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Comment by tptacek | Hacker News Reader

It's mostly not rational. For instance, much of the conversation over the last day has been about Anthem pushing back on anesthesiology pay on the East Coast. That's people angry about their insurers working to make surgeries cost less by employing the literal guideline Medicare uses, and yet people online were overtly suggesting Anthem's CEO be murdered over it. Incoherent.

This won't win me any points in this particular forum, where this opinion (that I strongly hold) is unpopular, but I'm reminded of what someone else said about Net Neutrality: it's a bunch of people suiting up and taking sides on behalf of one group of giant corporations against another group of giant corporations. That's the "health care debate" in the US, where medical staff are paid 2-3x more than they are in other countries, and expensive procedures are prescribed and delivered at drastically higher rates. It's my problem with "Medicare For All", which more or less absolves providers from their role in choking people out with health care costs, despite the leading role they have in this situation.

At any rate: there's no serious theory of change that begins with murdering health care industry people.

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> At any rate: there's no serious theory of change that begins with murdering health care industry people.

I dunno. This is the most publicly-united I’ve seen people against the industry maybe ever. Usually they’re separately-angry at the industry in their partisan silos (everyone hates it, more or less—hence the amazingly consistent and widespread reaction) but this has been the closest thing to a bipartisan healing moment since, like, the week after 9/11. Not particularly close to that, sure, but I can’t think of anything closer.

If this were part of a theory of change, it strikes me as no less serious than any other I’ve seen. At least.

I think it is the most disgusted I have been with a broad swath of the public in a long time. I dont think anything productive will come of it.

The trouble is that nothing productive was going to come of anything else, either. That’s where these reactions come from.

Yes, there is a lot of frustrations. Voters disagree on what they want. That does not justify people to start shooting people when they dont get their way.

The thing you don’t like is that the voters do agree they want this, though.

Want what? I dont think the majority of Americans endorse vigilante murder of law abiding citizens. That is just a vocal and bloodthirsty segment of the online population.

Literally everyone I know IRL was like, “nice. More please.” I was actually surprised and heartened to see the initial HN thread, even, was overwhelmingly supportive.

This is top of my list for conversation topics to steer things toward when I’m around Republican relatives, so we’ll have something we can agree on.

Law-abiding doesn’t mean much when you can kill lots of people for money and remain within the bounds of the law. Killing one such person is definitely far less bad than killing a bunch of people arbitrarily. Yet only one of these cases is illegal, and it’s the better of the two.

More please of what? Vigilante murders?

Specifically of antisocial CEOs, board members, et c. That specific kind of vigilante murders.

Compared to CEO's directing their companies to legally murder people ("law abiding citizens") instead?

This is logic that makes sense inside of filter bubbles on the Internet that I think most people --- most people are not in any one particular filter bubble and certainly not this one --- would find absolutely repellant. To put it in perspective: it is literally the logic used by people who shoot up abortion clinics.

How do you feel about murdering doctors who demand pay for treatment, citizens that vote against single payer, or people that fail to donate to your gofundme?

All of those are extremely different situations, so what are you getting at?

I see them as essentially the same. All of these people are choosing their financial interests over your health. People are dying from their inaction.

I can’t begin to relate to seeing someone with a median income failing to donate to some particular go-fund-me as the same as choosing to head an organization that makes more money when people don’t get the health care they need, and overseeing operations that did that even more recklessly than the industry standard. One has taken on a business relationship already and is taking people’s money then screwing them, at a mass scale. The other just didn’t donate to a gofundme that may not even be legit and for someone they have no connection to.

Similar reaction for the other examples. I’m baffled that they look similar to anybody at all.

[edit] hold on, ok, another angle that may clear up why I’m confused: if my health insurer denies my legit claim, should I be more, less, or equally angry with the leadership of that company, or with every single person in the country who fails to donate to my resulting gofundme? I’m immediately inclined to wish horrible things on one of these groups, and to find the idea of wishing horrible things on the other confusing and repulsive.

