inclusive enough that the case of going negative does not appear), which is closer to actual utility. LW recently had an article on this, here.

A fixed co-pay seems reasonable enough, the case you want to avoid with insurance is paying hundreds of thousands of dollars, and if you co-pay is a few thousand, then that limits your risk exposure.

But an insurance with a proportional co-pay feels different. I mean, if it is 1% co-pay, one could still argue that it scales the treatment options one can afford by orders of magnitudes. By contrast, a 99% co-pay would not be worth it for anyone, because if you can afford 99%, you can also pay 100%.

I would argue that 50% co-pay is more like 99% co-pay than 1%. If X is the maximum loss you could absorb, it will only be helpful for losses between X and 2X. For example, say you could absorb losses of 5k$ without insurance. Then for any treatment which ends up costing up to 5k$, you would have been better off to just absorb the losses in case they appear without paying a middle man. And for everything which costs more than 10k$, you could not afford your co-pay and thus would not benefit from insurance. Now, if it happens that most vet bills are in that range, then it could still make sense to buy it, but from my priors, they are likely much wider in distribution.

Insurance, for the most part, really is for the big stuff that can't be anticipated

Which is certainly what it should be for healthy people. A high deductible catastrophic plan. But the ACA outlawed that and instead young healthy people have to buy expensive insurance that they largely don't use.

It's called a health sharing plan. They exist mostly as religious exemptions to ACA requirements to cover the morning after pill, but nobody actually checks whether you go to church or not.

Your rate sounds not to far off from what a cash pay health sharing or a ultra high deductible plan would be- and that’s basically what you have.

How much has your pet insurance paid out? Seems that unless you're having major procedures regularly, self insurance is the way to go.

Roughly $5,000, dog had another surgery later on to remove a bunch of tumors.

Got the dog in 2018, at about $60 per month since then, I'm still ahead, but that's very luck of the draw. I'd prefer not to have some other incident that would make the insurance pay out and deliver more value for my premiums, I'd rather he just die in his sleep when the time comes.

These products are regulated and competetive, I expect the rates to be actuarily fair and the median customer to have been better of self insured.

I expect the rates to be actuarily fair and the median customer to have been better of self insured.

That doesn't make any sense. For an insurance to exist as a business, they have to take more then they're giving to the average customer. They have to pay for offices, ads and personnel. Maybe you got lucky and are temporarily ahead financially, but long-term insurance will always result in a net negative for the customer.

I think we agree.

I’m curious if survival rates are similar? That is, if the margin for error is much smaller when operating on humans it makes sense to me the cost may be orders of magnitude higher

Even if survival rates are similar, a dog's life is worth less than a human's in court.

I'll once again note that various excuses about how a treating physician probably can't really know what things cost ring hollow for anyone with a decent veterinarian. That end of things is admittedly a newish experience for me, but when I take my dog to the vet and he presents treatment options, I can inquire what they cost and his reply is, "about [$X], but I can get the exact number for you if you want".

Bingo. It's been a while since I went to the vet, but when I was a kid we had our dog neutered and they asked us to put a budget on lifesaving efforts if things went south for some reason (they didn't, everything turned out fine).

Anyway, yes, I think doctors could do this and it might help everyone involved think a lot more clearly about treatment plans. In fact, because people are so leery of hidden fees, I would not be surprised if it would save lives if doctors were required to post consultation prices and then notify patients of the cost of treatment beforehand. Nobody wants to get a surprise $1000 bill in the mail, if people knew that going to the doctor to check out that weird lump or whatever was only gonna cost them $50 it might be more effective than all the work Obamacare put into making annual visits free.

That's entirely believable to me.

Dealing with reputable HVAC contractors in my area, quotes ranged from $13k-35k for the same job.

A drywall contractor my dad barely showed up while continuously demanding new progress payments. He kept claiming he was too broke to finish the job without getting paid, couldn't afford gas to get to the job, the job was in worse shape than expected, etc.

Dealing with reputable HVAC contractors in my area, quotes ranged from $13k-35k for the same job.

I'm guessing a complete system replacement- they were likely quoting you different systems. Brand, efficiency rating, etc can make a very large difference in pricepoint, much bigger than markup.

No, it does not in most cases make any sense to pay for a more efficient system, although paying for a medium priced over cheap brand might.

Brands were different, largely because each contractor only carried one brand, but each quote required the same SEER ratings and tonnages, so the equipment prices were equal more or less.

