That subtilely implies it’s a decision to view oneself as a different gender from what was assigned at birth, but it’s not entirely clear it’s a choice in every case. Edge cases in biology get wild and sex assigned at birth can be a near arbitrary decision. Ex: https://en.wikipedia.org/wiki/Chimera_(genetics)
Parents making major medical decisions has a huge precedent in a wide range of procedures with significant risks and consequences. Separating conjoined twins for example.
There is a logical flaw in suggesting that something that occurs with a small percentage of a population such as “detransitioning” implies anything about every member of a population.
Child abuse exists, but doesn’t imply anything about every parent.
I do not suggest that detransitioning can indeed extrapolate to the whole group.
I am saying that it exists, therefore at least some people regret their transition, therefore they should not be allowed to make that decision at 12, or for their parents to do so.
That’s pretty flawed argument on the face of it, very few things win a cost benefit analysis if you disregard the benefit and thus require exactly zero cost.
The real question is whether detransitioning or other negative outcomes are greater than the number of suicides prevented by allowing early transitioning, and that’s a rather more complicated hurdle to jump.
> There is a logical flaw in suggesting that something that occurs with a small percentage of a population such as “detransitioning” implies anything about every member of a population.
> Child abuse exists, but doesn’t imply anything about every parent.
This is funny because that's the exact argument that transphobic opponents say about trans people themselves and the argument as to why gender fluidity or gender outside of sex doesn't exist. "Just because an extremely small number of people believe they are a different gender than their biological sex doesn't mean that gender is different from biological sex" is almost exactly the argument that transphobes use.
I think you fundamentally fail to understand what I just said. Proper unbiased random sampling allows you to create sub populations that tend to reflect the characteristics of a larger group, biased populations don’t share that relationship.
“Because some animals hibernate, all animals hibernate” is just as flawed as saying “Because only a small percentage of hibernate, no animals hibernate.” Instead the relationship is “Because some animals exist that hibernate, there exist animals that hibernate.”
So-called "detransitions" represent way less than 1% of the trans population. In particular, the proportion of people regretting their transitions is much smaller than that of mothers regretting having their kids. They receive massively inflated media attention because their stories are picked up and turned into propaganda in service of bigoted narratives.
So-called "trans" represent way less than 1% of the world population. ... They receive massively inflated media attention because their stories are picked up and turned into propaganda in service of [self-serving] narratives.
The vast majority of trans people wish their demographics received much less media attention... The issue is with right-wing bigots who feel it is their life missions to make their lives as miserable as possible, when they just want to be left alone.
It is quite common for babies to come out of the womb with blonde hair, only for it to darken to brown later in life. The baby isn't blonde, it just looks blonde right now.
Same with gender. Doctors observe a flavor of genitals, make a reasonable assumption, and legally assign the gender which seems appropriate.
Only in theory is it so easy to separate clerical errors from other issues.
So in practice clerical errors cause all kinds of long term havoc. Once declared dead it can be a monstrous effort to prove to various systems you are in fact alive.
Sometimes people use something called analogies or similar examples to help explain a foreign concept. In this case, the poster was trying to explain that our traits are birth do not always reflect who we are as adults. Gender is one such trait. Hair color is another.
There’s this phenomenon in this thread where commenters are taking something that’s superficially similar and then making an extreme claim that, upon inspection, does not hold up at all or is completely irrelevant to the argument being made. That is what is happening here. “An adult’s hair color can be different than what it was at birth” is a true statement, but of course is not relevant at all to the claim that one’s gender is just as malleable as one’s hair color, which is what this so-called analogy attempts to do. Real analogies do not do this, and when people deploy the above formulae it’s easy to recognize as bad faith.
Except gender is as malleable as hair color. Sex isn't, but gender is. Gender is the social expectations for a human in the context of a specific culture.
If I live in Virginia until adulthood, then move to American Samoa, my gender expression is going to radically change. I'll start wearing skirts. If I then move to Qatar, my gender expression will change again. I might still think of myself as a man through those changes, but whats expected of me and how I view myself with those cultures will shift. "What does it mean to be a man?" Is very different, globally.
So even if I consider myself a man, that definition regularly changes for different contexts. Clothing, conversational style, physical affection (it's common for men to hold hands in parts of the Middle East, and considered uncomfortable in the states.)