There are laws enacted by our elected government (Democrats under Obama) that say exactly how much overhead is acceptable for a health insurance company, and all business expenses and CEO pay comes out of that portion. If they collect too much in premiums to and their profits exceed that percent, they have to refund the insurance members.

Health insurance has a fixed profit margin on claims paid. Denying claims costs them money. Pay 10 billion in claims and they make 2 billion. Deny half the claims and they make half as much.

look up that ACA 85/15 law

There’s some nuance to this.

The ACA’s loss ratio rules don’t apply to self-funded plans (many large employers use these) even if they’re administered (and possibly re-insured) by a health insurance company, which is usually the case. Just doesn’t apply at all.

Certain plans also allow much lower loss ratios, like 60/40 for expat plans.

A provider that manages to have a lot of new plans in a given state in a given year is immune from loss ratios rules in that state, for that year. I don’t know how gameable this is but my WAG would be it’s only state insurance commissions preventing this from being the case in every state, every year, for every provider, and keeping it to only some states in some years for some providers (I bet the biggies manage to rotate their state[s] and have at least one most years)

So a company the only business of which is health insurance can easily spend far less than 80 or 85% of income on payouts, and only need maintain that ratio on some subset—possibly small—of the premiums it’s collecting.

I don’t know how the game of this affects decisions for insurers that also own providers, but I bet there’s something beneficial there and that’s why they’ve been snapping up provider offices for the last several years.

Most of that makes sense to me. there is a self funded plan, my understanding is that the employer is collecting (and usually subsidizing) the premiums.

At the end of the day, my experience is that my UHC healthcare is about 10% more than healthcare from non-profit Kaiser, and Kaiser is far more stingy with services.

I think there is a hell of a lot wrong with healthcare in the US, but I don't think that constitutes murder just because the stakes are life an death.

Ethics depend not just on the outcome, but the processes that leads to that outcome.

The incentives in healthcare are terrible, but it is the government which has structured the system and those incentives.

Not sure how this is relevant?

Because they arent murdering or killing people to make money. The less they pay out, the less they make.

Because there is a clear legal understanding of how much profit is acceptable.

> Because they arent murdering or killing people to make money.

Ahhh. I guess you're not aware of stuff like this?

https://www.newsweek.com/hospitals-are-reporting-more-insura...

Denied claims mean less profit for the insurer. They only get to keep a percent of what they pay to hospitals. Do you have a response to that?

One of the primary jobs of insurance companies is to vet claims. If we didnt want that, you could just make a shared bank account and let doctors and hospitals bill anything they want to it. You might save 10% on overhead, but it would collapse instantly.

> Denied claims mean less profit for the insurer.

If that were true then United Healthcare wouldn't have rolled out an automated system that (reportedly) denies ~90% of people regardless of their actual need.

I'm not going to stick up for UHC, which is an obnoxious company, but do you honestly believe UHC is denying 90% of claims? Have you thought the implications of that claim through?

> Have you thought the implications of that claim through?

The CEO getting shot seems to indicate it's probably more true than less true.

This is the second time on this thread you've pasted this Newsweek link as a rebuttal. I don't understand why you think it rebuts either argument.

Does this one help illustrate the problem?

https://www.theregister.com/2023/11/15/unitedhealthcare_ai_m...

What "problem"? You're not being clear about what you're trying to say. That a particular insurer has done bad things? Nobody was going to take the other side of that argument.

Justifications are meaningless when the end result is all the matters.

I staunchly disagree with this kind of utilitarianism. The ends do not justify the means.

Okay. So other than getting mad on HN, what do you propose we do to fix the feelings people have about this situation and prevent this happening again?

I don't think we're going to fix this problem on HN, so I'm content just to point out that a lot of what people are saying about this situation is unfounded.

