Friday, June 23, 2017

Snark Easy, Mathematics Hard v2.0

You'd think someone doing a stock market blog would have some clue about, y'know, numbers, prices, costs, and such. Maybe some insight into how things relate.

You'd be wrong.
Case in point, Karl Denninger's post on Market Ticker (h/t WRSA): 

Market Ticker: A One Sentence Bill To Force The Health Care Issue

Here it is:
"Notwithstanding any other provision in state or federal law, a person who presents themselves while uninsured to any provider of a medical good or service shall not be charged a price greater than that which Medicare pays for the same drug, device, service or combination thereof."

That's it.
One sentence.

If you want to add a penalty clause with it I propose the following:
"Any bill rendered to a person in excess of said amounts shall (1) be deemed void, with all services and goods provided as a gift without charge or taxable consequence to said consumer but not deductible by said physician or facility from any income or occupational tax and (2) is immediately due to the customer in the exact amount presented as liquidated damages for the fraud so-attempted."
It ends the "Chargemaster" ripoff game.
It ends the $150,000 snake bite or the $80,000 scorpion sting.
It ends the $500,000 cancer treatment.
It ends all of that, immediately and instantly.

I remind you that Medicare is required to set pay rates by law at a level that in fact are profitable -- that is, above cost by a modest amount -- for everything it covers.  Further, those pay rates are audited regularly to prove that they in fact are above cost.
Does this solve every problem?  No, and in fact that would leave alone the existing monopolistic pricing systems that many medical providers, whether they be drug makers, device makers, service providers or otherwise have in place.  It would exactly nothing to get rid of the 10 paper pushers hired for every doctor or nurse, none of whom ever provide one second of care to an actual person through their entire time of employment.

But it would instantly end walking into an emergency room and getting hammered with a $50,000 bill for something that Medicare will pay $5,000 for.
It's hard to fisk this amount of sophistry properly without noting it's akin to spackling over the Grand Canyon using a shovel, but I wasn't doing anything better, so here goes.

TL;DR version:

Some will hail this as a simple solution.

The word you’re looking for is “simplistic”, not “simple”.

If we can agree that I may purchase your home and put you on the street by offering you 3 cents on the dollar of its value in cash, we have an accord.

It not, I’ll provide an anatomical diagram for where to shove that communist codswallop.

And If Denninger doesn’t get that, or never thought of it, he’s too simple to be burping his Good Idea Fairy B.S. on the ‘net.

Longer version:

Medicare reimburses healthcare at pennies on the dollar of actual costs.
And deadbeats, indigents, and illegals pay not one damned cent anyways.
(You out there, with IQs above room temperature, see if you can puzzle out why, therefore, your private insurance gets charged $42 for a single Tylenol. Or a $50,000 bill for something Medicare only pays $5000 for. I’ll wait.)

Then factor in EMTALA, in which the feds dictated that emergency medical providers shall treat every recklessly irresponsible shitbag without insurance, and every illegal alien baby momma about to burp out another brat to cash in on Uncle Sugar’s largess to US citizens.

And then, oopsie, "forgot" to fund that unfunded mandate, which basically bankrupted every small community hospital in existence (in case you were old enough to have wondered where they all went somewhere around thirty years ago), and forced everyone to Big Giant Expensive Healthcare Palace, where everything is more expensive.

So, tell me, how long would McDonald’s survive if the feds decreed that anyone who was hungry would receive all the Big Macs and fries they wanted, simply for walking into the establishment…?

Beuller? Beuller…? Ferris Beuller…??

You want to “solve” health care, it’s simple:
get government out of the whole business. Because everything they touch turns to shit.

Here’s your one sentence:
The Patient Protection and Affordable Care Act of 2010, all provisions thereof, and all associated legislation and administrative guidelines, are all hereby revoked in their entirety, and in perpetuity.

Pay for your fucking care your own goddamn self, and qwitcherbitchin.

