[HN Gopher] A petabyte of health insurance prices per month
___________________________________________________________________
A petabyte of health insurance prices per month
Author : ageitgey
Score : 178 points
Date : 2023-07-11 18:36 UTC (4 hours ago)
(HTM) web link (blog.turquoise.health)
(TXT) w3m dump (blog.turquoise.health)
| FireBeyond wrote:
| I used to work for a company that writes claims benefit
| management software. This:
|
| > Notice how every item has a price that requires external
| information to understand:
|
| > Per diem rates are paid for each day a patient is in the
| hospital. We need to know how long the patient will be in the
| hospital to know the total amount. > Rates for Cardiac Studies
| require knowing the price the hospital will bill in the future.
| The rate is essentially "44.8% of another unknown price," which
| isn't terribly helpful to a patient. > Radiology rates are based
| on an external price list that has to be looked up in an entirely
| different database. External rate lists are very common in health
| insurance but are not helpful unless you have access to the
| latest price list and can do the math yourself.
|
| is where they stood out from their competitors, who typically had
| huge, and very wide database tables to capture this, but my ex-
| employer had written a DSL that allowed billing rules to be
| described with lookups and logic.
| paulddraper wrote:
| I'm curious...who was that company?
| redandblack wrote:
| Will LLMs eventually help with this - will be great if it can
| create structured data out of this to learn/classify
| yetanotherloss wrote:
| Why build LLMs when the problem does not need to exist in the
| first place. The rest of the civilized world does not need
| LLMs to solve this because they didn't build this dumpster
| fire in the first place.
| 6510 wrote:
| I always find it amusing what excuses people come/came up with
| when they hate on new ideas or inventions. Usually a few decades
| into the project/revolution the real issues appear. No one would
| have argued against computers back in the day because it will
| cause petabytes worth of important nonsense. It would have
| sounded unbelievable.
| carabiner wrote:
| Gotta wonder how other countries with functional healthcare store
| and calculate pricing. There has to be a better way. This looks
| like denormalizing a huge number of small tables such that the
| resulting list of prices is like n^n growth for any possible
| addition.
| ageitgey wrote:
| In England, the procedure costs for the entire healthcare
| system fit in one Excel sheet:
| https://www.england.nhs.uk/costing-in-the-nhs/national-cost-...
| pc86 wrote:
| That's exactly what it is, because as another comment pointed
| out the legislation currently doesn't allow them to just
| publish a [human,machine]-readable rules engine for calculating
| price, so they must publish this asinine amount of data every
| month in perpetuity until someone who's taken a math class in
| the last 70 years ends up in Congress.
| cool_dude85 wrote:
| This does seem to be machine readable, but inefficient. Given
| the fight the insurers have put up about publishing this, I
| would expect any allowance of "rules engine" to allow them
| not to publish anything, or to just play the same game again.
|
| For instance, my "rules engine" is to look up the price
| contained in my db table (proprietary, of course) and
| multiply by another record in a different table. Or if a
| court forces us to provide both tables, we find that the
| structure is similarly unusable as this one. So best case is
| to get the same garbage.
|
| Basically, I'd rather force them to be as explicit as
| possible, even if it's difficult to sort through, than to
| allow a loophole that might allow them to not publish prices.
| webstrand wrote:
| The rules engine could even be turning complete, even if it
| didn't need access to another data source.
| m0llusk wrote:
| Oddly enough, despite all the problems in Communist Cuba, they
| have been able to keep much of a modern health care system
| going with absolute minimum resources. It appears that
| empowering doctors to make decisions is a big part of that.
| Controversial to be sure, but also interesting if only for the
| extreme scale of contrast.
| Reptur wrote:
| They're using information overload tactic. This approach
| leverages a psychological principle that suggests when people are
| given too many choices or too much information, they can become
| overwhelmed and struggle to make decisions. The point is to
| overwhelm, the consumer, the people trying to fix this system
| etc.
| karaterobot wrote:
| What? No. This isn't user facing. And they are following a
| schema created as a result of regulation. It sounds like the
| schema sucks. It sucks because it implies a lot of redundancy,
| and _allows_ you to remove some of that redundancy, but does
| not _require_ it, resulting in a foreseeable and unfortunate
| amount of redundancy.
| NoMoreNicksLeft wrote:
| A simpler and more rational explanation, is that they're trying
| to overwhelm the adversary.
|
| The insurance company, its claims department. If you can't ever
| compare two medical treatments because they're never similar,
| let along identical, then any price at all might be attached to
| these.
|
| The consumer hands over a laminated card and says "I have
| insurance". No one's overwhelming him. He's not even really a
| party to the transaction. Not until the insurance company
| denies the claim, at least.
