Everyone assumed there would be malicious compliance here but it's definitely eye opening just how malicious they made it. Speaks volumes for the perceived risk releasing this data, IMO. Still waiting to hear about someone using this data to negotiate down a hospital bill, seems like it's just insurance companies that can weaponize this data for better rates.
> but it's definitely eye opening just how malicious they made it
As someone familiar with insurer, provider, and facility IT systems, I'd offer an alternate explanation -- the data is bad because healthcare IT is understaffed (and often incompetent).
These are businesses that have squeezed most costs out, and IT is definitely a cost.
Imagine banking... if there were much less competitive pressure and an inability to offer services across state lines without substantial additional effort.
They received a mandate.
They tried to respond in the way that required the least amount of effort.
From someone in the industry, it's entirely plausible this is the best they can do.
Which usually means it takes CMS threatening to drop them for them to launch a multi-year project to finally fix the issue (somewhat).
I'm pretty sure the truth is a mix of malicious compliance and inability, but I'd weight it heavily in favor of malicious compliance, especially for the insurance data. Insurers know their costs, and when and why they pay specific charges.
(My qualifications to make this statement: 15 years in healthcare IT, including UHG/Optum, and 8 years as CTO of a large clinical organization that included primary through tertiary care, research, and an insurance operation.)
I'm not so confident from my experience in healthcare IT, admittedly shorter than yours. One of the issues seems very telling, the fact that one of the listed rates from the insurer matched the portion paid to the radiologist but not the total. Problems with matching up different line items are really ubiquitous in healthcare systems because, despite the standardization that theoretically exists, there's huge variation in how different accounting and analytics systems represent line items. It seems extremely plausible to me that all the numbers in these MRFs are real numbers, but aren't the numbers they're supposed to be. Probably the reports were generated by people using BI tools that didn't have the expertise in the underlying data to understand what values they should actually be reporting on, so it ends up being a hodgepodge of different dollar amounts that are often not the actual reimbursement amount but instead a subtotal or breakdown line items used for analytics.
Sure, insurance companies ultimately know what they paid, but consider that these MRFs are almost certainly not being prepared by the people responsible for that knowledge. They were probably tasked to one or two data analysts who quickly banged them out in whatever BI/reporting tool they use and did nothing to verify correctness. It's not like they had an accountant audit these if they weren't absolutely required to (they weren't). Most healthcare analytics tools are complete junk drawers of data from numerous systems and getting these MRFs right was probably never a priority for anyone. Just a total "I have no idea if these are right but they sure are numbers" exercise.
I mean, how many times have you seen some Tableau report that's all screwed up because some of the MRNs aren't actually MRNs (even though someone named the model field community_mrn) but file numbers from the scheduling system, and now you've got duplicate patients? BI systems just breed that kind of problem unless you are extremely careful about managing them, and since they're "not systems of record" (these are scare quotes) few people are.
>> Problems with matching up different line items are really ubiquitous in healthcare systems because, despite the standardization that theoretically exists, there's huge variation in how different accounting and analytics systems represent line items.
Maybe the problem IS the line items. You know the labor cost of tracking the fact a person was given Tylenol is way more than the cost of the pill? Just give people the incidentals and stop billing for them. Half your overhead might vanish.
BTW, yes every medication need to go on their chart. But it does not need to go through the entire finance system and to insurance.
It's a good point and ties in to the broader issue of opaqueness of reporting, especially now that we've empowered self-serve report generation. We can democratize data systems... but documenting them is a whole different level of effort.
> Sure, insurance companies ultimately know what they paid
It came to mind reading the above that a more accurate/useful perspective might be "The insurance companies' system knows what they are paid," but those system may comprise multiple software systems, none of which have data in compatible formats.
Ergo, even though the insurance company "knows" operationally (it can generate a number on request), it might be unable to generate a list of all numbers (effectively: every path through the system).
But that's why mandates work in insurance: if CMS pushes hard enough, eventually the insurers will develop the functionality.
> Insurers know their costs, and when and why they pay specific charges.
I certainly don’t have your credentials, but my experience in being an insured person doesn’t match this. I’m willing to believe you, but having filled out forms for UHC to get reimbursed for an out-of-network doctor, it sure feels like they kind of make it up based on how they feel that day. I’ve submitted what appear to me to be identical forms for reimbursement (like the super bill the doctor gives me has the same codes, duration, etc.), and the reimbursement differs for no reason I can discern (had long blown past my deductible, etc.). It feels like sometimes you get lucky and the person evaluating your form gives you a break, and sometimes you’re unlucky and they don’t.
On the other hand, malicious compliance does seem par for the course for these assholes. So what you say makes sense.
This is the best they can do when all their incentives align so that being as opaque and disingenuous as possible about costs (and understaffing and often screwing it up helps with that!) helps them.
Not going to argue. In their defense, I'd say insurers are more innovative (especially on the operations side and post-ACA) than the federal government.
IMHO, best of both worlds would be the federal government taking over and centralizing the most core services (rates, interchange, data systems, etc) and allowing private insurance companies to build offerings on top of that (customer service, servicing, product mix, etc).
"insurers are more innovative (especially on the operations side and post-ACA) than the federal government."
They are certainly very creative in making the system as expensive as possible. See Medicare Advantage.
"IMHO, best of both worlds would be the federal government taking over and centralizing the most core services (rates, interchange, data systems, etc) and allowing private insurance companies to build offerings on top of that (customer service, servicing, product mix, etc)."
