A day in my life (health care thoughts)

Yesterday was a sick day. I needed a root canal.

I’ve always thought dental insurance is better visualized as a buyer’s discount club with some minimal insurance features instead of an insurance product with some buyer’s discount club features.  I estimate that my dental insurance has an actuarial value of about 50%.  The rest is out of pocket.

My endodontist started the procedure and about twenty minutes after I had been numbed up and the drill started to go through the crown of my tooth, she stopped and we had the following conversation:

“This is a little different than what’s on the X-ray”

“Is it a problem?”

“No, but I would like to do a scan to confirm the diagnosis, you okay with that?”

“How much would the scan cost and what does it get me?”

“$300 after your insurance pays, and it slightly decreases the chance you are in pain on Saturday”

“What are my baseline odds of pain?”

“Pretty low, I’m good at what I do…”

“Then no scan”


Twenty minutes later, the temporary crown was on and I was walking out the door.  As a health policy researcher and insurance geek, I was impressed with the radical price transparency and the discussion of value as my mouth was being worked on.  As a patient, this is something that I appreciated that I was not surprised with an unexpected $300 charge for minimal gain but it is not a decision that I was particularly able to make well.  I was operating at massive information asymmetry.  I had no way to evaluate whether or not my dentist was telling me the truth on how good she was and whether or not the baseline odds were accurate.

Once I got home, I checked the mail. And joy of joys, I received a revised bill from my son’s pediatrician.  We had taken him for his annual well child/vaccination update visit last July to an in-network provider.  The doctor’s office did not believe he was insured that day.  OOPS!

The HR office made an error on the special enrollment period membership file to the insurer.  He was initially deemed not covered so we got billed for the entire charged amount.  I fought and it took four rounds of phone calls to get everything straightened out.  Now we owe the standard co-pay and I dropped that check in the mail this morning on the way to the kids’ bus stop.

On one side there is radical price transparency fueled by low actuarial value coverage.  On the other hand, high actuarial value coverage required the paper work to work right.  One system worked as designed, I was a hyper informed consumer who decided to not get marginal care and the other took over six months to resolve to everyone’s satisfaction.  This is where we are probably going for health coverage where the insurer is more of a buyer’s discount club but the moment of decision felt like I was still operating under intense informational asymmetry and a power imbalance.  Getting the billing right for my son was a pain in the ass but I had allies from the insurer who do this multiple times a day so information and power were closer to symmetrical.


John, the ER and the prudent man standard

Cole illustrates why emergency room visits should not be adjudicated based on final diagnosis instead of presenting symptoms.

John had a bit of a scare earlier in the week:

Just got back from a relaxing seven hour visit to the ER. For the past couple of days I’ve had a little pain in my chest, but it felt like the pain I had when I had an ulcer a decade ago, so I dismissed it. Today it got worse and I could feel it in my shoulder and back, so I decided to go check my blood pressure. Checked my BP, and it was through the roof (200/100 normally about 135/75) and my heart rate was 84 bpm and it is normally about 55-65… so I decided I should probably go seek medical attention….

What do we know about Cole? We know he is a klutz. We know that he is middle aged. We know that he is carrying a couple extra pounds. We also know that he lives in the middle of nowhere and the closest hospital in Wheeling or Weirton is probably 30 minutes away once the vehicle leaves his driveway.

And we also know that he is having chest pains that were spreading and unusual cardiac measurements.

That to me sounds like a damn good reason to get checked out even if the eventual diagnosis is that there is not much happening. It sounds like a damn good reason because Cole is not a doctor but he knows his body and knows that something strange may be happening. It is prudent for someone with his demographics and chest pains to get a doctor to say “Okay” or “Oh Shit”. The cost of thinking he would be okay while he was actually going into an Oh Shit scenario is higher than the opposite way of being wrong.

The ACA requires insurers to use the prudent layperson standard to determine whether an ER visit a priori is an emergency. Using post-facto diagnosis codes imposes a knowledge requirement on the prudent layperson that they can’t meet.