Given gender expression and identity can change as you transit cultures, surely you can see that some people might belong to cultures whose definition of "what does it mean to be a man" might be "whatever the fuck you want". Punk and queer subcultures, for instance, have different gender expectations than say, the Vatican.
For some cultures, genitals have little to no bearing on one's social expectations. Fit into the role that feels right, who cares about what is in your DNA.
One cannot ask a baby what social role they would like to have. Typically, in approximately 97-99% of cases, that aligns with the genitalia. So no, no coin flip. It's typically done by looking at genitalia. You'll be right almost always.
Of grid homes are vastly more concerned with the energy efficiency of their appliances and thus DC refrigerators generally have more insulation. Most AC customers prefer more internal volume for food over slightly increased efficiency.
AC motors are using way more power than the puddly control boards in most home appliances. So you lose a little efficiency on conversion but being 80% efficient doesn’t matter much when it’s 1-5% of the devices energy budget. You generally gain way more than that from similarly priced AC motors being more efficient.
I agree with everything you said, except it seems like a false dichotomy. We can clearly build DC refrigerators with more or less insulation. We can clearly build them large or small. If you want to prioritize volume, then surely you could do that with DC. Right?
I know that a long time ago DC-to-DC voltage converters were very large in size, which meant AC would win on space efficiency. But unless I’m mistaken, that’s no longer the case. Wouldn’t a DC refrigerator with equivalent insulation and interior volume have nearly identical exterior dimensions as an AC refrigerator?
> Wouldn’t a DC refrigerator with equivalent insulation and interior volume have nearly identical exterior dimensions as an AC refrigerator?
Sure, but it’s important to separate what could be built from what is being built based on consumer preferences and buying habits. The average refrigerator could be significantly quieter, but how often do people actually listen to what they are buying? People buying Tesla’s didn’t test drive the actual car they were buying so the company deprioritized panel gaps. And so forth, companies optimize in ways that maximize their profits not arbitrary metrics.
Waymo as a system has crossed the threshold where I trust them more than average driver, but all this hardware is relatively new, well maintained, and their software is closely tied to it.
I’m way less confident of self driving in the hands of the general public when differed maintenance often results in people and even companies driving with squealing breaks and balding tires etc.
I am also not looking forward to the system transitioning from "big experiment, burn money to make it good" to "established business unit, tweak it to death for incrementally more money / personal promotion." We're still in the honeymoon period and I very much expect to hate Waymo in 10 or 15 years when they reach a steady state.
What levers are there, really? Waymo has a monopoly and it seems like they will for a while, so they have a lot of power, but all I really see them doing is making it expensive. Anything that makes the experience worse takes away from their ability to take market share away from Uber/Lyft.
Self-driving vehicles need aircraft-type maintenance. Yet there's nothing like the FAA to enforce a minimum equipment list, maintenance intervals, or signoffs by approved mechanics.
Is there a scratch or chip in the scanner dome? Are both the primary and backup steering actuators working? Is there any damage to the vehicle fender sensors? Is dispatch allowed with some redundant components not working? If so, for how long?
Here's the FAA's Minimum Equipment List for single-engine aircraft.[1] For each item, you can see if it has to be working to take off, and, if not, how long is allowed to fix it.
There's nothing like that for self-driving land vehicles.
What's the fleet going to look like at 8 years of wear and tear?
> Self-driving vehicles need aircraft-type maintenance.
That's a hyperbolic false equivalence.
Aircraft typically carry hundreds of people and can crash to the ground. As long as a self-driving car can detect when it is degraded, it can just stop with the blinkers on. Usually with 0 - 2 people inside.
The question is how broken can a car be when dispatched. What's the safe floor? See the other article today about a Tesla getting into an accident because of undetected sensor degradation.
> Aircraft typically carry hundreds of people and can crash to the ground.
Cars are more numerous and could spontaneously either plow into pedestrians, or rear-end someone, causing chain damage and, quite often, a spillage of toxic chemicals (e.g., a cistern carrying acid/fuel/pesticide).
Plus, you have a problem of hostile actors having easier access to cars compared to planes.
Waymo's software has crossed multiple generations of sensors and vehicles over almost two decades. It does not seem to be tightly coupled to a particular device.
Not tightly coupled in obvious ways, but as I understand it they aren’t putting it on pickup trucks, convertibles, or anything toeing a boat etc. Their vehicles don’t have aftermarket suspension systems dramatically changing handling characteristics, or turned one into a stretched limo etc.
