In other words we have a bona fide AI arms race between doctors and insurers with patient outcomes and profits in play. Wild stuff and nothing I could have ever imagined would be an applied use of ML research from earlier in my career.

He would sometimes pull up next door with a half dozen tote boxes overflowing with medical records. He would say "hey, dataviz1000, can you help me get these into the house?" He once asked me if I wanted a new job helping him go through all the charts. I don't get involved with illegal activities and I was earning more not breaking the law elsewhere. He did hire a young woman who graduated law school and was still working on passing the bar. Since they have married and started a family.

Yes, HIPAA laws got broken! Yes, this guy made 10s of millions in a few short years.

There are no good guys in this story.

Probably would make a good start up using LLM and bringing the process into compliance with HIPAA. There is probably several billion dollars in insurance companies that have been under billed.

And it's not necessarily a HIPAA violation to outsource medical billing and chart review as long as there is a proper BAA in place, and everyone follows the Security/Privacy Rules. Many small provider organizations pay outside services to ensure they bill at the highest allowable level.

HIPPA carves out this exception for using your health records:

“To pay doctors and hospitals for your health care and to help run their businesses”

It isn't difficult to bring the process into compliance. I offered to make an app which would have been easy because there was a predefined workflow that can be diagrammed on a sequence chart in about 10 steps. There were a couple interactions between the lawyer and the doctor. Then a step where the insurance company is notified. Then a lawsuit filed if not paid. At one point, I was researching how to store data in HIPAA compliance in the cloud. It was about 2 years later when AWS provided HIPAA compliant EC2 instances. I offered to build the app for $10,000. Having random people pour over private medical charts and undocumented and haphazard communication between the lawyers, insurance company, and doctors through email and text messages was a mess.

https://www.hhs.gov/hipaa/for-professionals/privacy/guidance...

I don't think so. The "paying" part is important - the neighbour becomes an employee for the duration of the work, which is fine, as then there's a contract between the employer and employee which includes, even if only implicitly, that the employers data is not to be exfiltrated.

If he were simply sharing it with his neighbour for shits and giggles that would be a different story.

[0 https://www.medicaltranscriptionservicecompany.com/blog/what...]

And yes, I think the lawyer does know more than you.

Checked with a doctor and they said the same and couldn't puzzle out a benign misunderstanding that was right - they pointed out that even if you meant the lawyer sued if the insurance company refused to pay, the economics would be all fucky on the splitting, because now the lawyer does have to go to court, no automated easy money, much less millions.

I searched for "how long does a doctor have to bill you in florida" and the a top result was this gem, "A doctor in Fort Lauderdale I saw in 2020 contacted me to tell me that there was a /"billing error/" 3 years ago that they now want paid. What can I do?" That sounds about right.

I don't know the specific details about the lawyer was doing.

I realize that there's no magic solution to perverse systems like this, but it really bothers me nonetheless.

An iPhone 16 pro battery appears to have about 18 watt hours. So approximately 100x less then a human uses.

The engine came up more favorably.

Turns out, eating any meat and industrial agriculture transportation are really heavy.

For example this study https://www.nature.com/articles/s41598-020-66170-y.

> our estimates suggest that the net emissions associated with the ‘fuel’ required for driving, walking, and cycling may be comparable in some settings

With the caveat that they're looking at *per-mile* emissions, and nobody in the developed world is walking 60 miles to and from work every day.

However there's an important clarification to your recollection.

- You're correct that eating meat (and dairy) is very carbon-intensive.

- You're not correct that agricultural transportation is significant. It doesn't even make it into the paper above, as far as I could find. Agricultural transportation, even things like flying blueberries to California from Chile, is negligible compared to the carbon cost of food.

You can see that in the following graph. Red is transport. You have to look closely even to see it. https://ourworldindata.org/food-choice-vs-eating-local

Note: not saying these metrics are what would be used, just giving examples of antithetical heuristics that could play together.

I put that air quotes because insurance companies don’t actually provide health care. They provide insurance. That’s a financial product, not a medical one.

It often goes unsaid, but America, on a cultural and political level, is really ideologically fixated on a distinction between working and non-working individuals, and, in a far deeper sense, whether an individual "deserves" healthcare or not. This makes access to healthcare intricately connected to class, wealth, and income, in America. That's why access to healthcare is seen as a product in and of itself. You can either afford it ("you've earned it"), or you go into debt for it ("you have to earn it"), or you simply have no expectation of ever paying for it ("you cheated the system").

The entire conversation is often dominated by these ideas in a way that often makes talking about healthcare with Americans baffling to people that come from many single-payer or universal systems.

