Monday, April 4, 2022

The Scam of US Medical Pricing



If you want some fascinating reading, do a web search on the "real" cost of x-rays.  You won't get any good answer, but you will spend however much time you can stomach reading case after case involving the wildly different prices being charged by various care providers for something that is surprisingly cheap anywhere in the civilized world. 

Of course some will point out that "No one really pays that much for an x-ray".  That's true, but only kind of ... sort of ... maybe not.

Let's go with a hypothetical example based on someone else's misfortune:

For whatever reason, J. Schmoe needs a chest x-ray.  Being blessed with endless patience and time, they call ahead of time to determine what the price will be, and after being repeatedly told, "We don't know what the price will be.  Come in and have it done and we'll find out after you're billed," they eventually find the one person who will quote a price:  $517.

Thinking:  Ya know, given how much I've had to shell out for testing and surgery and all in the past few years, that really doesn't sound all that bad.  Wait ... no.  It's total crap.

In some states or at some providers there's a discount you can ask for if you're paying cash rather than going through insurance.  If that happens to be the case the amount instantly drops to something like $310.

Think about this.  You know the provider isn't going to be losing money by charging you $310 for the x-ray, so the real cost is somewhere below that, and the $517 is some kind of magic markup they send to the insurers.  Why would they do that?  Let's see ...

Since J. Schmoe has health insurance the super-secret discount won't work.  They go ahead and get the x-ray, pay something like $36 as a "co-pay", and then wait for the bill.  This is where it starts getting really weird.

The care provider and insurance company have a chat among themselves.  The length of the discussion, and who wins it, largely depends on; 1. how big the provider is, and 2. how big the insurer is.  The loser of the discussion is always going to be the patient.  To add insult to injury, this part of the system involves a heck of a lot of people and time, and in itself significantly adds to the cost of healthcare - which is why a cash discount exists.

Eventually J. Schmoe gets a statement/explanation of benefits/bill that looks like one of the pictures below.  

Explanation of Explanation

Service:  The thing done.  Usually this will include an insurance code, which if you go down that particular rabbit-hole can lead to some amusingly specific insurance diagnostic codes which create more questions than they answer.

Provider Charged:  The number the provider came up with for the total bill.  Note that this might be different from what was quoted because of odd little fees added in.  There may also be situations where the amount quoted was for the procedure itself, but there was a separate bill for some other part that the patient couldn't avoid.  For example a single operation can involve separate bills from the hospital, the surgeon, the anesthesiologist, and the hospital's pharmacy.  This really ticks me off too but it's a whole separate rant.

Allowed Amount:  This number is essentially a "screw you" from the insurance company to everyone else.  They're saying, "I don't care what the provider charged, we're going to pretend the bill they sent only said this number."  I wish I could get away with that.  More on it below.

Insurer Discount:  This amount is really just showing who won the dick-measuring contest between the provider and insurer.  If the discount is high then the insurer won, otherwise the provider won.  The fact it exists at all is bad for everyone else.

Patient Liability:  The amount the patient ends up paying.  Sometimes it can be appealed and brought down, but the odds of that aren't good.  Of course it's still worth trying because a lot of crappy insurers automatically deny everything in hopes the patient will just give up and let them keep the money.


Low Suckage



This is likely the best possible outcome for the patient because the insurer paid for everything other than the co-pay.  This is also the least likely outcome, even for people who have good insurance.  Why?  Well if you were an insurance company would you want to pay anything if you could figure out a way to avoid it?

Moderate Suckage



This is like the Low Suckage results, except the patient probably has an unmet deductible.  Once that's met the insurer would (hopefully) pay more.

Major Suckage



Here something interesting is going on.  The insurer is insisting the bill is only $360, that they have a deal with the insurer to cut $150 off of that, and then they're paying the rest.  But they're going on to say that the patient's part of the bill is really based on the full amount charged by the provider rather than the numbers they were playing with.