This would be best. There is so much unnecessary bureaucracy at providers and insurers because the insurers have different setups. The medicare setup would be a good foundation .
They received a mandate. They tried to respond in the way that required the least amount of effort. From someone in the industry, it's entirely plausible this is the best they can do.
Assuming this is true for the sake of argument, saying that this sort of thing isn't malicious compliance is a sad kind apologistics for bad behavior that seems to regularly appear on HN.
How can these kinds of companies optimize their charge codes to get the max for the procedures, optimize their taxes to pay the minimum possible, and then do a poor job on these existential crisis kinds of things? I think they know what they're doing in all cases.
I've known at least a few insurers who have automated running test claims through their systems, because it's the quickest way to find out what will actually happen.
It's not rocket science! But it is decades of code on top of decades of code. There's a reason they still pay COBOL programmers...
>> These are businesses that have squeezed most costs out, and IT is definitely a cost.
What's the cost of an X-ray? Did you know they used to do a FREE X-ray at the shoe store back in the day to check fit? Yeah, don't tell me they squeezed out most of the cost.
They squeezed out most of the cost and gave the profits to healthcare administrators. Why did you think those savings would be delivered to the consumer (you)?
> seems like it's just insurance companies that can weaponize this data for better rates.
That’s because their negotiating power is mainly due to the size of their buying power, not special knowledge or skills. Health “insurance” is basically the lamest, most economically perverted form of collective bargaining ever.
And why federal governments make the best health insurance carriers.
Brokers, medical billing staff, and other middlemen serve no purpose other than increasing cost (in order for an inefficient, openly colluding private cabal to invest premiums, deny claims, and collect profit) because everybody needs access to medical treatment.
I live with free healthcare. The last three trips to the emergency department have been over eight hour waits. My father's cancer treatment was not covered so the last year of his life cost him everything.
On the other side my child's healthcare is amazing and all free. We get instant access to great services.
I live with private healthcare. The last few trips to the ER have been 8 hour waits, too. This is an under capacity thing. I live in a place that has boomed, and the mismanaged hospital hasn’t remotely kept up. They fired a bunch of folks during COVID, then shocked pikachu found themselves understaffed.
The point is, the entire thing is broken nearly everywhere you look. I don’t know what a better alternative is, but we sure need one.
It's not the same... But what about emergency clinics or walk-in clinics? My brother had a chainsaw accident and they were able to treat him in a few minutes. I kinda hope we get more clinics like this over ER options, I used to go to the ER for a lot of issues until I found these clinics available, now whatever country I'm in America or in Europe I look for them over ER options when available. Good for fevers, fixing injuries, most of the more minor things... I'm not sure about the 8 hour wait but if you already exhausted other options I understand.
I live in the US. Every trip to the ER has had <5 min. waits. They're so fast, last time my kid had a fever I went there because the after hours pediatrician was a ten minute drive (10>5).
ER visits really vary. In Austin, Texas you may be able to get in a few minutes to a few hours. Just really depends, when my mom when to the ER last year for extremely high blood pressure she had to wait half a day before she could she see anyone and they thought she might have a stroke. She was fine in the end, but if there was a real emergency I can't imagine what we'd do. I remember we went to the ER at like 4pm but it took until like 2am before she was able to get in and they decided to have her stay the day. I stayed up all night waiting for her to get help it was very stressful. Also what a joy of getting that bill literally a year later, you'd think they would have due dates of when they have to send these out!
You either live in a miracle land where no one ever gets sick yet ER capacity remains high just in case or your child was on the verge of death. The last time I visited an ER with my child it took 10 minutes just to check in. Then a 2 hour wait to be seen.
Miracle land, and it's probably unsustainable. The hospital is large, but opened just over a year ago. My guess is that my neighbors haven't incorporated it into their routines.
Also, where I live there are five (?) Hospitals with ER within a ten minute drive... in suburbia. There just can't be that many people getting deathly ill sick.
I should add this is for my local ER. Although I've never had a long wait in the US (my wife has), my local ER is literally half empty every time I go there, and the triage area 100% empty.
Last time I went to the ER with my dad it was about a 3-hour wait, and he really needed to get in. Saw a few people who looked like they definitely ought to get help, given the runaround and told it'd be hours and hours of waiting, until they left to try to find another ER with a shorter wait (in one case, the patient was delirious, sweating, and being guided around by a couple friends—I hope she got help somewhere), I assume because they looked like they couldn't pay and were probably uninsured (there was definitely a pattern to who got this treatment), so the staff were doing everything they could to discourage them. Some people who were there when we arrived, were still waiting when we got out, so they'd been there at least 4 hours.
US, and he's insured, and it's supposedly a pretty-good hospital.
I've been to the same ER within months of that, and it was empty and I was back in a room (well, cubby) within 15 minutes, with something just barely severe enough to merit an ER visit. Quick. Fucking expensive (think it was almost $3k by the time they were done sending bills, for 5 stitches and an x-ray—and that's with insurance), but quick.
It was mostly just timing and luck.
> My father's cancer treatment was not covered so the last year of his life cost him everything.
Sucks that it happens to anyone, but the final year(s) of healthcare finding a way to soak up every cent, before the end, is basically the norm here in the US. Everyone's retirement savings is just money the healthcare industry's lettings us hold temporarily.
