It's going to the administration overhead. If you have to document everything and argue for every medical procedure and deal with 20+ different processes for filing claims then it takes time. And, as a provider, you have to pay someone to spend that time if you want to get paid.
It doesn't help that our healthcare billing systems are so outdated and broken. I once had a doctor visit denied with the reason code that it should charge the other insurance (for people on multiple plans). I was only on one plan, but my wife was on two. The doctor and I went through all the paperwork - my name was right, my birthday was right, my policy number was right and when I got notice of the rejection it had my name on it. Eventually we traced it to an error - not in my insurance company, not in the company that handles claims in this areas for my insurance, but instead in some middle-man company that was responsible for transferring claims between the two. Nevermind that all three companies claimed to be BlueCross BlueShield. This took over a year to resolve.
No it's not. There is absolutely no way to get from $360B of insurer admin and net cost of insurance to $2.5T --- two point five trillion --- in practitioner costs on paperwork overhead. That is not a plausible argument.
> A new study finds that the extra time and labor physician practices spend on interacting with insurance companies and government entities cost U.S. physicians $82,975 each per year, while doctors in Ontario spent $22,205.
> Canadian physicians follow a single set of rules, but U.S. doctors grapple with different sets of regulations, procedures, requirements, formularies and forms mandated by each health insurance plan or payer. The average U.S. doctor spent 3.4 hours per week interacting with health plans; Ontario doctors spent 2.2 hours. The bureaucratic burden falls heavily on U.S. nurses and medical practice staff, who spent 20.6 hours per physician per week on administrative duties; their Canadian counterparts spent only 2.5 hours on paperwork.
All that falls in your $2.5T bucket. And their cleaners, HR, etc. And insurers have had 15 years of innovation since that study.
You haven't done the math here. Multiply the numbers out. This is what I'm talking about. How are you supposed to engage with these topics if you're literally recoiling from 7th grade arithmetic? Congratulations, taken on your own terms, you just found 3.6% worth of savings from practitioner costs.
My local grocery store wouldn't even bother issuing a coupon for that small a discount.
Yes, as I said, if we accept your claim at face value, that every dollar of American practitioner-side insurance overhead --- not the delta from Canada, but every single dollar of it --- is mis-spent, you managed to identify 3.6% of the waste in the system. Congratulations.
I said earlier we'd gone round-and-round on this topic before, and I was a little burned out on it, but I didn't expect you to refute your own argument like this. I'm glad we gave it another run this time! This is a great statistic; I'll be using it elsewhere. Thank you.
Insurance has more than one way to run the costs up; this is but one of them. Weird rebate deals with drug manufacturers. Vertical integration. Buying practices and paying them higher rates.
> I was a little burned out on it
I just did my taxes and am a little burned out by the $49k in healthcare expenses I got to deduct on them.
The reason it's going to providers is because US healthcare is extraordinarily inefficient. Providers spend too much time doing, well, everything. From admin, to medical records, to documentation. Very little of their time goes to actual, direct care and decisions around care. You can talk to a doctor about this if you want, they'll all tell you the same thing.
Even surgeons. Ask a surgeon how much time they spend in the OR. It's less than you think.
> Today, many of those practices have been bought up by large corporations, including hospitals, private-equity firms and even health-insurance companies. It’s a shift that not only has changed how money moves through the health care system, but may also be helping some insurers boost their profits, according to new research published in Health Affairs.
> A study from researchers at Brown University’s Center for Advancing Health Policy through Research and the University of California Berkeley found that UnitedHealthcare, the nation’s largest health insurer, pays doctors who work for its own physician network, Optum, more than it pays independent practices for the same care.
This isn't a response to anything I just said. I really don't understand why people collapse into all this handwaving when people point out the obvious: the money in our system is going to providers, and, in particular, it's going to practitioners.
What difference is that supposed to make? The money is still going into the pockets of practitioners. And: no, the claim you're making here about practitioners fighting insurers: closer to the opposite thing is true.