Given that reliability and efficiency were more or less similar according to reviews, inasmuch as brand increased prices it didn't really make any difference to the end consumer.

Construction / building works in general are one of the last industries where if you don’t personally know (and are friends with, and can afford to pay well in most cases) somebody competent to oversee building works, you’re pretty fucked.

Seconding this- construction has lots of A) crooks and B) drug addicts. You can find honest people who do good work, but as a complete layman you don't really have a way to do so.

We only employ the local Jehovah’s Witnesses. You have to put up with one attempt at evangelism per visit but they’re great, trustworthy guys who do good work for honest prices.

Seems ripe for disruption by a large conglomerate which lets tradespeople syndicate with them and verifies they are not A) Crooks or B) Drug addicts. It gives them a certificate of approval and then they can use that to prove to prospective clients they are decent and thus get more work, no different to how any certification regime (that's not been captured) works at the moment.

The disruption is always going to take the form of standardization of items into interoperable and easily swappable units. Custom work, that requires some degree of skill, will always be beyond the ability of large corporations to do all that well/efficiently.

The disruption in HVAC, for example, is going to be the decline of expensive and complicated central AC in favor of cheap and replaceable wall mounted mini-split units that can be installed by a clever homeowner or a cheap handyman. When part of the unit breaks, you replace it with another plug-and-play unit. Central AC requires skill in working with high amperage wiring, running ductwork, installing large and complicated and expensive equipment, and balancing the system across multiple rooms. Mini splits can run on regular 12-2 wire, each room has its own unit and its own thermostat so you don't have to balance or run duct, and each distinct element is relatively cheap and so can be replaced rather than repaired by a specialist.

The more you can turn the process into black boxes that an owner replaces in their entirety, rather than requiring skill, you can remove the need for skilled intermediaries and produce profit for larger corporations that can produce black boxes at scale.

Sure, I agree with that. I'm actually surprised by how many american homes have a central HVAC, the rest of the world already uses wall mounted mini split units everywhere (another benefit is that that you can cool down only certain portions of the house rather than running a massive power guzzler all the time). Plus you can upgrade your system incrementally rather than needing to do a building wide scale change if it turns out that you're not getting enough cooling in a certain part of the structure.

I blame the usual American largesse.

As others have mentioned, good contractors have enough customers lined up that they don't care.

One thing I've seen done several times is companies guaranteeing a quality standard. Basically, they are eager to tell you everything about what good framing/plumbing/wiring/stuccoing should look like and will either send a second guy with a checklist or let you do it yourself or hire a third party.

Two drawbacks:

  • this still doesn't scale much. Several hundred houses or renovations a year are a drop in the ocean
  • these companies charge more than good contractors do

One thing I've seen done several times is companies guaranteeing a quality standard. Basically, they are eager to tell you everything about what good framing/plumbing/wiring/stuccoing should look like and will either send a second guy with a checklist or let you do it yourself or hire a third party.

I asked for this once and they had no idea what I was talking about.

As others have mentioned, good contractors have enough customers lined up that they don't care.

I wonder if the right disruptive model here almost goes the other direction: not a clearinghouse for finding tradespeople, but a trusted service you can have "on retainer" effectively to subcontract the work. Ideally, you call 'em up, ask for [task], and they shop various provider options (some perhaps that they use often) with a reasonable expectation of the marketplace, and maybe even for an extra fee can manage the "will arrive sometime between 9:00 and 3:00" part where it's pretty disruptive for folks with full-time not-from-home jobs to let them in and get things done without the usual concerns. Bonus points for being able to make sure the job is done correctly the first time.

Although what I've described sounds a bit like a combination of the network of a general contractor (for larger tasks) and a rental property management company. But I've never heard a sufficiently-glowing review of the latter from a renter to want to consider asking "Hey, I own this house and live here: would you be willing to handle when something breaks?" Does anyone actually do that?

I’ve heard of gated communities, particularly for retirees, that essentially have this for homeowners, where the office will have their company / their guys who both built the homes, did the plumbing etc originally come back to maintain them without the owners needing to do more than call management and pay the bill.

"Hey, I own this house and live here: would you be willing to handle when something breaks?" Does anyone actually do that?

You might want to look into a home warranty company. Disclaimer- quality is generally not very high.

Work on a house is just too sporadic for a retainer that would be worth it to a tradesperson to also be worth it to a homeowner. Property management companies have enough work... but also pretty much care only about cost to do the absolute minimum to keep the renters from leaving or suing (depending on the market).