New Zealand has an accident compensation system which pays for accidents (though there may be a small surcharge) but not most medical events. They split the hair finer that is sane. Swallow a foreign body? Medical problem. Swallow a foreign body as say ‘it feels scratched’? Accident. Insect bite? Medical. Mosquito bite? Accident (it’s a distant memory from when I billed these things but I’m fairly confident I’m right).
It’s all to do with cause and effect, and each must be identified.
The accident compensation scheme covers a portion of wages too. Medical problems cost, not US style but not free.
Are you? I kind of try to avoid going to doctors and particularly hospitals and ER/EDs as much as possible. Between people with contagious illnesses, and huge amounts of wasted time, I have very little incentive to use as much healthcare as possible.
Staff, including very senior staff often work in both systems. They then hire staff from the public system into the private one. This runs down the public system.
There are accusations that they don't work fast or efficiently in the public system, leading to inefficiency.
Senior staff with roles or even ownership of private facilities arrange contracts for outsourcing of work to private facilities.
I have worked in both systems and currently work in the private setting.
No, you did not. You specified that you're only looking at competition, and then replied to yourself that there isn't anything else.
In case you really can't imagine alternatives: what if the private system spreads lies about the non-private system? What if they use their influence to change laws and regulations to prefer their system? What if they use their influence to make others with influence treat those using the non-private system worse?
None of these are competition in the sense you're asking for, and yet they are a natural consequence of private incentives.
I think another component to the equation in wait times is also doctors per capita and GDP per capita.
It's hard to compare apples to oranges but with high doctors per capita, low wait times for speciality services, long lived citizens and a far lower percentage of GDP spent on health, I wonder if there are any serious holes to poke in Italy's system when compared to the U.S. or if they simply just beat us on every metric.
I just had kidney stones, while extremely painful not very high on the er totem pole. Got in, got a bed, IV all within 10 minutes of walking in. There's at least 30 hospitals in my metro and hundreds of urgent cares.
$1500 on my HSA plan, which btw right now is returning 4.6% in a money market. How awesome is that?
Last time I was the ER in the US, I waited four hours with a pretty serious fever. Talked to a doctor for maybe 5 minutes and got sent home. Cost me only $500.
We have a free health line. It operates 24/7. You talk to an operator who puts you in a queue to talk to a triage nurse. They tell you if you need to go to the ER.
My urgent care facility, the only option between 5pm and 9am or on weekends, pretty much sends everyone to the ER as a precaution. If it’s serious enough, they’ll call ahead and get you into the triage system before you arrive.
Insuring massive populations isn't really insurance because of large numbers (there's no risk involved.) It's just an economic rent. It's a poker game where most of the players are cooperating.
Senior / elderly care can be enormously expensive. Especially towards end of life. I could agree with you if the population was all teen to 45 year olds but that is not realistic.
The same dynamics play out with pension schemes. Declining birth rates play havoc with proposals that rely on a large, young employed base who's work supports a small, retired set of pensioners.
My own perspective is that healthcare is extremely limited on the provider side. Professional organizations have been limiting the supply of doctors / doctor equivalents for decades. Not to minimize the work a family medicine or general practitioner puts in, but many important health services/early interventiona can be safely and reliably provided by a nurse practitioner or physicians assistant (what a horrible name) on a much larger and affordable scale then exists today.
I always believed that nurse practitioners would be just about as good at primary care as a doctor. But fuck me my nurse practitioner is useless. Like tons of British Columbia residents I don’t have a family doctor, so thought this would work. But they are afraid to do anything. At least a doctor will be confidently wrong like chat gpt.
Insuring populations that are too small/niche/finite or over which you have too much information and ability to price discriminate (i.e. charge them exactly the cost of insuring them) isn't insurance either.
It's a perverted cross between escrow and welfare in which the population basically pays their own way in the long run plus supports all the people who make their living by being "administrative overhead" along the way.
If you need anything more serious than your family doctor, expect a long wait in the US too. My colonoscopy is booking 6 months out for what should be a very routine procedure.
> NHS is not known for speedy treatment, for instance.
From what I understand (I am not a UK citizen, but me mum's mum spoke Scouse. My mother, on the other hand, spoke The Queen's English), everyone loves to hate on the NHS, but no politician in their right mind will touch it. It's a "third rail."
Companies are considered a person and legally have rights such as freedom of speech, can own property and enter contracts.
They are allowed to spend as much as they want for votes due to their freedom of speech. Sure they can't directly vote but ever since like 2010 have a lot of human rights and I'm sure would love more. I would not be surprised if one day they could directly vote considering due to their rights. I hope though we can push back before then and change things.
The current administration has basically decided that this will not be enforced so most of the carriers have ditched phase 3 - searchable 500 popular procedures.
Really is a shame, I was very much looking forward to utilizing this, especially for HSA and or ASO clients.
>That’s because their negotiating power is mainly due to the size of their buying power, not special knowledge or skills. Health “insurance” is basically the lamest, most economically perverted form of collective bargaining ever.
Now can you make a cogent argument for why more than one federal / national union should exist? Why does Europe allow multiple unions?
For a customer advocate, the pervasiveness of the artificial low rates seems to be an interesting opening.
You should be able to go back to the hospital and say - based on the hospital public fee schedule , total FFS for CPT should be (very low number) . Therefore, my deductible payment is overstated, please reduce my bill dramatically.
A lawsuit would follow, which would make it very interesting. Chief argument:
The customer can clearly say its fraud - he/she looked at the public rate schedule and believed the charges would be based off the public rate schedule.