When the bill’s coming out of your ass, you decide, with full responsibility for the decision, whether you want that CT scan or blood test or surgery, and if you die because you fucked up that guess, well, shit’s tough. No lawsuits, just personal fucking responsibility.

Too fucking hard, cupcake?
Contract with an insurance company to gamble on your health, and charge you appropriate premiums, and buy the coverage you want: just like you do in every single fucking facet of the rest of your life.

You want a Ferrari, you pay for it, and you pay Ferrari insurance rates, and Ferrari deductibles.

You can only afford a Chevy Caprice, or a Kia, you pay less, and you get less.
If you want the government to take pity on the poor, let anyone who doesn’t pay income taxes sign up for Medicare, or military Tri-Care.
 And force Congress on that too: put the Senate on Tri-Care, and the House on Medicare, effective immediately.

Or don’t do that.
Frankly, I don’t give a shit.
But whether I buy health insurance, and what it looks like, is my decision, and mine alone.
And who gets cared for is between hospitals, doctors, and patients.
None of that is any business whatsoever of anyone in the fucking government, at any level, except insofar as they offer insurance to cover some people.

(Ask around and see how many doctors don’t take Medicare patients, BTW. It’ll open your eyes, if your brain isn’t a shrivelled raisin. Ask yourself, if the reimbursement rates are so damned profitable, why they'd be doing that. Why is it, d'ya suppose, doctors and insurance companies have to hire shit-tons of clerks and coding specialists, to navigate the arcana of federal Medicare billing and reimbursement codes and regs, the very 10 paper-pushers that deliver no actual patient care Denninger damns so casually and thoughtlessly, if Medicare is so damned by-law profitable? {Most people, with a modicum of wit at this point in the discussion, would tenderly back their cleats out of their dicks, and STFU.} Hospitals, OTOH, don't have a choice: everyone 65 and over is on Medicare, and it's 75% of their patient-load.)

Medicare, foisted on the American public by the second-biggest communist ever to inhabit the White House, LBJ, was a tag-along Ponzi scheme like that perpetrated by the absolute biggest communist, FDR, when he passed Social Security.

In both plans, you, your kids, and your grandkids, are paying and will continue to pay for your parents, grandparents, and great-grandparents. In Medicare's case, by shifting the actual cost onto your private insurance. That's why grandma's appendectomy was only $5K: because your private insurance is picking up the balance. Well played, communists.

Apparently, financial genius Denninger can't figure this obvious truth out when it's smacking him in the face like a frozen mackerel.
He's probably also stumped as to why health insurance premiums have risen inexorably, as government piles more and more people and things into Medicare etc.: prescription drug programs, no children left behind, illegal aliens, the relatives of illegal aliens with 37 co-morbid chronic conditions, their kids with diseases normally only studied by med students in their tropical disease lectures, and so on. Paid for by Medicare at pennies on the dollar.

Gee, with more and more seniors, and less and less employed workers carrying private insurance, not to mention less full-time employees who even get insurance, why premiums keep going up is a real poser.

Back during WWII, US wages were frozen by law, and labor was tight, what with 1 man in 6 in uniform. So to allow companies to sweeten employment offers without causing economy- and war machine-wrecking inflation, they were allowed to offer benefits, like pensions and insurance, without them being counted (and taxed, thanks to the 16th Amendment) as wages.

LBJ et al finally got around to levying that tax in 1966, with Medicare, by jacking your premiums, so that your insurance would subsidize the costs of seniors' care.

For brevity, we'll skip over the MRIs, CTs, ultrasounds, and laparoscopic and arthroscopic surgeries that are commonplace for everyone now, but used to only be covered for NFL quarterbacks.