The idea that the problem with our system is health insurers is just slopulism. We have grave problems with our system! But they start with the providers, where the majority of all the funding in our system goes, not to the scapegoats they've stoop up in our insurers. The distinction is vitally important, because the most popular answer to this problem is to extend Medicare to everybody, and Medicare is just as victimized by this as everything else is!
We pay doctors too much, and we artificially restrict the supply of practitioners. Those doctors routinely overprescribe. Every other problem in the system is marginal.
"The money is still going into the pockets of practitioners."
And by inflating that amount...
> Using newly available federal price transparency data, the researchers found that UnitedHealthcare pays Optum physician practices about 17% more than non-Optum practices in the same region. In markets where UnitedHealthcare holds a large share of the insurance business, that difference was even larger, up to 61%.
their capped-by-law 20% cut of premiums goes up, too. "Oh, those mean old providers we own charge so much! We have to raise premiums again!"
Show me the more recent NHE table where this effect shows up and I'll be ready to have the conversation, but right now this seems like a dodge. Whatever effect you're describing, if it's material, has to have started after the NHE data I just posted, from 2023. I don't remember thinking that the health system in 2022 was good.
Fun thing about the NHE: you can project it as far back as you want. The data is there.
I feel like we've been in this argument before, and I like you just fine as a commenter, but do feel like you're tying yourself into knots to avoid a simple conclusion plainly supported by the data. I didn't post a trend story about what companies are doing or who they're acquiring; I posted the macro NHE table from last year. It simply refutes the argument you're trying to make.
> It literally breaks practice and net cost of insurance out!
But it's not a "Cost of Health Insurance" item. It's an expense at the practicioner level! They have to factor that non-billable time into what they charge for the procedure!
If an insurer manages to double a doctor's administrative costs for billing/appeals/etc., where does it show up in your tables, per your link's PDF of definitions?
You have no evidence for this argument. It's just vibes. The numbers here are stark. It's not like it's close, between providers and insurers. Insurers are almost literally a rounding error.
You asserted "the macro NHE table from last year… simply refutes the argument you're trying to make", but that claim is false. You are welcome to answer the question about where "doc spends two hours on phone arguing with UHC" falls in the expenditure list; it's not insurance, but it's caused by it.
> Insurers are almost literally a rounding error.
Again, the argument is that the raw cost of health insurance does not reflect its externalities imposed on the other items in your list; that insurers drive up hospital and practice costs, as they have to staff up enormous amounts of staff and expensive physician time to deal with the insurer.
You stated this claim upthread, for the record, and tracked down an actual Canada vs. US statistic on this, which turned out to account for roughly 3.6% of total provider inpatient/outpatient expense.
"His" companies seem to do better when he's not around. SpaceX has been doing good things while he was distracted with the Cybertruck, then Twitter, then stealing an election, destroying the government agencies that had the audacity to investigate his companies, and now this lawsuit.
I don't think it makes me more efficient at writing code. Its because the act of coding is like 80% reading existing code, only rarely adding new code. You spend far more time moving around and exploring the code, and in vim the keys to do that are single keypresses, or sequences like `]p`. Every other non-modal editor requires you to hit chords like Ctrl-Shift-F to move around, because the "easy" keys are all taken up by "add this character to the buffer", 100% of the time.
I've been using https://github.com/choplin/code-review.nvim, which looks like a similar UI, but in the NeoVim interface. `<leader>rc` to comment on a line/selection, then `<leader>ry` to yank all comments into the clipboard to be pasted into a chat.
It leaves the comments as markdown files in ./.code-review, so I also have my `/review` agent set to output in the same format, so an LLM can be reviewing the same code I am, I can edit or dismiss the LLM's reviews, then send the whole thing back to the first agent to fix.
Those who earn their living from their labor, and those whose income is derived simply by owning things they (often) didn't create themselves and charge for access.
If any of these people don't work or don't work enough, they undeserving immoral moochers and should be miserable and in pain.
> and those whose income is derived simply by owning things they (often) didn't create themselves and charge for access.