This is called "Balance Billing" and is illegal in some states/situations.  Sometimes insurers actually pay attention to those laws, but of course "mistakes" occur.

Ok, here's the "fun" part (and by fun I mean totally infuriating):  the patient liability at this level of suckage is actually more than it would have been if they had payed in cash with a cash discount and skipped the insurance altogether.  The insurance company would have preferred that too as it means the patient is paying for insurance they're not using.

But wait ...

Remember how I said the provider was certainly still making a profit when they gave patients a cash discount price of $310?  You can also be reasonably sure they're making a profit from the $174 payment after all the shenanigans are done with.

You know who pays the full amount?  Anyone who doesn't have insurance and can't afford to pay in cash.  For a "small" bill, say a once-per-year urgent care visit for a strep test that totals $150, they can pay it off over time.  For the big stuff though, the obscene overcharging gets added in as real numbers for the big providers to play financial games with (e.g. written off as bad debt for a tax deduction or to bolster tax-exempt status, or folded into overhead costs to justify increasing prices).

And then it all gets worse when it's noted that a free-standing private office provides that same x-ray with the same quality of service for a total of $73 ... in cash.  Pity J. Schmoe didn't know about that beforehand.

Oh, and if someone can't pay the odds are they'll just not have it done at all.  This means they're more likely to end up with more expensive medical issues, or just plain die.  But of course we're not talking about anyone important, right?  It's not like those are real people.  Yes, in case you missed it, that last bit was loaded with sarcasm.

Solution?

I'm not going to pretend to have all the answers, and I'm not going to say that government-run universal healthcare is the only option (though it is an effective option).  But I think a good starting point is to level the playing field between insurers, providers, and patients. 

The "Allowed Amount" and "Insurer Discount" parts need to go.  The cost for a frickin' chest x-ray from a provider should be the same regardless of who is paying for it.  Providers should be legally required to charge a consistent for a given service (they've got all those codes, after all), and insurers should be legally obligated to base benefits on that amount.

Thinking:  I'm still kind of curious if I can start using those tactics though  ...  Sorry, Fredonia Gas & Electric.  The Allowed Amount for my monthly utility bill is $120, but you'll be happy to know I'm paying that amount in full!

Thursday, March 10, 2022

Nuclear Power ... [Insert blank stare here]



Way back when I was shorter, I thought nuclear power was the future.  Then I learned more and I realized it had serious problems and I jumped on the anti-nuke bandwagon.


But then I learned more about nuclear energy and radiation and pollution and ecology and, believe it or not, became hesitantly pro-nuke.

That however was many years ago, and since then I've not only learned more about nuclear energy and radiation and pollution and ecology, but I've also learned a lot about human behavior, economics, business, and politics.  There have also been two big nuclear accidents in that time.

Now when I hear someone say "We need nuclear power to take up the slack while we transition to renewables to stop global warming," ... and I don't know about you but I've heard this a lot over the past few years ... I'm liable to stare at them and wonder about what they've been smoking.

If I feel like making the effort, my answer to them would be along the lines of, "No.  We really don't."


The Problem

Odds are I don't have any information off the top of my head and can't google and read fast enough to counter the gallop that would follow, most of which seems to be the "everyone knows" kind of stuff that sounds suspiciously like it was written by the National Atomic Boosters or some such group.

So ... this post is for future me to point them to.


Two of the biggest and most common arguments for why we need nuclear power are:

1.  We don't have enough space for all the solar panels and wind generators.

2.  We need extra, reliable power for when the wind doesn't blow and the sun doesn't shine.


The short answers for these are:

1.  Bunk.

2.  Bunk.


Of course that won't go over very well as it's uninformative and not very friendly.


1. How much do we need?

That's a tough question, and I'm sure if you ask a dozen politicians you'll get five hundred answers.

A quick search got me a number for 400GWh for the annual power consumption in the US.  That's a lot.