Which means the software can safely assume the vehicle will behave within a relatively narrow operating range.
I don't think the vehicle performance really matters in the typical case. They're using like 20% of what the vehicle "can" do. They're probably hedging against the long tail of variance on the road somehow. Kinda like how private people can tow whatever the f they want with their pickups but in a work setting you need to keep it fairly stupid proof.
I suppose owners will be motivated to have the thing do the driving (and so seek defeat devices and such), but at least the software can have "do nothing" as a safety mode if it manages to detect that the vehicle is not configured as expected.
And maybe the software can be designed to be coupled to a vehicle dynamics model that can be updated.
The new (as of now than a year ago) Waymo cars still had human safety drivers last I saw one (a month or two ago). I also don't see them taking customers. So they do seem to slow roll hardware rollouts.
The way I see it, self-driving cars have the potential to deliver us from the burden of ownership altogether--maintenance, insurance, liability, parking, and all the rest. This hinges on availability, quality of service, pricing, and a rather large shift in the culture around cars and driving but I have hope that we can get there with time.
It's not obvious that will exist in the near future, anyway. Waymo aren't planning on selling their cars, and the economics and liability structure of self-driving strongly bias towards just running a taxi service.
We're not even a decade beyond some poorly conceived software crashing two otherwise functional aircraft into the ground and now it's going to save us all...
Because raising taxes was never part of their deficit reduction strategy. Not that it matters, being fiscally conservative was never an honestly held belief but simply a campaign slogan.
Raising taxes was never part of their deficit reduction strategy, sure. But we're talking about the fact that they cut taxes. You can't fix a deficit by reducing income.
I don't think that's fair. He asked about statistical defensibility (implies an entire dataset) and was handed something that definitely does not qualify. What was provided certainly makes it clear that it's a reasonable thing to wonder about but it doesn't (at least I don't think) rise to the level of actually supporting the claim in question.
There's no obligation in either direction in this context (idle chitchat) unless of course you care to convince someone of something.
He objected to what was provided and you accused him of ignoring evidence. I'm voicing agreement with his objection. The original claim was one of a statistical nature. Thus any purported evidence should be expected to match.
> of a statistical nature. (True) … should be expected to match. (False)
If a group is more likely to be X than the average population then being a member of that group is statistical evidence you are X. Really when referring to statistical evidence here it’s an indication the evidence is of a very low standard not a high one.
He provided evidence that cops are more likely to be white supremacists which doesn’t actually mean much which is kind of a point on its own. That being it’s the same low standard as used by actual racists, but as you said there’s no actual obligation to go beyond such wordplay. Personally I was very amused by the whole thing but obviously it’s quite offensive to some people.
Taking the other side of this one, you could say something like “sure the odds at least one of them are white supremacists is non trivial, but suggesting all seven are is unlikely.” Again not a strong argument, but it’s at minimum an actual argument.
> He provided evidence that cops are more likely to be white supremacists
This is the crux of the matter. I don't agree with that statement. I believe the provided evidence does not support that claim in any meaningful sense.
I would at least agree that it suggests to seriously entertain the possibility though.
I'm not sure what to make of your true/false response. Suppose I claim that apples have a higher chance of poisoning you than oranges. Evidence that someone at some point made an effort to put poison into the apple supply does not directly support that claim. However if credible it is certainly cause to entertain the possibility.
More generally a claim about a possibility (discreet) can be supported by an event but a claim about averages (statistical) requires population data. Further, a claim that X is more likely than Y is a claim involving multiple populations.
> Evidence that someone at some point made an effort to put poison into the apple supply does not directly support that claim. However if credible it is certainly cause to entertain the possibility.
Go from the other direction suppose you had millions of cases. By your logic 1 cases is not evidence. Two cases is therefore 0 + 0 = 0 no evidence. Thus by induction 1 million cases is still not evidence. Instead 1 case is weak evidence because each individual cases adds up.
For more rigorous analysis see bayesian statistics.
Further the article isn’t referring to a single solidity case but instead multiple independent events.
Sorry, that's not how this works. Claims must be supported by evidence. I didn't ignore it, I reviewed it and explained how it doesn't support the claim.
I have no obligation to provide evidence to the contrary. Claims made without evidence can be dismissed without evidence.