I don't either, but people feel this way about millionaires and healthcare execs for a reason, they're not just being cruel for the sake of it. Think about the reasons for it, and try to come up with a solution. That's a way more interesting discussion than getting mad about people being dumb on BlueSky or whatever.

People have built a frustrating system for themselves with a century of complicated and messy political decisions (and resulting regulations). They don't have the will or attention span required to solve the various problems via the slow moving & gridlocked political system. So, they take out their frustration on the highest profile participants in the system.

Solutions? I'm worried that there aren't solutions. There are only bandaids.

There is really basic stuff that we're going to have to do no matter what that doesn't involve restructuring the system, like drastically increasing the number of practicing physicians, which is capped by (you guessed) Medicare, which sponsors residencies. But all we can talk about is payer structure because of a complete fixation on insurance companies as singular villains.

Heyyy, we're starting to talk solutions after all. Good stuff. What do you think is UHG's and its executives' role in supporting or opposing the policies and politicians who could enact these fixes? I didn't verify this, but I'm going to go out on a tiny limb and guess that UHG and its execs pay for legislative seats to be filled by Republicans. Republicans famously want to reduce Medicare funding. Do you think lowered Medicare funding would result in more or fewer Medicare-funded residency positions? Certainly there's more at play in elections than UHG itself, but I'm wondering which side of the solution they're on.

This could be an opportunity for me to learn something new...

I thought the American Medical Association were the ones who artificially constrain the supply of physicians. Is that not true, or is the AMA constraint transitively related to the Medicare caps in some manner?

The AMA is just a lobbying group. The actual cap on the number of new physicians is residency slots, which are funded by Medicare.

Which I think itself is a bit of a red herring. Medicare subsidized residency slots are not the only way training doctors could be funded, and largely an artifact of our billing procedures and criteria.

It is just one aspect of how incredibly constrained the supply of healthcare is in the US. Medications that are over the counter in many countries requires someone with 12 years of training.

It's not the only way they could be funded, but it is the only way they are funded.

Sure, and my point is that the entire bottleneck is based on a a completely arbitrary artifact of how we handle billing in the US. It is a policy choice.

Residents provide healthcare to patients with real value. This healthcare either gets attributed to the attending physician or goes unbilled. The market value of care provided exceeds what it actually costs to employ and train a resident.

https://pubmed.ncbi.nlm.nih.gov/21217491/

The "arbitrary artifact" here is literally Medicare!

Yes, largely the fact that Medicare forbids billing for resident services. Im sure there is also an objection on the insurance reimbursement side as well, but I see no reason why a successful procedure of adequate quality performed by a resident should not be billable at the same rate.

The notion that the providers are the ones sucking up all the money in the healthcare industry is certainly... novel.

The majority of people in this particular industry have nothing to do with actually providing health care, just as the majority of employees at a major university have never stood in front of a blackboard.

Here's a 14 year-old series showing that providers are the biggest chunk of the overspending in the system:

https://web.archive.org/web/20210421025041/http://theinciden...

In the United States, physician salaries were 6.5 times GDP per capita for specialists and 4.1 times GDP per capita for generalists.

(Shrug) I'm OK with the notion that doctors contribute somewhere between 4 and 7 times more value than your average schlub driving a bus, and I'm OK with paying them accordingly.

Now, how much do the administrators, insurance-company execs, and other noncontributors make?

If you look, you can find pie charts that make the point I'm making directly, so no, I don't think it's novel.

The problem with our health insurance system is that it's insidious. Our doctors spend ~25% of their time filling out information that only gets filled out to try to get insurance to not deny the claims, and hospitals have entire billing departments whose only job is dealing with the billing of our stupid ass system. The problem isn't just the ~15% that the insurance companies take directly, it's that since their percentage of profit is capped, they work to raise prices of the entire health care system so that their 15% cut is bigger. Insurance companies literally negotiate pharma companies to charge a larger amount to uninsured people so they get to take a bigger cut.

Is that why they make as much as 3x what doctors in other G20 countries make? Hazard pay for the paperwork?