So the wealthy and insured are covered. The lowest rungs and those that don't care and will just run away are covered. It's mostly lower / middle lower class that this really hurts, ironically.

They're really not. They are only entitled to "stabilizing care".

I work as a paramedic. We have had situations with "frequent fliers" where when we've called the hospital to give a report as we are transporting, the hospital will say "let us know when you're here", and when we've done so, there's literally been a physician come out to the ambulance.

"Hey, X, what's happening?"

"I got a lot of fluid in my gut (he had ascites)."

"Okay, well, that's not new, and it looks like you have an appointment for having that fluid drawn in two days."

"Oh, okay."

"Anything else bothering you?"

"Nope."

"Alright, we're good then." Gives us a nod.

"We're going in then?"

"Uh, no. You have been by a physician, you're stable, you're good to go, you can jump off their gurney and head home now."

Which is harsh - but also this person at this point was being transported 4+ times _per day_.

But EMTALA only requires acute stabilizing care, not definitive management.

If you have literally no income (or your income is entirely "off the books"), then you qualify for medicaid; everything is covered with no premiums, copays, or deductibles. At a middle-class level of income, you're probably looking at either a comparatively shitty ACA marketplace plan, or a comparatively shitty employer-provided HDHP plan. At an upper-class level of income, you can afford top-of-the-line healthcare.

TBH I think in the US it’s more than anything about how much more competitive industries here are vs in the UK. If X company feels it’s worth the extra cost by allowing unlimited PTO and 2 years of parental leave, etc. the worry is that X will be trounced by Y Company, who is ruthless enough to not offer those things and as such has much cheaper labor costs.

If you take an industry like retail, those companies have a point - Walmart and Amazon offer low benefits compared to what companies once offered. Their lower prices are part of how they killed off most of the department stores and put the rest on life support.

And if you think about a highly paid job, even though our fringe benefits suck compared to Europe style, my impression is that US salaries are higher for equivalent jobs, enough that it makes up for it. So we value the money more than we would the benefits, apparently. Only problem is you can’t use all that money to buy more time with your family (except for by taking breaks between jobs, if you’re good at saving!)

In my opinion, this is actually the reason for why we have so little innovation in Europe.

Mandatory, single-payer insurance very significantly raises the cost to be self-employed / have a sole proprietorship, which you practically need to run any side project that you want to eventually make money from. This means that if you launch a startup, you either need it to be profitable on day one, or you're vasting significant amounts of your money, not just your time.

This is true.

> This means that if you launch a startup, you either need it to be profitable on day one, or you're vasting significant amounts of your money, not just your time.

This is a false dichotomy. First of all, even ignoring health-care, you're still spending money on housing, food, electricity etc. If you're not employed and your startup is not profitable, you're paying money out of pocket to live.

Second of all, even in the USA, you are still going to pay for health insurance even if you are currently founding a startup. You could argue you are allowed to gamble that our health is good enough that you don't need health insurance for a few years, but that's just tossing coins. You could just as well not pay your taxes in the EU for a year or two, and gamble that the authorities will not catch on right away.

The US government spends a similar amount of money per person on healthcare as other western countries do. But unlike Europe, Australia, Canada, Japan and so on, people don’t even get free healthcare in exchange for all that tax money. The system is deeply flawed. I don’t know anything about the Japanese healthcare system, but I’d still choose to be sick in Japan than America any day of the week.

It cost about 25% of US prices to fly to Costa Rica, stay at a resort, and get the procedure done in a top notch facility. And that's if you just need 1 root canal and crown. If you need even more done the savings move closer to 90%.

And that is a really nice places. You could drive to Mexico and get it done at a decent place for comparatively nothing.

customer - insurer: the govt (or, far more rarely, the employer) is the customer

insurer - recipient: the recipient is you. You're really just a necessary but unwelcome side-effect.

As a citizen of a country with socialized health care, I will tell you the politicians promise the world but when the bill comes they can't seem to find their way out of the room fast enough.

The only way to avoid this adversarial relationship is to pay for it yourself. No insurance, no government, nothing. That means vast amounts of people will not be able to afford even a doctor's private practice.

It's sad but the bitter truth is nobody really wants to pay for other people's health care either. They only say they do because it wins them votes or clients. They all can't leave the room fast enough when the bill actually comes. Politicians have other far grander things they'd rather do with all that taxpayer money, and that's when they're not corrupt and pocketing it. Insurers obviously want profit. They're all betting you won't actually need all that fancy schmancy health care they promised you. They're literally banking on it.