Court cases look at things like when someone arrives in a city as evidence, that alone doesn’t make someone more likely to have done whatever than a million other people, but it’s still evidence. So you dismissed it, but it is in fact evidence that there were white supremests just as your post is evidence you are a serial killer.
It’s not poof after all you could be a bot. But out off all humans who ever lived 95% of them can’t be a serial killer because they are dead, that post is evidence you where alive recently therefore it is evidence that you are vastly more likely than the average person who have ever lived to be a serial killer. Again as apposed to a dead person who at most could be a former serial killer.
Thus demonstrating that evidence isn’t the same thing as strong evidence just something that increases the likelihood of something being true.
And to expand on that, this isn’t even a debate. It’s a casual chat about an actual courtroom debate. Here, no one is judging our presentation. We don’t have to meet a high standard of evidence to speak our opinions, lest they be judged invalid.
However, in the actual courtroom where very similar arguments played out with real consequences, Afroman was found not liable for saying more inflammatory versions of the same things. That is, he was judged, for worse, and he won.
Which isn’t quite accurate as for example people prefer to move out of their parent’s homes while young adults but aren’t necessarily homeless if they don’t.
Basic housing is a necessity, but people also huge homes and 2nd homes etc. So housing policy should therefore be more complicated than simply subsidizing anything you can call housing. Capping the home mortgage tax deduction at ~median home prices for example is probably a better use of government funds.
They are 0.8 ton each and last ~5 years. 10,000 / 5 * 0.8 = 1,600 tons per year at 10k satellites, and their goal of 40k satellites would put it well above the amount of asteroid debris impacting each year. Further asteroids contain very different materials and don’t all impact at the very low angles you see from de-orbiting in satellites. Thus, I don’t think you can presume this is meaningless without actually modeling it.
Space dust on the other hand behaves very differently on reentry because of the high surface area to volume ratio.
They last 5 years if they're dead in orbit. These satellites have electric thrusters and boost themselves regularly to maintain orbit, so your estimate is wildly off.
As for presuming them to be safe, there's fuck all evidence to the contrary. Whining with baseless speculations about the effect of satellites burning up is motivated by the base reflex to shit on any technological progress as an environmental disaster in the making, but nobody can come up with a story about how dolphins might choke on satellites so instead we get this "muh aluminum" narrative.
A 5 years useful lifespan sets the replacement rate and thus the average number burning up each year. In steady state the delta between end of life and reentry is irrelevant, instead the average number of satellites launched each year = average number that burn up each year.
As to harm. Aluminum is mildly toxic, you don’t eat your bike but vaporized aluminum from a satellite is way more likely to cause harm than if the things were made of steel. The plastic bits are likely fine though.
Saying let’s study something ahead of time rather than contaminating all the world’s farmland with and then seeing what happens seems like a perfectly reasonable standard. Technology has generally been wonderful, but that doesn’t mean everything is equivalent. We want to phase out leaded aviation fuel in the US even though it’s ‘only’ 2,000 tons of lead per year, that’s still enough to be problematic. Perhaps ramping up to ~5k tons/y of vaporized aluminum worldwide is a complete non issue, but if it’s not insisting on some other material isn’t the same as a ban.
> part of the healthcare system that is moderately competitive.
That’s only half the story though insurance companies also try and reject way more claims, cover fewer people, and are just harder to get money from than Medicare.
This means hospitals can’t afford to give them cheaper rates as they just require vastly more work from staff for the same procedure.
The industry isn’t blind to this effect, but has little reason to change.
Hospitals and clinics can only take so many Medicare patients as a ratio to private pay because it’s very well known that Medicare and Medicaid is often provided at below cost. It’s of course area and demographic dependent but as a rule any private clinic has a cap on these patients they will accept overall. Hospitals cannot cap it realistically speaking, so looking at clinics is a good proxy.
Private insurance subsidizes Medicare and Medicaid even after you add in admin overhead.
The MLR incentive question is one I'm digging into for a future issue. The short version: the ACA's 80/85% MLR floor was supposed to constrain overhead, but vertical integration changed the math. When UnitedHealth's Optum division provides services to UnitedHealthcare's members, those internal payments count as "medical expenses" for MLR purposes. The money stays in-house but reports as care delivery.