The problem isn't insurance. Insurance has been around since at least 1686, courtesy of Lloyd's of London (another boon to mankind courtesy of Dead White Males [tm]). An insurance company spreads risk, and charges you for the coverage. These charges are called premiums. The premiums are a wager on your part that something bad will happen, backed up at odds by the insurer(s) that it won't. They know they'll lose sometimes, and they have to absorb those losses and still make a profit, just like casinos. Because random acts, bad luck, poor actuarial forecasting and people skydiving and riding motorcycles. Call it the Shit Happens Factor.

So the premium calculates normal losses, plus the SHF, plus a reasonable profit to stay in business.

And because insurers have to be able to cut huge checks, and they have a monthly float of premium checks, they have to put their money where it'll grow. They also have to lay off their bets on other bookies insurers, so that one bad payout doesn't wipe out the company. So they do that, and invest a lot of their liquid assets in things like stocks, bonds, etc.

So far, so good, right?

Then government finger-fucks things.
They force insurers to do things they - and even the insured - may not want. Like ObamaCare forcing young healthy males to be covered for childbirth - an anatomically impossible occurrence, and akin to requiring flood insurance for desert dwellers in the Sahara, seatbelts on motorcycles, and diapers on dogs. It's what government does.

Which drives up insurance costs for the services you don't want. (Exactly like your cable TV bill and the channels you don't want, but still have to pay for.)

Then, more recently, government pooch-screws banks into making loans to people that can't afford houses, which plan predictably explodes. Banks fail, the stock market crashes, and insurance companies, just like your 401K, are suddenly out metric fucktons of money. So, gentle premium-paying reader, how, praytell, do you suppose they get that money back, to keep from cratering financially...?

Could it possibly be by...raising premiums??

If you got that on your own, award yourself the No Shit, Sherlock! Prize.
Unless you blog at Market Ticker.

And why would they do that?

Because if insurers fail, everyone loses all their insurance.
So, tell me again: Who was it that made banks give out loans to people who were horrible loan risks?
Who is it, in all of Denninger's hand-waving, that "audits" Medicare to make sure it reimburses providers at a "
profitable" rate?
(Bonus points if you can see a problem with letting the fox guard the chicken coop. But hey, "by law", the NSA and CIA aren't allowed to spy on Americans either. So that must never happen either, because government is so respectful and trustworthy of its citizens' rights, and circumspect in their duties towards...sorry, I had to stop before soda cost me another keyboard.)
Who enforces the law on that in case there's a disagreement between Medicare and the payee(s)?
Who piled on all the silly shit that you don't need?
Who's been jamming more people into the shitty-paying government plan(s)?

I'll wait why you write the same answer in all five cases.

Who is it that's been trying to break insurers, while forcing them to jack up premiums, which causes companies and individuals to drop coverage, which forces more people into crappy government insurance plans?

Denninger seems to be stumped on all this. Kind of like Democrats in Congress were.
Color me shocked! Shocked, I say!

This is why simpleton solutions don't work.
If you don't know what the blistering f**k you're talking about, maybe stay in your own lane.

And instead of defaulting to some infantile mental picture of insurers, hospitals, and doctors raping privately insured patients and carting the proceeds to their private vaults,

maybe show the sense God gave a jackass, and put the blame where it belongs:

Firing the government, and laying off thousands of lawyers is always a good first instinct in any problem. And anybody, like Denninger, who reaches for government as part of any solution like a gunslinger going for a .45 Colt, should be run out of town on a rail, after a proper tar-and-feathering.


Anonymous said...

minor quibble: EMTALA only applies to emergency departments at a hospital that accepts federal funds ('care and/or 'caid) Otherwise, as we used to say in the seventies, "rhawt awn!"

loren said...