Seth Trueger, an ER physician explains:

The ACA made the prudent layperson standard federal law (ACEP piece). The prudent layperson standard is exactly what it sounds like: the definition of a medical emergency is that a normal person with an average knowledge of medicine thinks is an emergency -– the patient’s symptoms make it an emergency, not the final diagnosis. So severe abdominal pain that turns out to be “just” an ovarian cyst is, by definition, an emergency….
If the patient is acting like a “prudent layperson” and thinks they are having an emergency, then it is an emergency and the insurer has to cover the ER visit. Full stop.

This is really important because there is a huge overlap in symptoms between simple benign problems (ovarian cyst) and serious life threatening problems (appendicitis) — see this fantastic paper by Maria Raven et al….

Tons of patients end up with final diagnoses like “acute viral bronchitis” which sound simple. Except when the patient is 80 and has CHF and COPD and it could easily be flu or pneumonia or a serious COPD or CHF exacerbation any or all of which could kill them.

We’re not medical experts. We know what does not feel right in our own body, that is a hyper valuable expertise but the layperson can’t self diagnose themselves and only go to the hospital when the chest pains are an actual heart attack instead of something else.

Look What You Done to Me

Just got back from a relaxing seven hour visit to the ER. For the past couple of days I’ve had a little pain in my chest, but it felt like the pain I had when I had an ulcer a decade ago, so I dismissed it. Today it got worse and I could feel it in my shoulder and back, so I decided to go check my blood pressure. Checked my BP, and it was through the roof (200/100 normally about 135/75) and my heart rate was 84 bpm and it is normally about 55-65 unless fucking Trump is on the god damned television, so I decided I should probably go seek medical attention. Went home, fed the dogs, packed up my laptop and sleep machine because if you go in and say heart at the ER those fuckers lock you up like Alcatraz.

Long story short, ekg and heart enzyme tests and chest x-rays were fine, but my lipase levels were elevated (but not double, so they could not give a diagnosis of pancreatitis), and my blood sugar was slightly elevated but they could not say if that was caused by the shit going down with my pancreas, but I am not dying and they let me go home and on monday I go to the doctor to get an upper gi and pancreatic tests done.

My blood pressure and heart rate are back to normal, and spiked because once again the #1 FUCKING DRAMA QUEEN IN WEST VIRGINA worked himself into a tizzy. I am absolutely the worst. I can handle physical pain no problem. I’m pretty sure I could have an arm amputated and I would wrap a towel around it (but not one of the good ones fer fucks sake I’m not a monster) and drive myself to the hospital. But if I cough funny twice I’ll be convinced I have fucking lung cancer and then work myself into an epic lather.

At any rate, I live to see another day. And for the love of everything holy, no remote diagnoses in the comments as I am already on a self imposed WebMD ban that has lasted close to 6 years.

CHIPping away at the deficit

Let’s imagine that there is a situation where a popular program can be extended.

Let’s imagine that popular program uses public-private partnerships.

Lets imagine that popular program’s extension needs no hard to agree upon pay-fors.

Let’s imagine that popular program’s extension is actually deficit reducing.

One would think that the vote to extend a deficit reducing popular program would be 422-7 in the House and 95-2 in the Senate.

That would be a nice strand of the multiverse to live in.

It is not our strand of the multiverse.

The Congressional Budget Office (CBO) estimates that extending CHIP saves money compared to the counterfactual of doing nothing.

The CBO thinks the following in their estimate:

  • Some kids currently on CHIP will get insured by going to the Exchanges
  • Some parents of kids currently on CHIP who are currently uninsured will get covered on the Exchanges
  • The repeal of the individual mandate increased projected premium subsidies
  • Fewer net kids will be covered even with spill-over coverage into the Exchanges

That to me sounds like a reasonable set of assumptions.  CHIP is cheaper for the federal government than paying Exchange subsidies for low to middle-income kids because CHIP is primarily paying near Medicare rates to providers instead of usually more than Medicare rates on the Exchanges.

A clean extension of CHIP saves money against the counterfactual of no change in policy or law.   That money could be used to enhance state match rates.  It could be used to reduce the total debt load.  It could be used for reinsurance.  It could be used for 5,001 things.