In my experience, people barely want to pay for their own health care. They "want" to but start appealing to the altruism of their fellow man the second the bill comes. In my country, doctors are shamed every day because of our "oath" to help others. People act like we are their slaves, not even entitled to payment for services rendered. The good doctor is the one who pursues medicine as a hobby, who walks the earth helping others in need, with no needs of his own to tend to. The good doctor somehow absorbs the costs of it all. Including the costs of the cures involved. Especially the opportunity costs.

People are not prepared for the soulless utilitarianism of public health care. The bitter truth is there aren't enough medical resources for everybody. You must pick and choose who gets that fancy MRI scan. If you pick right you kill people. If you pick wrong you kill even more people. You have hundreds of millions of citizens, how do you help as many as possible as much as possible with the resources available? Decentralization via hundreds of basic clinics and hospitals turns out to be better than centralizing everything into one well equipped giga hospital. It's not about any one guy. It's about saving costs now so that you can help more people later. That's what primary care is all about. Saving costs, by promoting healthy lifestyles which means less sick people later in life where treatment is more expensive. It's about money, about resources.

But people don't want that. Good lifestyles are hard to lead, they require sacrifices. They want to do whatever they want, then go to the doctors when they get sick, then they want others to pay for whatever's necessary to fix it, and they want it fixed good as new. They are like consumers who don't want to pay for the services they need. Nobody wants to pay for it, even the people who directly need the services.

I know 'pro status quo' people will say online anecdotes are all lies and not relevant, but there are a heck of a lot of people with a lot of animosity to the current system and it's 'for profit death panels'. I think it would be easier to swallow if it were societal chosen death panels over failed doctors (that can't make it so they go work for the insurance company) or random AIs doing the decision making.

To be fair, it's impossible to know of it matters :)

I moved back to Europe from the US. And I can certainly feel that healthcare is slower, less eager to jump and investigate everything.

But on the other hand, in the US you most certainly risk talking your self into procedures you don't need!

I was discharged the next day. I didn’t pay a cent. I didn’t even see a bill. I don’t think they made one.

I keep hearing stories from Americans about wait times in other countries. I’m sure it happens, but I’ve never seen it myself. My experiences with the medical system here has been pretty universally excellent.

When I was in America I was very impressed with how proactive everything is. My insurer paid for yearly physical exams. I’d never done that before. It’s certainly possible I would have even better health outcomes in America. But, I’m way happier here. And I’m a lot less stressed than I was when I lived in the Bay Area. That counts for a lot.

Outside of certain screenings, there is no proven benefit to yearly physical exams for healthy adults. It's a waste of resources and doesn't improve patient outcomes. Some people seem to want those annual exams, but they aren't justified on an evidence-based medicine basis.

https://www.health.harvard.edu/blog/a-checkup-for-the-checku...

https://www.healthcare.gov/coverage/preventive-care-benefits...

I was talking to a taxi driver in SF a few years ago. He said he was in a car accident once, and his car rolled and flipped upside down. The police & an ambulance showed up. Even though he seemed mostly ok they still wanted take him to hospital. But he couldn't afford the ambulance or the hospital - without health insurance, it would have bankrupted him. So he told them all to get lost.

In telling the story, he got kind of angry about it - I think he was mad how pushy the police and ambulance people were about the whole thing.

Thats vaguely horrifying to me. A man who was just in a car accident should never be put in a situation like this. If you're wealthy in america, yeah - you get top notch medical treatment. But I'm not sure I'd call that a successful system for emergency care.

The No Surprises Act did give many consumers significant protection against excessive ER bills.

https://www.cms.gov/newsroom/fact-sheets/no-surprises-unders...

I live in Québec, Canada and my wife had breast cancer and her periodic scan happened at a 4 months interval. When they detected oligometastasis on her spine she had radiotherapy 2 weeks after the biopsy.

The only thing not covered by the gouvernement is a drugs called kisqali that sucessfully keep her alive (may it continue to works). If I did not had gold plated drugs insurances, the public alternative was weekly chemo (taxol or taxotere i dont remember).

Now this is a really scary application of AI, but you won't hear those wanting AI regulation such as Musk complain about that, right?

Without it, health insurance companies would have every incentive to do what car insurance companies do -- buy profiles and records from third parties and use those to adjust rates and willingness to insure.

E.g. the obvious step of buying genetic information from 23andme, because it isn't covered by HIPAA

https://www.hhs.gov/hipaa/for-professionals/special-topics/g...

Instead of regulating only some of the uses.