"You want to “solve” health care, it’s simple:
get government out of the whole business."
Most, like you concentrate on the payment side of health care. How about the cost side?
Based on experience (Australian health care) the single greatest thing the US could do is get fucking layers out of the system.
Do you know why it costs a billion dollars!! to get a new drug on the market? Not the FDA, but funding the future lawsuits that inevitably occur. Hell, Johnson & Johnson is being bankrupted because they sold talcum powder and some old ladies claim they got twat cancer from it. Imagine the liability of some real helpful health product.
In Australia, medical damages are awarded by a judge and are for actual proven damage, not what some dirt bag lawyer needs to fund his life style.
The result? Public insurance is funded by the tax payer and is limited by how much money is available. A lot of procedures have to wait. If that doesn't work for you then you get private health care insurance. Cost? My family of 3 was around $1200/year with very little deductible. My wife stayed 10 days in a private room in a private hospital after my sons birth (CC) because she liked them taking care of her and the baby. Cost me nothing. Here they kick you out the next day.
Here? My friends wife went in the ER(holiday weekend of course) for a UTI which she's had before and knew the drug she needed, etc. No exam but still cost her 5K.
As for me, when shown a +50 PSA here I had a choice of signing over my house to some cocksucker of a doc or taking my chances. I'll take my chances down under.

zuk said...

Eh, Karl has been blogging about this issue for a long time. He's actually talked about a lot of the things you bring up, and this latest, short post is just one aspect that should be taken with all the other prerequisites he's proposed. Short makes a good rant, long and detailed doesn't.

.gov out of healthcare.
full pricing transparency
real competition
no cost shifting
repeal of EMTALA
enforcement of anti trust laws re: price fixing, collusion

it goes on and his point never was that .gov pays a living wage, so to speak, but that costs would come down for everyone if you got rid of all the dead weight (non-patient care positions) and got some pricing competition into the system.

Anyway, his body of work on the subject is much more comprehensive and sensible than this one post.

Anonymous said...

One thing that will help in the future (not right now but it's coming FAIRLY soon) are robotic systems that will do a lot of basics that doctors are having to do now. One of the problems is a doctor and nurse shortage. Look at Intuitive, Verb Surgical, Auris, etc., all looking to make the more basic surgeries more automated. A lot of what goes on in Family Practice can also be automated, along with some nurses' duties further along the line (Japan on leading edge on that). That lets doctors and nurses concentrate efforts on the more difficult cases. Later that should cut costs quite a bit, but probably not in our lifetimes unfortunately.

Aesop said...

@ Anonymous 0645
Yes, EMTALA only applies to the ER's of hospitals that accept federal aid.
That would be all of them by default, and ER costs were one of Denninger's specific examples. And the ED generates far more than half of the admissions in most hospitals.

What you're talking about is tort reform, which requires the practice of defensive medicine. It's a modicum of the cost, but not the bulk.
a) It should happen, but it never will, because almost all congresscritters are lawyers.
b) It had nothing to do with Denninger's asinine post.

When you're wrong, you're wrong. Denninger is wrong. And the monumentality of how wrong he is can scarcely be contained. I glanced at one of his related rants, and it's even more wrong than this one. While he and I might agree on a bare few ideas (price lists up front), I frankly haven't got the time to fisk the totality of how much he else doesn't have a fucking clue about that which he tackles on the subject. Like icebergs, 8/9ths of his ignorance on this subject remains unseen, but it's there nonetheless. As I said, he should stick to stocks, about which one might wish he's not such a hopelessly misinformed neophyte.

@Anonymous 12:22
You'll get robotic doctors and nurses when you get robotic airliners, i.e. when you get jet packs and flying cars. Warp drive and teleportation are about as likely as any aspect of Star Trek medicine.
Damned little of what I do as a nurse in the ER is something that could be relegated to a robot anytime soon (my guesstimate is it'd be less than 2%, and most of that is stuff that has little to do with actual nursing practice, and more the bullshit like fetching blankets, pillows, straws, and other non-nursing tasks that fall to me by default, because there's no one else to do it.), and then you'd need ten times as many techs to apply/supervise/service the robots.
So, let's all take a guess, and see which ancillary personnel, despite being the lowest paid, are the last ones most hospitals want to hire at all now, and ponder how that will go when you add a multi-million dollar machine that lets them decrease the number of nurses at the bedside (in theory).
Not. Happening. In. Anyone's. Lifetime.
I'll leave mostly pointless and wildly inaccurate speculation to the futurists at Popular Science.

grey said...