On the denial rate point: 15-17% initial denial rate, 80%+ overturned on appeal, but less than 1% of patients actually appeal. That gap between the overturn rate and the appeal rate is where the profit lives. If you deny 100 claims and only 1 patient appeals, you've effectively reduced payouts on 99 claims at the cost of processing 1 appeal. I'll have the numbers on this in a later issue.
All the other managed care organizations have similar 2% profit margins.
It is funny seeing complaints of excess profit margins from businesses earning 2%, that compete against non profits, from people on a forum composed of employees of tech businesses earning 20%+ profit margins. I wonder how much Epics’s profit margin is?
And then there is also pharmaceuticals, also earning double digit profit margins. And then the law firms in medical malpractice suits, who I imagine are not working for 2% profit margins either.
Profit margins are difficult to compare across industries, game developers on average have great profit margins in part because all the studios that fail quickly stop counting.
Grocery stores on the other hand are a known as a low margin business, but as people constantly need more food every month it can be really stable. Further as most stock turns over multiple times a month your return on capital can be extremely high. Even better during a downturn when people buy 20% less food you also need to buy 20% less stock and employ fewer people to stock shelves etc, which makes your profits far more resilient.
Suddenly grocery stores are looking like a much better investment than making games.
The point of a profit margin is to be able to compare a seller's pricing power across industries. It invalidates attempts to claim the seller is able unilaterally act in their interests without the customer having recourse. For insurers, not only do customers have a choice to switch to a different insurer, but insurance prices have to be approved by government employees.
And total returns are the end all, be all for measuring investment performance. Just because some volatile video game businesses go bust does not make the grocery business or insurance business attractive. I could just as easily put my money into SP500 and earn far more with far less (almost zero) risk.
> It invalidates attempts to claim the seller is able unilaterally act in their interests without the customer having recourse.
By that logic the cap’s on annual profits by insurance companies suggest significant pricing power by insurers.
As to S&P vs a grocery store, there are grocery chains in the S&P there’s nothing wrong with the business model. As always the arguments for starting a business are more complicated than the alternatives due to the amount of leverage you can get etc. Further a weekly turnover at 2% is a rather insane annual ROI, we’re talking 100% return on investment though obviously actual business don’t just concern themselves with groceries, labor, and rent.
>By that logic the cap’s on annual profits by insurance companies suggest significant pricing power by insurers.
I disagree. If I was a seller, and if I had pricing power, then I would not settle for a 2% profit margin when the cap is 15% or more. The only reason I would settle for 2% is because I cannot sell for my product or service at higher prices or in higher volumes to get more than 2%.
>Further a weekly turnover at 2% is a rather insane annual ROI, we’re talking 100% return on investment
I don't know what definition of return on investment you are using, but it does not match any that I am familiar with based on share price and dividend history of any publicly listed grocer (kroger/albertsons/walmart/target). Obviously, Costco has done well, and Amazon, but those are not strictly due to selling groceries, or retail in general.
A 10% or 20% cap is only relevant if the company is hitting the cap. Operating a subdivision with a lower profit margin is a different matter, that’s no longer an insurance company hell they could be selling porn and it would be equally irrelevant.
Instead what matters here is that insurance companies by your own admission clearly have pricing power and that’s a problem.
> does not match any that I am familiar with based on share price and dividend history of any publicly listed grocer
Return on capital when starting a company is different than return on investment when buying a public company. If a company is kicking off 1 Billion dollars a year it doesn’t matter if it cost 10 million or 10 billion dollars building the company, you pay for the share based on future revenue. When starting a company however it very much matters if it takes 10 million or 10 billion to get off the ground.
Yes but the Medicare and Medicaid reimbursement rates are below breakeven so cash and insurance rates have to be above provider breakeven. The main cost frictions are administrative costs for billing on both the insurance and provider sides.
That's true to an extent, but some provider organizations manage to survive with patient populations that are almost entirely Medicare / Medicaid. Many provider organizations are just badly managed and haven't taken steps to optimize their finances through automation or participation in value-based care programs.
I'm working on a project in an area of healthcare where there was massive Medicare fraud decades ago. Medicare now requires extensive documentation for each claim and the paperwork is so onerous that providers have exited the market and it's very, very difficult to access care.
Right, CMS plays whack-a-mole with Medicare claim fraud. When they catch on to a systemic pattern they clamp down in a way that creates extra burdens for everyone, and then the fraudsters move on to something else.