Ultimately, the disconnect between published rates and the EOB is going to come back to bite hospitals, once people shop around using the data.
I wonder, does the law have any whistleblower provisions? Seems like a programmer who had been coerced to fudge the data, and kept receipts, could be in a good position...
Imagine a world where one entity received all the peoples medical bills and was incentived to negotiate for the lowest possible rate from each provider. Imagine the savings alone from reducing a massively overly bureaucratic and complicated system down to just one entity negotiating and paying the health service providers. Just imagine in that world this article would have never needed to have been written.
The reality is that both systems suck, and I say this having lived in systems with universal public healthcare.
They just suck in different manners, different countries have different degrees of "suckness" and so on.
And then there's the big problem beyond the question of who is paying: How much is being paid.
Healthcare costs in the US are absurdly high both on relative terms (things are way more expensive) and on absolute terms (more of the same things is needed because the American population is relatively too unhealthy for what you'd expect in a developed country with similar demographics). You need to ask why relatively inexpensive stuff like insulin is so much expensive in America than say, Germany or the UK.
If you don't solve this issue, a single payer system would probably become more similar to the terrible situation in most Latin American countries, where you have terrible supposedly universal public healthcare systems, but where in practice if you can pay for private insurance, you will do it.
> Healthcare costs in the US are absurdly high both on relative terms (things are way more expensive) and on absolute terms (more of the same things is needed because the American population is relatively too unhealthy for what you'd expect in a developed country with similar demographics). You need to ask why relatively inexpensive stuff like insulin is so much expensive in America than say, Germany or the UK.
Must be that law of economics that says the more you make of something the more expensive it gets.
Yes, and let's also imagine all of the existing single-payer systems (de facto or otherwise) work as advertised and didn't have elites-with-means flee to other nations for quality care.
Let's also imagine these systems provide stellar quality care and more importantly, timely care.
We can daydream all we want - but the reality isn't so obvious or absolute.
For those who are really in the know... the US already is a socialized medicine nation. Look at how much of the US annual budget is blown on medical care. Hint... it's larger than the military budget.
My personal experience as a European citizen living in the U.S. is drastically different.
I flee the U.S. to have all my medical related tests and work, out of pocket, in the E.U.
And it is cheaper and much much better experience.
(And I don't get different treatment compared to any members of my family that are insured in Europe for paying out of pocket.)
First of all: I speak with a doctor. Not a nurse, an administrator to size me up, to see if I am in actual need of an appointment, but a doctor. (Yes, this has happened to me in the U.S. I find it unacceptable, especially given that I was apparently in much more dire situation than I even thought, and was lucky to be seen by a doctor, otherwise I would have joined the disabled group of individuals.)
I am not sure why people in the U.S. keep bringing up the UK [Edit: -- not sure if that is what you are implying but most people are in other comments]. Pick any EU country. Sure, you might not have a 5 star doctor's office, but you are going to be treated by a doctor efficiently. And that is what matters. Don't waste money on administrative tasks and fees.
Not a solution for everyone... but I have to ask, since you have the time to go to the EU for routine medical work, why not move to somewhere in the US that has doctors?
Also looking at a primary care wait time is fine, but what is broken in most single player systems is specialists and "non-emergency surgery"... which is often stuff that significantly affects your quality of life.
(the colors represent a primary care, but actually hover over each country...)
-
I ruptured a ligament in my knee and since it wasn't a traumatic injury, the surgery to repair it was considered a non-emergency and I was sent home from the ER.
My uncle is an orthopedic surgeon in Norway and was shocked to hear I was already scheduled for surgery to repair within a week. He said in Norway that would easily have been a month or two wait, which is alarming to me.
At the end of the day the US system is broken, but I think this illusion that single player is some strictly better concept that the US is just rejecting is also wrong. Care is noticeably worse in many EU countries when you look past the singular measure of "Time to see your primary care"
> why not move to somewhere in the US that has doctors?
Do you have a suggestion where in the US that is? The US has many doctors but essentially all of them are gated behind insurances and especially hospitals.
You can see your doctor pretty much freely within the US for nearly any reason. This idea you cannot see your doctor in the US, or that you receive treatment from nurses or administrators is simply not true.
> insurances and especially hospitals
You may be confused, because some doctors operate private practices, while others choose to work for large hospital organizations. Private practices may be more akin to what some people's idea of a doctor should be. Most insurance plans offer a selection of hospitals and doctor networks, allowing you to chose the style and type that works best for you.
In all cases, you can see your doctor if needed, with very little lead time if any.
> You can see your doctor pretty much freely within the US for nearly any reason.
Sorry, as someone who knows multiple people in various parts of the US healthcare system, this is pretty laughable. At the very least, we have different definitions of 'freely'.
Most of the urgent care clinics near me, for example, no longer accept patients without appointments. ER wait time is several hours, and you will owe hundreds if not thousands of dollars after unless you have _very_ good insurance.
> This idea you cannot see your doctor in the US, or that you receive treatment from nurses or administrators is simply not true.
Not from administrators, but nurses yes. Many clinics will only have a RN on duty large parts of the time. There are also systems where you can set up telehealth appointments, but a lot of the time they will be with a nurse and not a doctor.
> In all cases, you can see your doctor if needed, with very little lead time if any.
My parents have been trying to address some conditions they've developed, in one case, pretty serious. There's a several month lead time on their appointments to deal with this.