That's not all of the reason (some of it is higher cost of living, compare G20 vs G7 and the gap narrows a bunch). Some of the reason is because of US education costs, and immigration policies that make it harder for people to come and work in healthcare.

Does it? Average physician cash comp in Germany is 75kEU, and average cash comp in the US is something like $350kUSD. Note here I'm using one of the largest and soundest economies as a comparison, and one with substantial uptake of private health insurance.

If I look, I can find pie charts demonstrating that the Moderna COVID vaccine provides 8 dB worse 5G reception than the Pfizer shot.

So, yeah, you'll have to do a little better than that.

No, I don't.

You can't come to the conversation with "everyone else is being unreasonable" and then not cite your sources.

If what I was backing with "pie charts" was "everyone else is being unreasonable", sure, but that's not what I said. Go look it up. Zero out all insurer costs. What percentage of health care costs do we save?

There's a lot more than just "Insurer costs" and "Doctors' BMW payments" in the pie chart. Again, relatively little of it has to do with actually treating injuries and illnesses. And that's not even getting into the massive market distortions associated with forcing the concept of "insurance" into a market where virtually every single customer will eventually need to file multiple claims.

You usually come up with better arguments than this. We all have off days, I guess.

I've lost track of what you're saying. I'm saying that if you zero out the insurance companies, you don't significantly impact total health costs, because the insurers aren't where those costs are; that's the claim I made upthread you found "... novel", but it's not novel, and it's easy to go verify.

How much care costs can be attributed to providers needing and paying for departments to deal with insurance companies? How much care costs can be attributed to providers needing to spend x% of time merely documenting to ensure insurance will not deny claims/services? We can deal with going after provider fraud separately.

> there's no serious theory of change that begins with murdering health care industry people.

To be fair, we’ve never tried it.

I'm honestly not sure if I should attribute this comment to disingenuity, ignorance or just bad faith.

> pushing back on anesthesiology pay on the East Coast.

Not even close. BCBS was just pushing extra charges onto patients.

> insurers working to make surgeries cost less

This is laughably ill-informed, I don't know where to begin. The only thing insurers are doing is increasing the gap between what they collect and what they have to pay out. They do this by denying claims. Making the service cheaper has nothing to do with it.

> where medical staff are paid 2-3x more than they are in other countries

Because medical school is so expensive. Also, doctors spend 3-8 years working for minimum wage (ie medical residency) and the cost of billing and administration is enormous. One study showed a primary care doctor spent $99,000 a year on billing and roughly 25% of ER income spent on the same [1].

The US spends the most per capita on healthcare than any other OECD country, by about 50% (Switzerland is #2) [2] for less coverage, worse outcomes and lower life expectancy.

Medicare spends almost all (~98.5%) of its funds on patient care and ~1.5% on admin, compared to 15-25% on admin for private insurers (including Medicare Advantage).

It amazes me how concifently wrong and ignorant about a subject can be while having such strong opinions.

[1]: https://www.fiercehealthcare.com/finance/study-billing-for-m...

[2]: https://www.oecd-ilibrary.org/sites/7a7afb35-en/1/3/7/2/inde...

Anthem proposed to apply the precise guidelines Medicare uses to pay for anesthesiology, including references to those CMS guidelines. Billing for anesthesiology has been a hot button issue: the search you want is [anesthesia surprise billing]. Anesthesiology is one of the highest-paid specialties in American medicine.

You cannot reasonably support Medicare and claim that Anthem was doing something unconscionable, because Anthem was adopting Medicare's own policies.

Medicare's admin cost ratio is a function of who it covers. Somewhere in the comment history on HN, there's a short writeup I did of how the math works out if you extend Medicare to the whole population; the admin overhead, for obvious reasons, shoots up --- people pay the same amount of money but require far fewer services, reversing the "advantage" Medicare has in the metric currently.