They waste billions on fraudulent claims because they don't fund the program well enough to have compliance enforcement or auditing.
Also, I'm not going to trust a podcast owned and operated by Stacey Richter, who also just so happens to be the co-president of Aventria Health Group and QC-Health.
> They waste billions on fraudulent claims because they don't fund the program well enough to have compliance enforcement or auditing.
These are synonyms for having higher overhead, right? If you pay a billion dollars in claims with ten million dollars in administrative costs then your "administrative overhead" is 1%, even if half the claims are fraud. If you increase "administrative costs" to a hundred million to get rid of the fraud, in practice you just saved 410 million dollars but now your "administrative overhead" is up to 20%.
There's another reason. The harder you make it for a provider to get reimbursed for a service (in order to cut down on fraud), the more difficult it is for legitimate patients to access that service. Medicare patients are elderly. Many of them aren't able to chase after doctors to get the services they need.
This isn't even close to true. Keep in mind that Medicare, together with Medicaid (which operates under much of the same administrative rules), account for nearly half of medical spending. So basically, if a provider doesn't want to play by their rules, they MUST deal with Medicare. That is, the government is nearly a monopsony in this industry.
There's a common, misleading, claim that Medicare is more efficient because they spend far less than commercial insurance on overhead like claims processing. This claim is true. But the impression that it gives is absolutely the opposite of reality. The reason that Medicare doesn't spend as much on admin is that they offload all of this work onto the providers. Every hospital in America has a "Medicare Reimbursement" team. A moderate-sized hospital is going to have something like 2 FTEs focusing just on the reimbursements from Medicare and Medicaid. And that's a lot more work than just filing the right forms for each case. There's a ton of additional work. Each spring they have to file a HUGE "Medicare Cost Report", requiring a couple of months of work to get all the data in place for it. (Source: my wife was "Director of Reimbursement" at various hospitals for quite a few years, before going into consulting.)
That Medicare Cost Report that I mentioned is, beyond a huge effort sink, the source of many other evils. Because of the amount of work that's needed to gather and collate all this data, hospitals naturally structure their Accounting around the way Medicare wants them to report. The thing is, that's largely orthogonal to the way a rational person would do cost accounting. The result is the common criticism about how widely varying the cost of a given specific line-item is between hospitals: they don't really know how much a given procedure costs because that's not how they track their expenses, so they apply some allocation heuristics, and every hospital does that a bit differently.
There are also various perverse incentives in the system. For example, Medicare is smart enough to know that it costs more to deliver care in NYC or SF and so forth. Every locale has a Cost Index that scales how much they expect to need to pay. This leads to hospitals needing to show that their expenses are higher so they should be classified into locale X rather than neighboring locale Y.
Another one my wife told me about her hospital: Medicare realized that a lot of UTIs were hospital-acquired, and they rationally said that they would no longer pay for UTI treatments unless the hospital could prove that they were not hospital acquired. Well, maybe that wasn't rational, because with Medicare/caid being such a huge portion of their business, they changed their policy to test for UTI for everyone at admission, so that they could furnish the proof demanded. Think of all that wasted lab work...
So no, Medicare is NOT more streamlined and efficient. It's absolutely, 180-degrees, the opposite of that.
> something like 2 FTEs focusing just on the reimbursements from Medicare and Medicaid
2FTE’s vs what?
The question isn’t is this free, the question is how large is the total staff including price negotiations, doctors, and IT time spent handling billing issues, and is Medicare more or less than 50% of the total.
I am ware of one hospital and 2 medical clinics where the difference is very much in favor of Medicare.
2 FTEs vs a department. Most hospitals have entire departments to handle insurer coding and some even have departments just to handle insurer disputes.
I think maybe I did a bad job of explaining. Of course providers have teams to deal with getting approvals from, submitting to, and disputing with, all the various Payers. At this level, we can consider all the Payers roughly equivalent.
But for Medicare/caid, there's an ADDITIONAL layer of work that CMS requires Providers to perform. The Providers need to ensure they're compliant with all kinds of standards, and jump through hoops to document and prove to CMS that they're compliant. These standards aren't limited to the specific care - procedures, meds, etc. - being expended on a particular patient. They encompass the entirety of the Provider's operations. For example CMS makes Providers provide documentation about their average pay rates, stuff that's not related to the care of any given patient.