HHS already had to administratively extend to cover gaps (we'll see how that goes, post-Chevron) and Congress attempted to repeal it for workplace purposes in 2017.

And there's still the gray market question about 23andme -> Equifax-alike packaging it into a blended proprietary risk score -> insurance companies using that (of course 'without knowing that genetic information was included').

The closest were:

- "In constant battle with insurers, doctors reach for a cudgel: AI" from NYT (via Salt Lake Tribune), 2024 July, which is mostly on doctors using law-compliant LLMs to draft prior authorizations and has a passing one-graf mention of insurers likely doing the same: https://www.sltrib.com/news/nation-world/2024/07/11/constant...

- "The AI arms race over your medical bill" from Politico, 2024 Jan., summarizing LLM use in coding, billing, and fraud prevention: https://www.politico.com/newsletters/future-pulse/2024/01/05..., linking to https://www.politico.com/news/2023/12/31/ai-medical-expenses... and https://govciomedia.com/how-health-tech-leaders-use-ai-to-co...

Aside from that:

"Large Language Models to Help Appeal Denied Radiotherapy Services" from JCO Clinical Cancer Information, 2024 Sept. (abstract only; full-text paywalled) https://pubmed.ncbi.nlm.nih.gov/39250740/

"The potential of large language models in the insurance sector", 2024 Feb. (commercial white paper), largely focused on "fraud detection" in claims: https://www.milliman.com/en/insight/potential-of-large-langu...

"IQVIA NLP Risk Adjustment Solution (undated commercial white paper), marketing pitch on using AI to improve coding accuracy and reduce chart review times: https://www.iqvia.com/-/media/iqvia/pdfs/library/fact-sheets...

I've personally had postural issues that were for many years simply attributed to poor discipline. It later turned out that I have a connective tissue disorder that was destroying the joints in my body.

All you I can see your proposition doing is giving insurures another reason to decline potentially legitimate claims. Your case would be more rational if you were arguing for no insurance at all.

It's not that hard. In the example you've given you could sue the doctors for misdiagnosis, or if research showed that a condition had been mislabelled, people would receive compensation. It doesn't seem any more onerous than any of the other negotiations over conditions and treatments that go on in any medical industry and legislature anywhere in the world.

I personally feel uncomfortable labeling these as lifestyle choices to drop insurance liability. Alcoholism isn’t really the same as skiing.

Statistical methods can be used to assess the risk of each.

> I believe it’s pretty widely accepted that some component of addiction and substance abuse is genetic / hereditary. The same is true of depression.

High risk people should:

a) have most costly insurance against those things

b) be given help to avoid those things, which

c) could be used to reduce the cost of their premiums

Men are more prone to violence and also more likely to be victims of violence, and this is largely biological (hence the huge disparity between the sexes) - would that be some sort of excuse? Should men and women pay the same for the same relevant insurance even though they present wildly different risks of both perpetrating and befalling violence? That would be unfair.

I'm firmly in the "you are responsible for your life as an adult" camp. From a family of smokers thus making you more likely to be a smoker? Don't smoke. History of alcoholism in your family? Don't drink… need I go on?

Does having one vice deny a person for life from having coverage for any disease which my potentially be caused by that vice? How long must a person partake in this vice to be denied coverage for life (i.e. is it okay to smoke for a few years then quit?)

Your example also has the problem of measuring the "lifestyle questions" being presented. How would you prove a person isn't exercising enough? If I know it will get me denied I'm not going to self report. We would need some sort of invasive "health audit" industry to insure compliance with insurance requirements. A physical exam at the start of insurance doesn't solve this, because like I said, the existing issues could have been caused by any number of problems.

Your dismissal of my specific example is silly - I don't want to sue a doctor for misdiagnosing a relatively common issue. Connective tissue disorders are not that rare, and I'm far from unique. Do you want to live in a society where we have to fight tooth and nail to get basic care for problems on the basis that we might have caused them ourselves?

That is just not the case, and I shouldn't have to point out such basics on HN.

> A physical exam at the start of insurance doesn't solve this, because like I said, the existing issues could have been caused by any number of problems.

And yet I have to… People do a thing called "collecting data", on a large scale, and then they apply the lessons learnt from that data to calculate statistical risk. An imperfect system but, strangely enough, very effective (when not interfered with, as in the US health system).

Of course, you are welcome to open a car insurance company and offer everyone the same insurance for the same price and watch as young men and previously uninsurable people flock to your service. Maybe you'll get lucky and won't have to pay out more than you take in. All the best with that.