It got me thinking about where would be a good place to put solar panels that wouldn't be adding to negative environmental impacts (a lot of pro-nuke people bring this up like it's some kind of "gotcha" and like somehow nuclear energy has no effect on the environment).

You know what we have a heck of a lot of here in the US?  Roads.  Specifically, the Interstate Highway system.

So, look up some numbers, do some math.  Not trying to solve problems, mind you.  I just want to make sure I'm thinking on the right scale.

We've got 46,876 miles of Interstate Highway (an oddly specific number, eh?).  A 3' x 6' solar panel on average puts out around 250W.  That means if we put a row of solar panels in the median, in both directions, [ math math math probably got some stuff wrong math ] it comes up to around 40GWh.  Yes, that's about 10% of what we need, but it includes using zero new land and would be pretty easy to tie into the existing grid because all roads lead to the grid.  That's a new saying I just made up.  Feel free to use it.

What that really means is the scale is right.  We might not want to actually do it but we've got a lot of other options as well so I'm very sure 100% renewable is both possible and feasible.

Is there anyone else out there that says it's possible and backs it up with better numbers?  Turns out, yes.  An article was published in Nature last year saying 100% could be met using just rooftop solar alone.  Do I understand all the math in it?  Hell no.  Did I look for articles to the contrary?  No, but to be fair I really didn't look hard for this article either.


2. How much do we need?

This line of thought is much less about the numbers and more about just plain easy.

"Yes, we need X units of power per day, but demand isn't evenly spread out.  So with the variability of renewables how are we going to fill the gaps?  We don't have any way to store sunlight or wind for when we need it."  Notice how they've wrapped two arguments up into one?

Well first, we don't have to limit ourselves to X units of production.  Here's a really neat chart I found.  It shows that for the cost of nuclear power we can build a heck of a lot more renewables.  




So instead of developing enough sources to generate X units of power, we make it 2X, or maybe 1.5X, or whatever.  We end up with plenty of power and it's still a hell of a lot cheaper than building new nuke plants.

And storing the extra power?  We don't have to try and keep sunshine and wind in our pockets.  We can actually use electricity generated by renewables to make hydrogen, which I suspect can be stored in ways similar to natural gas, and can be burned on demand to generate electricity in ways similar to natural gas ... and if you're going to complain about efficiency for that step just bump the factor up for X a bit and all is good.

We need nuclear power?   No. We really don't.

Disagree with me?  Cool.  Show me the consensus of experts in the field and I will change my position.

Want to just call me a poopyhead?  Fine.  Do it somewhere else though.  I don't have time for that.


Monday, March 7, 2022

Refugees, Asylum Seekers, and Immigration

Continuing my recent theme of stating positions that I know a heck of a lot of people aren't going to like, today I thought I'd alienate people by talking about immigration.

As with all of my viewpoints, I'm happy to entertain the possibility that I am wrong, and if presented with a cogent argument supported by the real world there's a good chance I will admit my mistakes and change my position (it's happened before, and I hope it will again because that would mean I'm still learning and growing).

With that said, here we go ...




Background

Way back when, before any of us were alive (specifically before 1875) , the immigration policy of the US was pretty much, "Welcome to the United States."  There were some vague requirements about being "of good moral character," and non-whites only got the right to citizenship five years earlier, but that was pretty much it.  If they found their way to the US, they could become "one of us."

Of course we all know such a state couldn't last long, and a steady stream of restrictions were added to just who could and couldn't immigrate.  Some of these seem reasonable on the surface, such as the bans on criminals or people carrying contagious diseases, but others start to edge into the category of "keeping out undesirables".  Polygamists, anarchists, and beggars quickly made the list.

Then in the early 1920s, as the sources of immigration shifted from northern Europe to other regions, all sorts of caps and quotas were implemented.

From that point on it's pretty much all down hill.  Whether intended or not, US immigration policy was (and essentially still is) geared towards maintaining a degree of whiteness.