I couldn't reply to your post over on WRSA.

So I will reply here.

This is what you wrote:

a) It’s an ER, not a parking meter: they don’t charge rent by the hour.
b) Does your arm function properly now?
c) How much is that arm being functional worth to you? Round numbers.

If someone held a gun to you and forced you to go to the hospital, you’d have a point.
You are always free to treat yourself, or avail yourself of the services of the local curandero, witch doctor, or what have you, right?

But instead, you wanted a board-certified ER doctor, someone who spent 12 years of his life after high school getting an education – at enormous expense – just so that he could examine, diagnose, and treat you properly in only two hours.
And you got precise pain relief, something largely unknown for most of recorded history.
We’ll skip over the costs of the building itself, machines, supplies, clerks, technicians, and nurse(s) who took care of you, the support staff in the pharmacy, radiology, and supply departments, as well as the staff that maintain the facility and clean the rooms, all in compliance with the local, county, state, and federal regulations that, combined, occupy about three yards of bookshelves, and all in compliance with another five bibles of practice sufficient to not only solve your problem, but prevent any part of the process running afoul of ambulance-chasing lawyers and another thirty yards of regulations and case law.
For comparison, ask around, and see what a law firm gets for two hours in court. Bear in mind the average lawyer has less than half the post-grad education most doctors do.
Then ask them what they’d charge if they had to go to trial on the very day that you were arrested.
Don’t take their laughter personally.

Here is my reply:

A) it wasn't an ER. It was a small ( less than a 1000 sq ft) rural clinic in a small western town. Of course I understand they don't charge by the hour.

B) My arm doesn't function properly now. The "board certified doctor" completely ignored the damage to my shoulder and wrist. The upper arm bone that was broken is healed. I am doing my own rehab because the rehab clinic I did do was worthless.

C) answer to this question is above. How much is worship of the mainstream medical establishment worth ? In round numbers? The RN told me I was lucky, "the doctor loves to operate and if there was the slightest reason to operate, I would be on the table".

D) I am free to treat myself. Of course. That wasn't the point.

E) I didn't want or not want a board certified doctor.

F) " precise pain relief" That is really funny. It was just enough to knock the level down a tiny bit. The glass of whiskey on the 40 mile trip to town was much more effective. And that is largely known for all of recorded history.

G) We’ll skip over the costs of the building itself, machines, supplies, clerks, technicians, and nurse(s) who took care of you, the support staff in the pharmacy, radiology, and supply departments, as well as the staff that maintain the facility and clean the rooms

My reply:

One front desk, one RN, one x ray tech and one doctor. No pharmacy.

H) For comparison, ask around, and see what a law firm gets for two hours in court. Bear in mind the average lawyer has less than half the post-grad education most doctors do.
Then ask them what they’d charge if they had to go to trial on the very day that you were arrested.

Comparing Emergency care to whatever and how a lawyer charges is silly.

I) Don't take my laughter personally.

Dan said...

Your proviso is acceptable....on one condition.
Payment MUST be rendered IN FULL at the time of
service otherwise NO DEAL.

Aesop said...


I understand WRSA's auto-close feature plays some havoc with comment replies.
I have the same problem from time to time.

I understand your situation better now.

You're bitching (justifiably) because you went to some half-assed doc-in-the-box thing instead of a real hospital, and got cut-rate care, but charged as if it were full fare at a real facility.
That's not "emergency care" as you identified it, it's barely first aid.
And fraud masquerading as standard practice.
7K is going rate for far better care than that - if you'd gone to an actual hospital. You (unknowingly, I'm sure) thought you were getting actual emergency care.
I can assure you that you weren't. Nor anything even remotely close.
Just like painting a red cross on a kid's red wagon doesn't make it an ambulance.