Insurers use the Medicare schedule as a weapon to simply reduce how much providers get paid and/or increase how much patients have to pay out-of-pocket.

The Medicare schedule is generally low because of the negotiating power of the Federal government so when Anthem (or whoever) says something like "we'll pay Medicare rates" or "we'll pay 120% of the Medicare rate" they're really just cutting payments and increasing patient costs. Nothing more.

In the recent BCBS case, all they were doing was saying "it may take 8 hours for the surgery but we're only going to pay you for 3". They haven't made the surgery cheaper to provide. They just wanted to pay out less.

Also, if we're going to simply do everything based on Medicare, why exactly do we even need private insurers? Just expand Medicare to everyone if the schedules are good, right?

You're saying "the Medicare schedule" as if it's an abstraction, but it is literally the payment process used by the largest buyer of medical services in the country. What Medicare pays matters more than what anybody else pays, because most medical services are performed for Medicare patients. So I'll ask directly: how is it unconscionable for Anthem to use those policies, but not for Medicare to use them?

You are exactly right that Anthem is demanding providers charge less for surgeries, not for surgeries to take less time. Providing "less anesthesia" is not a thing. This is entirely about preventing health providers from charging more money to Anthem and, in turn, their customers. That's why Medicare does the same thing.

The fundamental difference between Anthem and Medicare is that when Medicare cuts reimbursement, that cost isn't passed on to patients, but when Anthem does, it is. Medicare's rates are arguably too low, but low Medicare rates are getting a good deal for the country. Low Anthem rates are passing costs onto consumers and profits onto shareholders.

That is not how any of this works. Insurers and health chains are in a continuous process of rate-sheet negotiation, and the result of that negotiation is reflected in your premium costs. Most people's out-of-pocket costs are capped, and even the most routine surgeries (like a tonsillectomy) exceed the out-of-pocket cap (I checked! This is a number people report.)

This is about the trade association for anesthesiologists deputizing angry people on Twitter to go to bat for them overcharging for their services.

Us republicans here don't like them facts and prefer alternative facts

we like to think we are just da best at everything

after all, I sometimes read about people coming to the US for care so it must be better?

maybe so but it's definitely cathartic and that counts for something

I dont think it counts for something good. I think it is giving in to one of the worst possible aspects of humanity. Like people cheering at a lynching.

I suppose though if one of my children grows up to be a CEO of a place like UHC, I'd consider myself to have failed as a parent and would disown them

if they are that successful to make it to a point where they can be hired to be CEO of UHC or Monsanto or other axis of pure evil, perhaps they would choose to take their talents elsewhere

Likely a placebo effect.

> there's no serious theory of change that begins with murdering health care industry people.

You sure about that? Show me one theory of change where the oppressed somehow rise above without violence? Even the groundwork for Ghandi's peaceful protest were laid by a strong anti-colonial military force that led assassinations of British military officers. You think Britain left because Ghandi said some profound things and changed their minds? The official position was that continued occupation of India would be met by violent resistance and they retreated.

There have been many many examples throughout history of oppressed people rising up with violence against their oppressors. The majority of the substantial changes in culture happen this way - things reach a boiling point and it spills out on the streets.

I'm not saying mob justice is an ethical or principled way to instill change. But historically it has been extremely successful.

Yes, I'm sure, in that it's mathematically incapable of solving the problem people have.

Bullshit. Show me the proof. Given that nearly all successful revolutions against oppressive powers have been backed by violence, I'm curious what you come up with.

There is one group, the insurance companies, which have unequivocally stated that they will physically harm other people if it yields marginally higher profits. That's not up for debate, that's the stated business model. It is extra-judicial killing for profit, backed by the state. And when the state abuses their monopoly on power, history shows that people will claw it back as violently as they feel necessary.

The proof is that you'd be going to war over a 5% discount in prices, and it's based on an accounting of where the money in our health system goes. Sorry, the numbers here are easy to find and they are unforgiving.

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