| lotsofpulp wrote:
| An even more rational explanation is that the human body is
| one of the most complex machines there is, and we barely have
| an understanding of it. Those who do have some understanding
| of it spend decades learning about it, and so a layperson
| will simply never have the expertise to make informed
| purchasing decisions.
|
| That is why the insurance company (ideally) can serve as an
| informed agent (employing doctors and pharmacists), who
| (ideally) will more often than not know what is and is not
| worth paying for.
| yardie wrote:
| Medical billing coder is one of the most bullshitiest of bullshit
| jobs. Even when I was chatting with a coder a while back and she
| was explaining to me, a programmer, her job. And in the back of
| my mind I'm thinking, "I'm sorry, but why does this job exist?" I
| guess in the government's battle against medical fraud they have
| created a convoluted system that is even easier to defraud.
| Buttons840 wrote:
| Companies are going to grow around this data. An entire
| _industry_ might grow around this data, and it will be an
| industry that I support every time I pay an insanely high
| insurance premium or medical bill.
|
| 15% of our workers are in the medical system [0], and this
| doesn't even include the surrounding insurance industries or
| pharma industries (I think). Someone has to pay all these people,
| and that someone is me when I pay high insurance premiums and
| high medical bills.
|
| I'm picturing a satirical 40s style poster that shows the doctor
| putting a bandaid on Timmy's knee, and then mom doing her
| patriotic duty and writing out a $1000 check. The poster then
| shows that the $1000 supports medical coders who know all the
| codes for duck attacks, and the pharma advertisers who one-up
| even Broadway and Hollywood with their 90-second advertisements,
| and the people who reassemble the poorly organized data this
| article talks about, and--oh yeah, there's a few bucks left for
| the doctor too.
|
| I used to work at a company that does background checks on
| doctors. We'd gather data from all 50 states, all of it in
| different formats, all of it a pain to work with. Hundreds of
| people were involved in this process, all of us ultimately paid
| through high hospital bills (hospitals were our customers). With
| the right regulation, we all could have been replaced with a 50
| line Python script.
|
| Ultimately, if we're going to build a medical system that takes
| 15% to 20% of our workers to run, then we're going to have to pay
| for that. The problem is that "let's make the industry more
| efficient and put a lot of people out of work" is not politically
| popular.
|
| [0]: https://www.census.gov/library/stories/2021/04/who-are-
| our-h...
| Wojtkie wrote:
| [dead]
| elcritch wrote:
| There's a similar issue in academia. Tuition costs have risen
| far faster than inflaction but the number of professors per
| student is roughly similar. Where does all the extra go?
| Administrators and bureaucracy!
| lesuorac wrote:
| I mean based on all the numbers provided it could have also
| go into
|
| - Construction costs of smaller classrooms
|
| - Advanced labs
|
| - Land Taxes
|
| ---
|
| But also if the number of students & teachers has increased
| at a proportional rate then tuition would be expected to
| increase to cover the more administrators required to
| administrate the increased staff.
| secabeen wrote:
| There's two things here. First, payment for the cost of
| education has two major parts: tuition, and state allocations
| to higher ed. When tuition goes up, it can mean that
| education costs have risen, that state allocations have gone
| down, or both. Although there have been some understandable
| increases in the cost of education, the main driver in the
| increase in the nameplate tuition is the decreases in state
| allocations. https://fivethirtyeight.com/features/fancy-
| dorms-arent-the-m...
|
| Second, the nameplate tuition number that looks to have risen
| is not even the amount that most students pay, as most
| students get financial aid. The correct number to judge
| whether tuition has gone up is the Net tuition number. Most
| reports of the net tuition number show that it has gone up
| much much less than the nameplate number, but it's also not
| public in the same way. If we had an anonymized national
| database of net tuition paid by all students receiving any
| amount of a federal financial aid, it would go a long way
| towards improving the quality of the discussion around higher
| education costs.
| FollowingTheDao wrote:
| They are making it impossible to handle the data so everyone
| gives up trying so they can go on screwing people over.
| omnicognate wrote:
| Hanlon's razor maybe applies. I have no way to know if they're
| trying to do what you say, but the article explains what's
| going on and it's not hard to see how a flawed schema and
| implementors going by the letter and not putting any effort
| into minimising the data volumes could result in this without
| any malice. Any individual company is presumably producing a
| fraction of the petabyte total and people are as astonishingly
| lazy with data sizes now as computers are astonishingly capable
| of handling them. I'm routinely seeing multi-gigabyte
| _executables_ these days (don 't get me started).
|
| Also the article says the schema is published in github and CMS
| is responsive to feedback on it, so things will hopefully
| improve.