The good ones have no trouble filling their schedules, there's no incentive for them to join such a system.

If someone advertises you can treat it as signal that they're not good enough to book clients via word of mouth only.

On a small scale, things like Angie's List exist. I've used them a couple times and was happy.

On a larger scale, my guess is that there is a lot of laundering of immigration status that happens which a large company might not be able to do.

But finally, honest contractors do exist. Both my brother and parents did a complete rebuild with a contractor and were not in any way screwed over. Honest ones may be hard to find, however, since they will get so much positive word of mouth they will quickly have a full slate.

On a small scale, things like Angie's List exist.

Angie's List, as it once was, hasn't existed for years. It's now basically just an advertising service for contractors.

Yeah, it's called Angi. I've used it twice and both times got services at a reasonable price. If I had bad service, I could have rated the contractor which would have made it less likely for them to get future work. And it also saved me from having to call 50 places for my $200 job that no one would have wanted.

I know this is an internet forum and it's cool to be jaded. But, I don't know, this corporation provided value to me 🤷. I wish there was an Angi for health services.

I wish there was an Angi for health services.

Their is. Sort of - and they fucking suck.

The industry has essentially landed on patient reviews as the mechanism to do this and you can find all kinds of websites that track this, and certain forms of reimbursement may be partially contingent on patient satisfaction metrics.

The first layer of problems is the usual review issue - most people don't bother to leave a review if they had average care, a small fraction of people who receive great care leave a review, and a lot of people who are mad leave angry reviews, this creates a lack of realistic balance in the reported experience.

The other piece is that what makes for good care isn't usually legible to patients. NPs like to brag about studies where they have higher levels of patient satisfaction and it's often tied to not appropriately saying no to patients or things like unnecessary testing and treatment. People don't like being told "no" or "I don't know" doctors are better at doing that but it pretty uniformly pisses people off. The classic example is telling a patient no when they ask for antibiotics for a viral infection. This is good healthcare but obviously decreases patient satisfaction, and that's not bringing up things like angry patients seeking drugs of abuse and review bombing, or psychiatric patients who are angry because they have poor insight and received good care.

Outside of outpatient clinic medicine things get even trickier. The best hospitalist in the hospital is spending his time not in the room with you running down to pathology and radiology, calling insurance companies or social workers for dispo, teaching students, etc. The worst is sitting in his office playing Sudoko. Both only spend five minutes with you a day, you'll have no way to tell if they are good or not unless you have an avoided near miss or something like that.

I was hospitalized a little while back at my own hospital and was the victim of a pretty severe and unacceptable/easily avoidable medical error. I don't think a non-doctor would have even noticed.

Some other examples - anesthesia.....you'll wake up either way, the horribly wrong outcomes aren't generally the doctor's fault. With good gas you'll have an easier emergence, or if you know exactly what to look for on your anesthesia record you could see you were getting good care. How many people get enough surgeries or have the training to read those tea leaves?

For surgery... a lot of aspects of outcomes are patient and not surgeon dependent (like overall health status, engagement with PT), you don't know if your insides are an avoidable mess afterwards or not. The good surgeon might make your next surgery much much easier but you are unlikely to ever know. Patients will also often jump at the chance to get surgery not realizing when NO surgery is the better outcome. You might be a better doctor for saying no...and get worse reviews.

Exceedingly hard to manage this.

There have been attempts to look at more formal outcomes and this rapidly runs into pretty severe juking stats and perverse incentives.

A classic example is transplant surgeons forcibly keeping patients "alive" to get them to die outside of various thresholds (since that gets reported).

Surgeons will sometimes refuse to operate on risky cases because of the morbidity and mortality outcomes. Some of the best surgeons have the worst outcomes because they'll swing on cases that others won't. Some of the worst surgeons too - they'll swing on cases that they shouldn't.

It's a mess.

I do get asked "how do I find a good doctor then." I don't have good advice for this. In my specialty and my area? I already know who is shit and who isn't and hoard that knowledge like gold. Some related specialties? My specialty further away than I don't know them personally? Sometimes I can guess, but mostly I just have to know someone in that specialty in that region who has the wisdom to be able to determine which of their colleagues are ass.

That is not generalizable.

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Those syndicates put 1000% markups on everything. A conglomerate which can do this will prove unable to restrain its greed.