There are large parts of the US where private practices are very rare and the major care provider organizations have multi-month waits for both primary care and specialists. As I understand the overall trend is towards longer wait times but it is significantly worse in some cities than in others. Where I am, for example, it is around six months to get an appointment with some fairly common specialists... and that's a mid-size city with a university hospital and everything. My former primary care doctor only had availability about three months out, but I am fortunate enough to have found a small private practice that has far fewer patients per provider... at the cost that I pay a large annual practice fee to be a patient.
I think this is pretty uneven across the country but it is definitely far from guaranteed that you can see a doctor on demand with a short lead time. I have heard of similar problems pretty much throughout the central region of the country. In an attempt to alleviate the situation a number of states have programs where they pay subsidies to providers in areas with longer wait times, but this turns into a complex billing system and states often can't afford enough to really make a big difference.
In some ways the private insurers are doing some good here, as several offer "patient concierges" that will do things like try to find a provider for you that's accepting new patients. But in a recent experience that involves calling every two weeks and being told they still can't find any availability, for a couple of months.
I’m happy for you that you have been served so well. However that is not the case for everyone, and your dismissal of others’ experience is so strong and condescending to the point that you sound like a real jerk. Other people report a lot of problems with their healthcare. You should listen to them, as they have very little incentive to lie.
I mean I've lived in 4 cities in the last 8 years, and in every single one I could see a primary care provider on a day's notice.
Although actually re-reading your post, it sounds like you're really just trying to take a dig at Nurse Practitioners, most of which hold doctorates.
I guess if you're too good for a DNP, the primary care must in fact seem like an impossible thing, in which case I do wish you good luck on the 8 hour flight for "all my medical tests".
> There are plenty of countries which operate functioning public health systems with optional private care.
You mean the US...?
It's a quaint idea... but nobody likes the reality once it's implemented. Evidenced by the fact that the US is already the largest public health system in the world, and people do not even realize it.
The states that were well on their way to having public options before obamacare generally have ok public options at this point. Frankly they probably would have done better without the federal wrench being thrown into things.
> I'm not sure why you're ignoring a lot of Europe, Canada, Australia and New Zealand.
These are exactly the ones I had in mind.
> universal public health care with costs covered by the government.
To be pedantic, this doesn't exist anywhere in the world. The taxpayers foot the bill universally. You may not personally care, but it matters when we're discussing spending other people's money.
In the US, we already have universal public health care. If you cannot afford to pay a portion of your premium, you can be eligible for healthcare at zero expense to you.
The US government spends more on healthcare than any other nation. The US is already socialized healthcare. It's just not the utopia people thought it would be so they continue to complain...
It gets way more complicated than we can discuss here - things like private premiums are so expensive because the socialized system does not pay it's entire bill, etc. The entire thing is a massive C.F. but speeding further down that same tunnel is not going to suddenly magically make it better. It's very much-so the "but we can do it better" mentality, despite however many previous attempts there has been.
Those countries citizens rate their happiness with the healthcare system in their country ~2x higher than US citizens do. So that line of thinking doesn’t hold.
>> it matters when we're discussing spending other people's money
That’s not how money works and until that fundamental misunderstanding is eliminated, learned helplessness will prevail. A country that issues its own currency cannot save money in its own currency.
The hard limitation a government faces is resources, not capital.
> That’s not how money works and until that fundamental misunderstanding is eliminated, learned helplessness will prevail. A country that issues its own currency cannot save money in its own currency.
Ah, the so-called "Modern Monetary Theory"... the same one that told us governments can spend infinitely without consequences... and then runaway inflation and looming recession happened. Of course, not MMT's fault...
In case my sarcasm wasn't thick enough - it is indeed how money works. The attempts to "1984" economics thankfully are failing spectacularly enough to put it to rest.
> Those countries citizens rate their happiness with the healthcare system in their country ~2x higher than US citizens do. So that line of thinking doesn’t hold.
This is a false statistic designed to mislead people into thinking some other system is objectively better.
“The inflation worriers’ objection seems to be largely over the “stimulus checks.” While we prefer targeted spending in normal times (and prefer pay for work over transfer payments), these are not normal times. The extra $1,400 (above the $600 already approved) will and should go to most families to help cover those bills. The propensity to consume out of these checks will not be high, as most people will use them to pay down debts or replen- ish savings (only 29 percent of the first round of checks was spent on consumption, while 34 percent was used to pay down debt and the rest was saved). What little boost to consumption they will provide can be handled without inflation, as production around the world has rebounded sufficiently.”
Before we dive into the relief part, note the “While we prefer targeted spending in normal times (and prefer pay for work over transfer payments)”. This refutes your argument as being a strawman. MMT doesn’t say what you said it does.
That doesn’t refute that stimulus is mostly inflationary though, so let’s look under that rock.
All spending, private or public inescapably contains inflation risk, however we saw something else for the most part.
Building on Randall’s reference to what the first relief was spent on (mostly non inflationary - but with some inflation where checks were issued to those without need for relief), we then went on to see supply side shocks (it’s still a pain to source some cars). There were demand shocks very early on - toilet paper predated stim checks so something else caused that demand side shock…
To this day We still see the predictable bullwhip in some markets.
We also see evidence of suppliers opportunistically increasing prices - some of our largest corporations are currently enjoying record profits.