There have been attempts to reform the policies with the stated aim to "help reunite families" or improve "border control," but unsurprisingly they haven't been that successful.

My viewpoint is that the reason attempts at reforming the process have failed is that they're like trying to repair a broken clock by changing when you have lunch.




Yes, the current system is expensive, problematic, and somewhat ineffective.  It's also unnecessary.

If you do a web search on "economic impact of immigration" ... heck, I'll even make it easy on you, go ahead and click the link ... you get references to countless studies (well, I'm not going to count them) all saying the same thing: immigration is great for the economy.

Not to surprising really if you take a moment to think about it.  If you bring in more people then there are more people who need food, clothing, housing, etc.  With more consumers you get more business, and that means more employment, and more more more more more.  Life is good, right?

Whaddabout ... ?

What about crime?  Searching for "crime and immigration" (I'm so helpful!) returns heaps of studies showing no causal link between the two (thought I've seen some that show recent immigrants are more likely to be the victims of crime).

Ok, how about protecting our vaguely defined "Cultural Identity"?  Ugh!  Setting aside that this is usually used as a euphemism for "whiteness," just what kind of identity are we talking about here?  The US is a bunch of people from all over the world living on land taken by force from those who lived there before.  A lot of the people sent over from Europe were criminals, exiles, debtors, religious nutcases, and people who were just trying to get away from where they used to live.


The only real cultural identity we have as a nation is that of the scrappy, mixed breed dog that will continue to chase huge trucks because one day it's certain it will catch one and win.


Why isn't anyone concerned that
we're all being boiled alive?


Our national language?  No.  Just don't.  Remember that Benjamin Franklin wanted the national language to be German?  If we're going to pick one single language for everyone in the US, I would propose either a language that originated on the frickin' contenent, like maybe Zuni, or one that's completely made up and isn't anyone's native language.  But really, no.  Just no.  We don't need to declare an official language or keep people out who speak something else.

The "Solution"

When you find yourself doing something that is both counterproductive and incredibly stupid, most often the solution is to cut it out.  In this case that would probably work.

1.  No more quotas, limits, or restrictions.  The officer at the border looks at your papers, runs a quick check to make sure you're not on a terrorist or most-wanted criminal list or whatever, takes a photo, gives you a green-card number, and sends you on your way.

If you're not a terrorist or wanted criminal, why wouldn't we want you to come in and spend money? 

If you're going to be in the US, why wouldn't we want you to be allowed to work and pay taxes on your income?  (and no, they're not taking jobs away from hard-working real Americans.  It doesn't work that way.  Go back and read all the stuff at the economics link above)

2.  Um ... actually that's it.  There is no step 2.

Bonus

The part that really gets me is what this saves us.  I mean, aside from all the good brought about by the economic boost immigrants bring, and ignoring the really cool cultural stuff like great restaurants that serve something other than cheeseburgers (which I love, by the way!  Cheeseburgers are awesome!  But have you ever had Thibetan food?  ZOMG that stuff is awesome!).

As a bonus our government doesn't have to spend money looking for "illegal immigrants" to deport.  We don't have to keep a small, permanent, specialized military force to have roam the country, busting down doors, breaking up families, and in general being horrible people.

We also don't have the absurd humanitarian crisis of people camped out on our boarders because they're fleeing war, crime, persecution or anything else, but we want to be sure they're really deserving of asylum and not really just trying to sneak into the country to build a better life.

It would even speed up things for citizens coming back from abroad.  Right now they look at everyone's documents to make sure you're really you and not someone trying to sneak into the country to build a better life.  Instead it would be "Yup, the picture looks like you, and you're not on the bad list. Reason for visit?  Who the heck cares!  Have a nice day.  Next!"


Do I really believe this is what should be done?  Pretty much, yes.

Do I think it has a snowball's chance in hell at actually happening?  Nope.  It would let too many brown people into the country.