As a kid, I knew someone who was sued for torrenting (or their parents were) a movie of some kind. The initial fee for settlement (especially after late fees etc were added in) was insanely high, but the parents dragged it out and eventually settled for cents on the dollar. So much stuff is like this, the perpetrators rely on occasionally encountering people who are the perfect combination of rich, dumb and neurotic/anxious to just pay immediately. Even if it’s only 5% of people, it’s more than worth it. Debt collection has worked this way for millennia.

Yeah, there are many scams where the scammer isn't actually doing anything illegal, they're just relying on people's anxiety with saying, "no, fuck off". All the way down to beggars trying to guilt people into giving them money for gas with a ridiculous sob story, all the way up to patent-trolling and blackmail. For the party being harassed, there is both the cost-benefit analysis of what it takes to get your harasser to go away to the skillfully crafted guilt or anxiety inducing attack on their conscience.

As an addendum, one small thing that I really hate about this is how developing the hardened shell of being quick to tell people to fuck off subverts judgment and charitable behavior towards people. Years ago, maybe about a decade now, an indigent looking man in a wheelchair tried to stop my wife and I on the sidewalk. I ignored him on the basis that he was almost certainly trying to get money. My wife stopped; it turned out all he wanted for someone to pick up his lighter that he'd dropped (there was no add-on begging, he thanked her kindly and everyone went about their day). I felt bad about that and still do, but my alternative would be hearing approximately 38 bullshit stories that end in, "so I need $20" for every one disabled guy that just needs a hand with something real quick.

I hate to say it, but people probably shouldn't torrent movies or other IP. The analogy there would be more if this contractor's truck was in the street, maybe he was working on a neighbors house, and the redditor went and swiped a few screws from it. Then, when the contractor noticed, he threatened to sue the guy for OneBillionDollars.jpg. Like, okay, buddy. Silly, yes. But kind of different in kind. Perhaps one could make other analogies to try to make it somewhat more sympathetic, like if the contractor was working on the neighbor's house, and the neighbor swiped the screws and gave them to the redditor. I get that there are complications here, but I think it's really just a different type of thing.

Debt collection should mostly be premised on the validity of a previously-agreed-upon debt. That's usually the first line of defense - "Prove that I owe this debt." When done above-board, the debt collector can produce a document that the debtor signed that specifically authorized the terms of the debt. Things get sketchier as the underlying facts get sketchier. Usually, how sketchy it gets depends on how sketchy the original transaction was. The extreme end of sketchy for underlying debts would be, "We refused to give them a price, just did the service, and then unilaterally made up a price." (Yeah, I guess even more extreme would be that they just didn't even do the service or just totally made up the whole thing, but that would probably be better categorized as obvious outright fraud rather than "sketchy".) I guess if the conclusion is that routine practice in the medical industry is akin to the sketchiest versions of underlying debts that are claimed by debt collectors, that's damning with faint praise.

There is some magic that occurs in debt collection. You can go through more and more layers additional sketchiness and eventually they just call it taxation.

A debt that is owed to "society" because you were born here. Services were sometimes rendered before you were born, and the debt is still being paid off. You get voice in what services are offered via voting, but if you don't vote you still owe money. And a candidate can lie about what they'll charge you to get your vote and suffer no consequences.

Any attempt to make these comparisons through a metaphor just make it sound like you are talking about a criminal syndicate.

And in case you didn't feel like you were taking crazy pills a majority of people think that this is a better and more fair way to pay for medicine.

And in case you didn't feel like you were taking crazy pills a majority of people think that this is a better and more fair way to pay for medicine.

Well, yeah. Organized crime is easier to deal with than disorganized crime.

That said, I wouldn't be against some of the proposals in this thread for laws forcing price transparency, since as another poster pointed out, veterinarians are able to do this, so there should be no reason human doctors or surgeons can't.

Organized crime is easier to deal with than disorganized crime until a point, at which point it becomes completely entangled with the state to the point of being either coup-complete or requiring intercession by some faraway as yet un-completely-corrupted power, as happened during the Italian anti-mafia campaigns where Rome was still able to exert some pressure on the completely corrupted Sicilian political system.

The US is lucky in a way in that mafias have been local enough and ethnic enough that control of institutions has been relatively limited and temporal.

The US has a comparatively unusual system where the Mafia became an arm of the state rather than the other way around.

More common than you think. Look at the relationship in Russia, or how the Yakuza used to assist the Japanese Government (they fell out after a government official was murdered and now the Yakuza is a shadow of what it was. But I heard that a lot of COVID restrictions were informally enforced by the Yakuza).

That would be surprising since I've heard that the great majority of Yakuza members are over 50 now.

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