So let’s be more direct in knocking this argument down - what are the cases of inflation that can’t be completely explained with one of:
1. increased profits in the supplier
2. global supply shock (oil, gas, manufactured goods etc)
That leaves us with only real estate, financial products including stocks, and…?
So what exactly is the argument around inflation if it is limited to a few asset classes that are ripe for obvious taxation solutions to eliminate said inflation?
>> it is indeed how money works
but going back to this bit, ignoring bs macro fairy tales and looking specifically at the system itself (which most macro theories rarely do, the stated assumptions in most macro bs are laughably absurd).
So how do things work in practice?
Ignoring that the fed has bought treasuries and thus literally means the government created money from nothing on a whim - ignoring this case because while it does sink the argument that taxes come before spending, it is a complex case with lots of gotchas that mean it’s not fair to characterise it as govt create money regardless of circumstance in all cases.
So instead let’s look at the policy that gives exactly this operation:
Step 1: The fed finances the primary dealer banks that participate in treasuries auctions - it accepts treasuries as collateral for repos.
Step 3: and the Federal Reserve ensures there are sufficient reserves to do so by supplying them through temporary repos (a matched purchase of Treasury debt with a requirement that the seller must repurchase later). While the Federal Reserve is not in that case directly buying the new issue directly from the Treasury, it uses the open market purchase to buy an existing bond in order to provide reserves needed for a private bank to buy the new security. The end result is exactly the same as if the central bank had bought directly from the Treasury.
The MMT people always do this... bury people in bogus articles, references and walls of text to try to make people think everything known about economics was and is wrong.
Sorry... these are borderline crackpot theories. The devastation left in the wake of only a taste of MMT implemented is enough to drive MMT to bed, thankfully.
It's also rather interesting how one can tell a MMT'er is in their midst without much even being said.
The provider of care gets paid "a reasonable amount". The care is provided. No bureaucratic nonsense. Sound ideal. Except... someone invents a novel care. They can choose to provide it "for a reasonable amount". But it can ONLY be provided by the entity paying "a reasonable amount". That entity has to make the call "novel care/old care". Old care is ALSO provided at a "reasonable amount" and has entrenched interests. There is no way that novel care wins. Without setting up an alternate system, or going OUTSIDE the system. Then, consumers of old care can see novel care and its benefits. They can then demand novel care. This happens within the American system, and the American system provides that "outsider status" to other systems (like the one we have in Canada). What does the Canadian system eventually go? Without sufficient external force, it is less expensive to provide MAID (medical assistance in dying) that actual healthcare. The current debate in Canada is whether mental illness is a sufficient trigger for MAID. Depressed? Best cure is death. And, yes, Canada has been mocked for that.
> was incentived to negotiate for the lowest possible rate from each provider
So, not an entity which by its very nature spends other people's money and can never run out? I agree, sounds like a great idea, but someone will have to invent such an entity first. The ones we have would not meet the requirement.
Thank god no-one's tried, I'm sure the population of any such country would riot to reform to something free-market-based instead in short order, because expenses would rapidly grow out of control, vastly in excess of, say, what the US spends per-capita, and service would be completely terrible, leading to plainly-worse-in-every-way outcomes than in countries that retained more-enlightened systems.
... what's that? The entire OECD has more centralized government control of healthcare than the US, ranging from extensive price controls, to de-facto or de-jure monopsony, to outright direct control of the healthcare system, and nowhere is there a strong populist movement to ditch that for a heavily free-market-based solution? And literally all of them are way cheaper per-capita than our system? And outcomes remain between pretty-good and great? And instead of the bureaucratic billing mess we have, that's all nice & simple and takes up almost none of the time of sick people and their families? This makes no sense, I read several columns on mises.org proving from first principles that this is impossible!
So not only shouldn’t healthcare be a market good (moral argument), but healthcare profiteers are actively distorting the market and are not taking seriously efforts to provide a modicum of information to participants in this so-called market.
It’s one of the most complicated and regulated markets on earth. Yet both the critics and supporters think it’s a free market.
Would a free market be better? Probably overall, but the bar is very, very low. Instead of running another decades-long experiment, perhaps just use a model proven to work? There are many to choose from.
Whoever is doing this due diligence is truly helping millions and millions of people. Good luck. There are very few among us here that could pretend the same, and I'm not one of them.
If anyone is interested, the arm and a leg podcast covers how people leverage transparency data and other strategies to fight hospital bills. Most recently it was covered that so few people take hospitals to small claims court over their billing practices that hospitals can afford exorbitant teams of lawyers to establish more case law that their behavior is legal.
There used to be, and I'm not in a position to find it, a forum that specialized in cash paying the least amount for all procedures, lab tests, imaging etc.
It truely was impressive how these forum members unearthed massive savings and really, once you knew what to do, didn't seem all that invasive or difficult.
We are writing more groups using Referenced Based Pricing. Good idea.
There are two problems here:
1) Hanlon’s razor
2) The author doesn’t understand health insurance data.
I’m not trying to excuse the other bad behavior, but within the data itself, he’s experiencing a combination of health insurers’ incompetence, the kludged up data models they’ve had to build to represent the output of the multiple generations of claims processing systems and other administrative processes, and the general mess that provider identifiers are. Every payor calculates values differently. Every payor uses different codes (beyond the standard CMS and CPTs). Every payor has different arrangements that are difficult to represent in standard schema, eg capitation in Florida, delegation in California, or the oddness that are Taft-Hartley plan.