|
| I thought this was a really good article. I wasn't expecting to
| read all the way through a blog about something that doesn't
| affect me in the slightest but I did.
| ceejayoz wrote:
| /r/MaliciousCompliance, in other words.
| birdman3131 wrote:
| Not the same article but it has come up on here at least one
| other time with a lively discussion. Can't find it off hand
| though.
| jaysinn_420 wrote:
| !maliciouscompliance@lemmy.world for the post-Reddit
| fediverse
| searine wrote:
| Hanlon's razor. Never attribute to malice what can be explained
| by stupidity.
|
| The US healthcare system is a mess, but I don't think it's
| intentionally malicious. It is just a mash of a thousand
| different systems, creating one big stupid system.
| coding123 wrote:
| I don't think the billing system is malicious. But at the end
| of the day, each "provider" is given incentives to bill. They
| get promotions based on this. So the maliciousness is a
| distributed system that does not get codified at all.
|
| It's the exact same thing as cops getting incentives for
| speeding tickets. Then you start getting more speeding
| tickets for 5 over instead of 10 over.
| leetcodesucks wrote:
| [dead]
| micromacrofoot wrote:
| It's absolutely intentionally malicious, despite the
| individual employees not having much say... have you ever
| tried to bounce between calls to get information for an
| insurer from a hospital billing department? they can make
| vogons look efficient
|
| I've spent hours trying to get an estimate for a inpatient
| surgery only to find out afterwards that the surgeon used a
| different billing code than the billing department gave me
|
| then the insurance company won't cover it because it's not
| the billing code they cover, and the hospital won't change
| the billing code
| leetcodesucks wrote:
| [dead]
| FollowingTheDao wrote:
| If it's stupidity, then I would assume they wouldn't be
| making so much freaking money.
| RhodesianHunter wrote:
| A little of column A, a little of column B.
| [deleted]
| bigbillheck wrote:
| I think there's plenty of malice in the system, for example
| https://www.propublica.org/article/cigna-pxdx-medical-
| health...
| searine wrote:
| I agree, but is the design of the system malicious? I don't
| think so. It's just stupid, and exploited by malicious
| people.
| rqtwteye wrote:
| There rarely are systems designed in a malicious way.
| Most malicious systems slowly get shaped actors to their
| advantage. In some cases (insider trading or corruption)
| the government steps in and stops the abuse by laws and
| regulation. In the healthcare system they aren't doing
| this and are letting profit oriented players shape the
| system.
| calibas wrote:
| They made a ridiculously complex and obscure system because
| it was insanely profitable. It's not really stupidity or
| maliciousness that's responsible, but simple greed.
| ryandrake wrote:
| Yea, we need a corollary to Hanlon: Never attribute to
| malice OR stupidity that which can be explained by greed.
| sdthionsdionoi wrote:
| Even a stopped clock is right twice a day. Stupidity can't
| explain why _everything_ is wrong. The American healthcare
| system is so totally broken, and broken in ways which so
| consistently benefit the rich at the expense of everyone
| else, that I can 't see any way it could come about by
| accident.
|
| (Plus we have seen some of the corruption that goes on inside
| insurance companies.)
| burkaman wrote:
| Never attribute to malice that which is _adequately_
| explained by stupidity. In this case stupidity is not
| adequate - obviously insurance companies know how to make
| this data usable, otherwise they couldn 't exist. They have
| just chosen not to make the public format usable.
| chris_va wrote:
| While the pitchfork argument may be appealing, the actual
| article makes a convincing case that it's just combinatorial
| expansion:
|
| > As a result, the Transparency in Coverage rule requires
| insurance companies to do the math for patients and, in most
| cases, publish prices as dollar amounts. That's helpful for
| patients, but it requires that a price be pre-calculated for
| every possible service.
|
| ... So, they could publish the rules engine instead of the
| combinatorial expansion of all possible inputs, but it sounds
| like the regulation did not specify that.
| [deleted]
| ramraj07 wrote:
| I work with petabytes of data. A petabyte of text is an
| insane amount of text. You need a billion X multiplication of
| basic data. That's not just combinatrionics, it's deliberate
| obfuscation.
| abraae wrote:
| 4 tables, each with 1k rows and one of them with a 1K text
| column in it, joined together to give a cartesion product,
| will give you a petabyte of data. So it doesn't sound
| impossible (just absurd).
| grumple wrote:
| That's a very artificially bloated way of compounding the
| data in memory with lots of data duplication. From
| storing the example tables you used, you'd need to store
| 62.5 million times that to get a petabyte of data. It's
| an absurd amount of data.