What you got has fuck-all to do with medical costs in general; you were simply ass-raped by what passes for poor urgent care anywhere that can afford something better than veterinary medicine. My condolences.
I now completely understand your pique, but pardon for noting it's got little, if anything, to do with the topic, there or here.
If you drove 40 miles for that level of doinking with your pants on, next time, please, keep going until you get to a town with a hospital.

As far as surgery, why in hell would/is a clinic doc doing it? In a
"less than a 1000 sq ft rural clinic", with one RN.
That's nine kinds of fucktarded.

And what damage to your shoulder and wrist?
Unless you broke something else, that'd normally be addressed at a follow-up visit with an orthopedic specialist, along with follow-on care for the fracture(s).
(I should have caught it earlier from your original post, but WTH would anyone put a cast on a fresh fracture?? Normal standard of care is a temporary splint, not a cast, and then a cast by an actual orthopedic doctor - a couple or three days later, after the initial swelling has a chance to go down.
Which might be why you have other problems now.)
If said ortho referral - and scrip for Rx pain meds - wasn't given as part of the initial visit, they fucked that up too.

Your gripe therefore isn't with the medical system per se, it's with a shitty clinic and a sub-par doc in Bumfuck, going solely from your description.

In order:
a) don't go there anymore
b) report them to your state's medical board
c) retain legal counsel
d) when it feels like rape, it is. And it sounds like you were.

Anonymous said...

I agree wit Zuk. Karl Denninger has some damned good suggestions about how to cure the healthcare system.... as well as the banking reserve and equity market systems to name a few others. A look at his larger body of work is required. Like Racounteur, Denninger is a guy who doesn't merely complain, but offers actionable, reasonable, and every-man-achievable solutions.

Anonymous said...

Aesop, you said "I'll leave mostly pointless and wildly inaccurate speculation to the futurists at Popular Science."

If I old you in the early 90's that nobody would be cracking open a chest to cure AF and instead would be using a disposable device that uses a small incision in the leg, and those devices would be used on a regular basis within the next 5 years, you'd likely be saying the same thing. You're wrong on this one. I'm going to let the devices and a couple of years speak for themselves, I don't need to prove anything to you, because I KNOW what's coming. I'm saying this to you:

Happening. In. Your. Lifetime.

Aesop said...

@Anonymous 0618
Deninninger has some good ideas. And some, like the exemplar above, that are accumulated and stacked stockyard patties.
That point granted, a hamburger composed of half steak and half cowshit is not one which I'd wish to consume.

@Anonymous 0802
Maybe. They told me only 25 years ago all nurses would be BSNs. By 2000.
They only missed that by maybe 50%.
So not so much the other stuff either.
I use bedside technology (and I use that term loosely) daily for a couple of decades, in the exact field whereof I speak.
It does far less than what it's supposed to, every damned shift.
Despite a cacophony of dings, clangs, bells, whistles, beeps, and other assorted assaults on my hearing every shift, I can count the number of useful alarms I've received in 20+ years on my fingers.
For machines which currently have one job.

BTW, that AF device is a tool used by a surgeon. It's not a replacement for the surgeon. I expect technology to improve. The likelihood of it replacing anyone couldn't be calculated with the NSA's Cray supercomputers.

But maybe, if I live to be 150, you might be right.

Mike_C said...

Huh. I was reading this post on a small phone screen at the airport while in line to be yelled at and groped. Anyway, I initially mistakenly thought that the Denninger quote was our bloghost his own self speaking and thought Oh shit! First WeaponsMan has a heart attack, now Aesop's had a stroke!

Whew. Incidentally, I have no opinion on Denninger one way or the other overall, but the "Medicare rates" thing was what made me think that the writer was suffering from acute brain damage.