There is a link in the article to a discussion with CMS. Another participant in the discussion works for IQVIA, a long-time claims data aggregator (and CRO and a bunch of other things), and clearly understands what’s going on. It would be extremely difficult to do this work at all without significant experience working with multiple payors’ data, which requires time and access, and pays well once you do have that specialized experience.
Other countries manage to successfully wrangle healthcare billing & coding such that they can apply, to good effect, outright price controls on various procedures. See, for example, Japan.
I absolutely don't believe this complexity is inherent in the problem space, because it very much looks like it is not. I'd believe that one or more actors in our healthcare system really like for it to be this way, though.
The point of the author's exercise is to see if the requirement of public transparency enacted by Congress actually means anything.
If the meaning of these prices is only decipherable by an elite priesthood that is too busy to work on the problem, there is no real public transparency.
I don't know how closely you've worked with this data -- you clearly have some kind of expertise -- but how do you explain this?
The insurance companies had 18 months to talk to the CMS and ask for a better data model. If they're not able to explain how much things cost with 5 different negotiated types -- negotiated, percentage, derived, fee schedule, and capitation -- then they should have asked for another one.
The hospital and insurance rates are both fee-for-service base rates for items billed individually. If there's some nuance in interpreting how "fee for service" "dollar amount negotiated" goes, definitely write to me and let me know. I talked with experts in healthcare pricing before I published this.
You can write to me at alec@dolthub.com if you wanna hit me with more questions.
I've worked within the health insurance industry (workers' comp, specifically); I know what a shitshow it is. As a fairly green programmer, I was tasked with creating a flat file export from our IBM mainframe's database for a new/changed regulatory requirement, and within just a few weeks (including a bunch of time spent waiting for return files from overnight batches), my export complied with the stated spec better than the agency's own files did.
But the health insurance industry makes absolutely jaw-dropping profits. The only reasons they can't harmonize their systems and produce something at least resembling standard outputs are because it would cost them slightly (on their scales) more money than just continuing to do what they're doing now, and because the higher-ups are (as with many industries) chronically unwilling to commit to one particular standard if it will make it even a little bit harder for them to change their minds whenever they want.
But the given examples are basic procedures like “wrist x-ray” or “endoscopy”. Surely they have simpler rate calculations than the potential special cases you mention?
Let’s do wrist x-ray and keep it simple. I’m sure I’ll mess up the formatting here.
When you get an x-ray, you would expect to see 3 claims (again, simplifying).
—— One is the x-ray tech taking the picture. That gets a professional claim with a CPT code and is straightforward.
—- One is the interpretation by a radiologist of the imaging. That is a professional claim with a CPT and a modifier.
—- The last depends on the place of service. If it’s in a hospital, or at an outpatient facility, or at an ASC, then you get a facility claim to go with it.
Next, under what circumstances did the x-ray occur? Was it during an inpatient stay? If so, the payor might pay based on a DRG, which is basically a bundle of all the services that occur during the stay. How do you decide how much of the cost to allocate to the various parts of the x-ray? There are more variations on this.
Next, how are the providers contracted? Are they participating providers? Par vs non-par have different payment rates.
Next, was the service in-network or out-of-network, defined by the patient’s insurance benefits?
Does the patient’s PCP participate in a capitated arrangement (fixed fee to the PCP’s office per month)? If so, what is the allocated cost for the service based on the submitted encounter?
What about fees for network rental? Sorry, this one is esoteric, but it’s another factor.
I'm the author. When I write articles I have to make a choice: make them readable by the public, or detailed enough to satisfy the experts. I try to strike a balance, but I can't have both.
The metadata you're talking about is specified in the files themselves. I've limited my search to fee-for-service (non-capitated, non-derived, non-bundled) institutional claims.
You can write to me if you have more questions. alec@dolthub.com
Forgot one. The doctor who looked at the X-ray practices under one ID on Sundays, another ID MWF, and another T,Th,Saturday. In each case he’s also part of a different provider group. He might still have more than 9 TINs or NPIs under which he bills, all with different rates. How much does it cost to have this doctor interpret your x-ray?
I think you're far off base here. An X-Ray will never come on more than 2 claims. It only has two parts, an interpretation and a facility fee. You are right it is confusing. It is true that billing context (as part of a grouper/stand alone) needs to a part of the publication of the files. However, that has nothing to do with the author raising valid points of inconsistency that can make the data unusable.
I really wish we could effectively apply Hanlon’s Razor in these cases and force the CEO and board of directs to literally chose between "are you and your CIO malicious" or "is your CIO so grossly incompetent that you have utterly failed in your fiduciary duty"
Isn't that the problem? In for profit healthcare being malicious IS the fiduciary duty. So long as everyone else is playing the same game, there's no reason for one insurance to suddenly "break good".
This could have been much much easier if they just required the medical equivalent of certificate transparency. Every insurance company is required to post publicly every single claim they receive, the full information of the provider(s), the name/code of the plan, the billing codes, whether it was approved or denied, how much the insurance was billed, and how much insurance actually paid (where paid doesn't mean discount, it means the literal dollars that left the insurance company's bank account), and the "patient responsibility" along with where the patient was with regards to their deductible and oopm. Every medical provider is required to do the same every time they create a bill.
Fine, "you don't know" how much things will cost. We can figure it out for you. No thoughts, head empty, just post and sign every bill you generate as it comes.
Completely agree. There are databases like this out there (All-Payer-Claims database) but they're extremely expensive (it would cost millions to get data for the entire US) and I have no idea why.