> Your example also has the problem of measuring the "lifestyle questions" being presented. How would you prove a person isn't exercising enough? If I know it will get me denied I'm not going to self report.

And then the insurance company can decide what level of fraud it will tolerate (something HN has discussed previously[0], and the linked article[1] is enlightening) and thus adjust its costs, and perhaps premiums.

> Your dismissal of my specific example is silly - I don't want to sue a doctor for misdiagnosing a relatively common issue.

If it's not a problem then don't sue. If it is, that is what the court system is for (or whatever system doctors and medical companies would put in place to avoid going to court).

[0] https://news.ycombinator.com/item?id=38905889

[1] https://www.bitsaboutmoney.com/archive/optimal-amount-of-fra...

You wouldn't even need too much surveillance to do this. Give people a yearly "fitness checkup" to encourage physical exercise, monitor weight to encourage healthy eating habits, do periodic drug tests to discourage drug use etc.

If you combined this with a (privacy preserving) fitness band that would monitor your vitals, and only send a list of premiums you're eligible for, you could do even better.

You'd have to account for preconditions that make it hard/impossible to exercise, but this would work for most people.

I’m in DE and have filed a criminal complaint about a company that runs fake personal ads targeting the elderly:

When an elderly person calls, they schedule an appointment at the person’s home. Then, over several hours, they talk them into signing a 3,000 EUR contract for an objectively useless service (getting contact data of 7 or so random people over a period of several weeks).

The guy running this scheme has been doing it since the 1990s. We know they did > 40 Million Euros in the last 10 years alone.

We filed the complaint a year ago and police and district attorney have done nothing so far. At the same time, the criminal himself has sued journalists who have covered the story multiple times.

Seems like the criminals are more resourceful than those who are getting paid to stop them.

https://www.youtube.com/watch?v=2IT2oAzTcvU

Sometimes the bank interface will tell you name and address, after you type in numbers, but who validates this?

My bank (in Denmark) sometimes sends me emails from an domain that isn't their primary domain.

The bank uses a login system that is provided by the state. In theory it's a good idea, but you sign-in on domains that are not owned identity authority. Like I sign-in on the bank website, instead of sign-in by redirecting from the bank to a trusted domain owned by the identity authority (how like OIDC flows usually work).

Sure the login flow still involves an app, but my point is:

There is a lot of bad practices around. These should incur liability.

Just start looking at what domains emails are sent from. And complain if they are not the primary domain of the entity contacting you, you'll get tired real soon.

It's just old fashioned con man stuff but over email or phone. And of you're dumb enough to believe that the only way the IRS (US tax agency) is willing to accept payment is by Visa gift card (and yes this is actually a common scam here) it's just not your bank's problem.

If I make a payment using my visa card, how is it that I'm not just redirected to visa.com, and that's the only place I enter card credentials? Like how OpenID works.

I'm sure there are reasons, probably legacy reasons :)

But it's still weird that payment uses a third-party domain I can't verify. Often called something sketchy.

Pay your taxes by Visa gift card. Then you’re a blood idiot.

https://youtu.be/RmhgGm4joEQ?si=bJzbF8Gnz-G5Nt6b

The way these scams work is to get someone to intentionally send money, usually through gift cards or wire transfer to an account.

Some of the common schemes are to pretend these are taxes that they didn't pay ("you owe the IRS a huge amount, send this money and all the penalties won't be applied immediately"), sometimes it's urgent money needed for a loved one (a common one is "your son/daughter just hit someone with their car, send money to this lawyer to try and save them from prison"), sometimes it's promises of future riches (such as the infamous Nigerian Prince who will send his fortune to you if only you send a little money first).

Requires the person to want to do that though.

I guess this has something to do with my phone number starting with +38 and that nobody actually calls their relatives by mobile phone anymore

I also think it's extremely simplistic to call the people making the calls "slaves". A lot of the time, they are in facr the perpetrators. Even when they are part of a more organized operation, they (1) are likely paid per successful scam, so they are co-interested in hurting you, and (2) fully aware they are scaring and stealing from someone.

So I wouldn't call these people slaves, I'd call them low-level criminals.

CodeBot: Word tables blank sometimes. Hmm.

SupportBot: What version? Try a repair.

CodeBot: Memory issue maybe? Bad alloc?

SupportBot: Rare. Repair is next.

CodeBot: Threading problem sar? Data races?

SupportBot: Try repair, new doc please sar.

  ScamVictimBot:
    sound = tts("Say again?") // constant, might as well cache
    while(true):
      phone.out(sound)
      _ = phone.waitUntilNextPause()