It totally fine if these people never lift a finger in their lives. In fact, they deserve it. NEVER question that. N-E-V-E-R! It's great! Capitalism is great! Capitalism is fair!
Same with Maui Gold pineapples. I can't eat the Dole crap you get everywhere else. The ones at the markets in Maui are a completely different fruit, they're like candy. Whenever I go I eat them until my tongue burns from the citric acid.
This is what happens when you optimize your food supply for profit instead of being edible; varieties are selected for yield, longevity and shipping rather than flavor or nutrients. But for a beautiful moment in time we created a lot of value for shareholders.
> Whenever I go I eat them until my tongue burns from the citric acid.
Been to Maui once, and this was pretty much my exact experience as well. Thought I was the only weird one to do that. I only slowed down though until it got really bad before stopping. Wish I was smarter to stop earlier ::face-palm::
The current iteration of the Supreme Court has made it pretty clear they're going to decide whatever partisan truth they want, and that pesky Bill of Rights will not stand in their way.
Fun story about that: In Ruby 2.x, the version GitHub originally launched with, every object implemented the method `id`, which returned the object id (in 3.x, it was renamed to `object_id`). Every object had this id, ActiveRecord models, strings, floats, integers, booleans, etc. Some objects had fixed object ids, like `true.object_id #=> 20`, `false.object_id #=> 0`, `123.object_id #=> 247 (2n+1)`. The `object_id` for `nil` is `4`.
Yehuda Katz was the first external user of GitHub after the cofounders, so his github user id is `4`.
The way Rails works, if you want to look up a user record, you do it by id:
author = comment.author
user = User.find(author.id)
Now, if there was some bug, and for some reason a comment had no author, `comment.author` would return `nil`, `nil.id` would return `4`, and the UI would show Yehuda as the author in the UI. People would ask, "Who is this Yehuda guy, and why is he commenting on my PRs?"
Just "adjusting for inflation" isn't good enough. Minimum wage was $4/hr. Now its $8. An elementary school custodian could afford a mortgage, a car, support a family of 4 and go on vacation on just that single income. They had healthcare and a pension. You could work over the summer and pay for a year of college at a state school.
Yes, the house now is more energy efficient. The car is safer. But if the price of everything went up 4x-10x, and the median income only went up 2x, AND you have to pay for more things that used to be included, then everything is more unaffordable, inflation be damned.
"An elementary school custodian could afford a mortgage, a car, support a family of 4 and go on vacation on just that single income. " Can I ask what you are basing this off of? I'm fairly skeptical of this claim.
The head custodian at my elementary school (in the 80s) was a friendly guy that loved talking with the kids. He'd talk about his life, ask us if we did anything fun over the summer, and tell us where he went with his wife and kids. The school was in a small town in the rural midwest, not particularly affluent, but not poor either.
The elementary school where my kids went (in a much more wealthy district) doesn't even have a custodian that I'm aware of, just a 3rd-party cleaning service that hires immigrants for as cheap as possible, and I'm sure doesn't offer healthcare or even full-time work. They have too many highly-paid administrators to afford a custodian.
Ok so you're moving the goalposts here. What you said was a custodian (who I'm assuming did a lot more than just clean) and now you've switched to a head custodian and are comparing him to contract workers. So you're comparing two different jobs in two different school districts. Now is it possible that they've eliminated or reduced those positions? Sure, but you haven't actually shown that at all. Like I could easily counter with the fact that the school my wife teaches at still has a head custodian but I don't know what his family situation is and we'd just be trading anecdotes. So do you have any actual evidence for your initial claim? Because the overall stats with wages and prices are the opposite from what you claim.
I'm spending a ton of tokens because it insists on manually correcting code that fails the linter, despite the instructions in the AGENTS.md to run the linter with autocorrect.
And also because the Plan agent generates a huge plan, asks me a couple yes/no questions with an obvious answer, and then regenerates the entire plan again. Then the Build agent gets confused anyway and does something else, and I have to round-trip about 5 times with that full context each time.
reply