The existence of that additional layer of reporting and compliance is the work that they're offloading onto the Providers, and thus increasing costs of providing care without it being legible if you were to audit CMS's own expenses.
> At this level, we can consider all the Payers roughly equivalent.
No we really can’t, economies of scale means when Medicare changes something you’re spreading costs across a lodge number of visits. When an insurance company changes something that same cost is spread among a vastly smaller pool.
Coding is a different layer. Everything needs coding, whether for gov't or commercial payers. So the folks doing this coding can't be separated out for commercial. In fact, it's kind of the opposite:
CPT codes (for procedures) - these are defined by AMA, but mandated by CMS (i.e., Medicare/caid). Because the gov't mandated them, the commercial payers adopted them too.
HCPCS codes (equipment and supplies) - defined by CMS.
ICD-10-PCS codes (hospital inpatient stuff) - defined by CMS.
versus nothing. Hospitals don't have to maintain a whole team for UnitedHealth, or for Anthem, etc.
This is my point. Medicare cooks the books to look more efficient by offloading their administrative costs onto providers. Other payers can't do that because, even if huge, they don't operate at the same scale.
Think about it: we often hear on the news about disputes about contracts when a local hospital's agreement with some insurance company comes up for renewal. They play hardball, getting local news to run stories on how many people will be affected if they can't come to terms. But you'll never hear this in the context of Medicare/caid. Hospitals have leverage to negotiate with commercial payers, but not with the government.
Depending on the size of the health system it may not be a team of multiple FTEs but they absolutely do expend significant resources on managing differences between commercial payers. They all have different rules about covered services, step therapy, prior authorization, hospital admission, etc. Sometimes those differ significantly even between health plans offered by a single carrier.
This isn't really true anymore (if it was ever true). Providers are spending a huge amount of time dealing with prior authorizations and appeals for private insurance.
I work in this area and you're right that Medicare can require a huge amount of paperwork from providers. And a hospital will have far more than 2 FTEs for this (it's called Revenue Cycle Management).
Medicare has overhead, but you’re not saying whether it is more than commercial insurance. The admin expense/profit portion of commercial insurers also don’t take into account provider admin costs (not to mention the huge amount of time patients can deal with denials, appeals, etc.)
It's further the case, regarding Medicare expense ratios, that their admin costs are low relative to private insurance because the median private insurance customer incurs far lower medical costs, leaving admin as a higher fraction.
It can't be both: either insurers are incentivized to authorize as much care as possible so as to fit more money through the 20% opening, or they're incentivized to deny care to minimize their expenses. Which is it?
What do you mean elevators go up and down clearly someone only wants to go in one direction. If they are below 80% they want costs to increase, over 80% costs better decrease.
The ideal long term strategy is to drive everyone’s costs to go up slowly over time slightly faster than inflation. Adding administrative burden to medical institutions is a perfect way to achieve that, but clearly that never happens…
Regardless of their motives they're all subject to the same regulatory system so they can only stray so far for so long from the net effect of the incentives and remain not bankrupt and being auctioned to pay back creditors.
It seems to me that the leading vaccine manufacturers, who spend billions of dollars yearly in order to lobby US lawmakers that establish the bureaucracy the article is complaining about, are interested in just that (maximizing profits).
It doesn't really matter much if there are individuals or other organizations interested in curing disease, when we have a system that allows for legal bribery of lawmakers, and other individuals / organizations with more money that value profits over anything else.
A large portion of the US healthcare is through nonprofits who are more interested in continuing to exist than in maximizing profits.
Vaccine companies are very interested in preventing disease not the kind of extended treatment people so often expect the healthcare industry to be looking for. They have an endless stream of new people being born every year so have no interest in people getting sick.
If people aren't getting sick, they have no revenue stream. Those non-profits you mentioned obviously aren't as capable of lobbying congress to influence industry regulation / bureaucracy as for-profit organizations are.
Nonprofits constantly lobby congress for a huge range of reasons, but they also get results with a surprising amount of federal money going directly to such organizations independent of Medicare, Medicaid, etc.
> If people aren't getting sick
People also get sick outside the US.
People still get vaccinated in the US for diseases with effectively zero new US cases because they haven’t been eradicated worldwide and would come back as soon as we stop vaccinating people.
Parents making major medical decisions has a huge precedent in a wide range of procedures with significant risks and consequences. Separating conjoined twins for example.
reply