Seems like really important work that gains more value as more people hear about it. I hope that what you're doing will lead to better data and greater transparency.
At DoltHub, where we build databases like codebases, we're running a data bounty, collecting rates for popular medical procedures for all US hospitals. Then we'll release the data under CC. Find out more here.
If you want to be a part of this battle while also not being a part of the "middleman" (e.g. price transparency venders), come join us at Yuzu Health. We are hiring for a senior engineer to help us build a modern health plan tailored to the needs of startups and their employees.
Most hospitals have provided flat files, phase 2, and now the current administration has decided not to enforce this through completion of phase 4 fully searchable due next year. Enforcement began with the previous administration fwiw.
Just to throw out a possible next step to put pressure on the payors: consider reaching out to the CMS technology ombudsman to ask if you can CC him on a round of follow-up inquiry emails.
His nominal role is to assist with Medicare-related matters, but given that the ostensible goal here is to compare rates (and most payors define rates as a percent of Medicare), I think the request wouldn’t be too much of a stretch.
Similarly, might be possible to get some congressional offices to lend their weight. Happy to personally lend a hand with the outreach if there’s interest.
There should be fine a 1% of annual revenue for every day these companies are in non compliance with prison for the ceo if they are non compliant for over thirty days.
Author here. The problem is checking compliance. By publishing these files, they seem compliant, but really aren't. Since the payors are the guardians of the data, it's very difficult to check that what they're posting is correct. That was the main thrust of the article.
The reasonable solution that people in the US arrive at is to avoid going to physicians at all costs.
I recently found out that a simple blood test at the physicians office costs ~$600 (with insurance), along with all of the annoyance of dealing with setting up the appointments waiting for several months, waiting on insurance, the trouble and time off work to get there - all for a material that takes a few minutes to extract and few moments to run.
Due to the cost I was curious, and found out that I could literally purchase all of the FDA-approved* lab equipment for my house and run tests on myself for less cost than it was to go to a physicians office. The physician (i.e. expertise) is irrelevant here (almost always are) as the most input I've ever seen provided by one amounts to 'take an Aleve if you're hurting'.
Home labs are likely where the future is headed, and it's the fault of the medical industry being so utterly useless.
I've been through most medschool (neurology-focused) courses, and most physicians or any medical professional uses essentially zero of that knowledge.
My expectation is that costs for these simple tests will become competitive as physicians become more and more scarce -- if the person doing your blood test is no longer an expert, and is just feeding it into an off-the-shelf machine, then there's a lot more flexibility in cost-cutting.
(In fact, my local hospital has pretty great lab prices for this exact reason, so I'd assume this kind of price competition for simple tasks might already be a thing in some urban areas.)
I know it's even stupid for me to say this, but capitalism should have no place in hospital health care.
It's lives on the line. In a somewhat realistic ideal world, any monies that exchange hands at that level should be to cover costs plus a moderated profit.
The lack of moderation and accountable oversight on the profit centers of healthcare is a real issue that we could solve, but too many people would rather have a 0.00000001% greater chance of becoming a millionaire in their lifetimes rather than put checks on unchecked capitalism.
Unfortunate that the man in this analogy is Hannibal Lecter (Silence of the Lambs, Hannibal is a violent psychopathic cannibal in that movie), and should be stopped from getting his meal.
Insurance companies are a problem, and they've grown fat skimming a fair fraction of this nation's GDP for no observable value provided. Our healthcare system is more expensive and has on average worse outcomes than other first world economies.
haha - don't tell that "fact" to any republicans...
none of my colleagues believe it (they also don't believe in human caused climate change or that ectopic pregnancies are unviable, all sorts of nonsense)
I'm waiting until we meet that great filter in the sky
The big problem with health insurance is that the people who buy it think that they are buying a health subscription.
The second big problem is that they are being forced to buy it.
So you have something that isn't what people want, but that they are legally obligated to "purchase"... Is it any wonder most people are dissatisfied with it?
Monopsonies require a single buyer with a stick to work. Economics teaches that to us since inception.
I am not sure why this is even a divisive topic. Sure discuss how a doctor decorates their office. Who cares. When you are dying or are in pain, nothing but treatment at any cost matters.
While there are arguments for and against a variety of systems, this one is weak and specious.
Oh, sure, in a crisis you need care immediately. What about all the other circumstances? What about the possibility of making pre-arrangements in event of crisis, some sort of “insurance” even? Not to be confused with the comprehensive health care delivery product called “insurance” in the US (which, hey, also exists as a model and could persist in a market.) Maybe some markets are still monopsonies, but surely not all. I can surely find a variety of GPs, allergists, physical therapists, …
A sound argument for or against a market health system recognizes that emergency care is only one circumstance of many, a minority of health care costs, and it’s possible we might be better off if it does not drive the overall design of healthcare.
Article says "contracted rates that are wrong, mislabeled, or missing" so I want to see what a correct, properly labelled example looks like according to the author. I want to see what they think correct data looks like.
But that's entirely dependent on the data - if you read the article, you'll see that the author is pointing out how different datasets are reporting different values for the same healthcare service. A correct, properly labeled example is just that - a document where values are accurate rather than misreported.
If you want to get a sense of what a correct, properly labeled example might look like, you should visit the CMS's guidance [1]. Health insurers should be providing documents that follow the format described there, and most importantly, reporting values that are accurate.