And yet, CHIP is still not being extended, 103 days after its long term funding was not renewed.



Anger Bear

I’ve just been in a seething rage the past 48 hours. This tax bill may have pushed me over the edge. Oh, and shitheads like Mike Murphy, who looks like a conehead with pubic hair for a combover:

His response was to block me. Lying ass prick.

Penguins look like shit. At least SNL is new with Kevin Hart and the Foo Fighters.

Late Night Open Thread: Doubling Down

When life gives you a new version of an old Nazi-punching video game to market… own the fuck out of your Nazi-punching.

Thereby chafing the highly refined sensitivities of a group that usually delights in screaming snowflake! and flaunting FUCK YOUR FEELINGS t-shirts…

Critics aren’t exactly arguing that the Nazis were nice, decent folks, but they say that in co-opting the president’s tagline, the video game company is quietly equating Trump supporters with Nazis.

Others claimed that the video game — or at least its marketing — is simply parroting the aims of the antifa, a loosely affiliated group of mostly communists, socialists and anarchists who aim to stop the advance of white supremacy, sometimes violently.

Is it good to give people in that group tacit justification to attack people who fit an ever-expanding definition of Nazis?…

The definition is hardly “ever-expanding”; marching with Nazi flags and screaming Jews will not replace us! has fit the parameters ever since the 1930s. It’s just that you didn’t used to see them mobbing around American college campuses, at least not with their faces unmasked.

Read more

I’m Making Myself Mental But Enjoying It Anyway

For the past several months I have been undertaking the herculean effort of finally importing every cd I own. I have several terabytes of music (the vast majority of which is dead and little feat and other live music from the archive), but I probably have about a terabyte of cd’s.

I got completely done with the import several weeks ago, and the itunes organized my library and fucked everything all up. So I dutifully started over, backing up my entire non live music library every night.

The most frustrating thing for me so far has been the artwork. I know there are taggers and the like, but I have found they make mistakes and do not import the art as I remember it. So I am doing it manually. A lot of the time, itunes will autopopulate, but since it is a public thing where any reject with no sense of decency can upload his shit and it fubars everything.

The other problem is it is just hit and miss. For example:

I mean fucking hell.

At this point, many of you are probably wondering why the artwork is so important- “Why don’t you just listen to the music?”

Well, for starters, it fucks with my sense of order. When I open itunes and there is:

Instead of this:

It hurts my soul a little bit. People spent a lot of time designing album covers. There were multiple revisions to them, the artists had to approve them, and it meant something. It’s part of the whole feel of the album. It’s part of the experience. And let me take a moment to give a big fuck you to Tipper Gore for those fucking warning labels.

Second, a very formidable portion of my important years as a teen was spent in two places on the college campus on town- first in the computer lab playing on dummy terminals connected to the PR1ME mainframe and the Apple desktops, and at the college radio station working as a dj. I spent thousands of hours there, either actually live on air, or engineering a show (I did Monday Night Oldies with a professor who was technically incompetent and the Ashborne Hour playing classical music with another professor), but I spent most of my time just learning how to do things and listening to music.

And I would sit there on the floor, or lie under the turntables, and hold the album in my hand and look at it while listening to whatever it was. It’s one of the reasons I love music, and the album art not only means something about the album, but it brings back good memories. Maybe this is lost in the digital era, when people don’t listen to albums but just have playlists. But when I listen to music, I listen to the entire album. The way it was meant to be. From start to finish.

I mean, if you are at a bar or a club or listening to radio, I understand mixed tapes and shuffle and playlists. And I get greatest hits albums- I am not a complete monster.But if you are at home or driving or whatever, it makes no sense to me. You don’t just pick up a book and randomly read a chapter. Oh, I really like chapter four of The Sun Also Rises, and after that maybe chapter seven of Naked Lunch. Oh, and maybe a chapter of Brautigan.

I mean, maybe that works for you all, but not me. Rambling. The end.

Fuck you itunes users who can not get your tags and labeling right. You probably voted for Trump.