| samstave wrote:
| I've been a designer for a number of hospitals (tech, and
| physical, some systems) but never in the billing, however I can
| attest that billing codes are complete BS (billing codes are
| basically a number for the procedure/system/resources used such
| that they can say 'Code 10 == $10,000" to simplify it...
|
| Hospitals are usually 'health *groups*' and they work just the
| same as insurance companies - they have actuaries that do all
| the calc to determine what they CAN charge for a procedure, not
| what its summary cost actually is...
|
| When youre in a hospital GROUP you have more negotiating power
| with the insurance companies - so the exact same procedure in
| one group may be significantly different than what another
| group charges you....
|
| HOWEVER - and this is important, and they wont ever tell you
| this - you can "haggle" with hospital billing departments...
| NEVER pay a hospital bill once you receive it.
|
| ALWAYS call and ask for more details about the bill, with a
| line item receipt for every single action, drug, interaction
| 'encounter' and you will generally see your bill reduced
| significantly.
|
| -
|
| As example, I went to the ER with chest pains. waited 2 hours
| for an MD to come see me, he didnt even touch me, take a BP,
| EKG, etc - then 'prescribed' me some motrin (over the counter)
| and then billed me $1,500 for a 4 minute interaction.
|
| I refused to pay this and they tried to drop it to $900 - and I
| told them, that if they can drop it from $1500 to $900 with
| just me protesting, then they needed to pay me for the two
| hours I waited to speak to the MD
|
| They dropped the bill entirely.
|
| Good Samaratin Hospital, Los Gatos CA.
| caseyh wrote:
| The standard is excessively verbose. Instead of being able to
| represent a price of a range of procedure codes (as most of the
| rules engines define it), you have to list every single code
| individually when often the price is the same. How that
| standard was set is probably an interesting questions.
| talldatethrow wrote:
| While there are huge problems, I think the majority of the
| problem is people expect their health insurance plan to be like
| a prepaid maintenance plan.
|
| If you crash your car today without insurance, you understand
| it won't be covered by getting insurance tomorrow.
|
| Why people think they can finally get healthy "insurance" at 45
| from company xyz, knowing they need this pill or that pill, and
| expect the new insurance company to pay for it I will never
| understand.
| lotsofpulp wrote:
| In the US, federal law requires the insurance company to
| offer any applicant insurance coverage and pay for necessary
| healthcare (after accounting for deductible/out of pocket
| maximums).
|
| https://www.healthcare.gov/how-plans-set-your-premiums
|
| >Five factors can affect a plan's monthly premium: location,
| age, tobacco use, plan category, and whether the plan covers
| dependents.
|
| > FYI Your health, medical history, or gender can't affect
| your premium
|
| https://www.healthcare.gov/appeal-insurance-company-
| decision...
| talldatethrow wrote:
| I understand the law says so. My point is this makes no
| sense as an "insurance". It's basically a service plan now.
| lotsofpulp wrote:
| Yes, health insurance as expected by people has never
| made sense as "insurance".
|
| Once an event goes from unlikely to likely, buying
| insurance for it turns into simply prepaying an amortized
| amount for future expenses. Not dissimilar to paying
| taxes for road maintenance.
| flangola7 wrote:
| Why wouldn't they expect it? If they need that
| medicine/treatment, they need it. If I don't have car
| insurance my organs won't shut down and I won't die. If I
| don't have medicine, they do and I will.
| talldatethrow wrote:
| If you need medicine to live, you should pay for it. If you
| can't, the government should step in.
|
| However, making me pay $400 a month for insurance in case I
| need stitches next month because I have to subsidize your
| medicine is annoying.
|
| I want insurance in case something I don't know about goes
| wrong. You want something you know you need.
| flangola7 wrote:
| Right, but the government doesn't step in. I've voted for
| universal healthcare sorry supporting candidates at every
| local, state, and federal election.
|
| I'm sorry that my illness is "annoying" you, but your
| anger is misplaced. Not that long ago I used to only have
| insurance for stitches too.
| talldatethrow wrote:
| Your illness isn't annoying me. The fact that I need to
| pay for it via my health insurance premiums is.
|
| If we want to pay for it via government mandate, fine.
| Raise taxes. That way during my lower earning years I
| dont need to artificially pay for it through health
| "insurance" that isn't really insurance.
| peatmoss wrote:
| It also feels like these codes are also closer to stated
| preference data than revealed preference data. "Given this
| permutation of factors, we'd choose to bill X, but insurance
| companies dictated we actually paid Y."
|
| Would be neat to see both kinds of rates with billing codes and
| actual billed procedures. Guessing there aren't petabytes worth
| of actual procedures either.
| hospitalJail wrote:
| The medical cartels need to be destroyed.
|
| They are mathematically the most corrupt industry according to
| open secrets all time lobbying data.
|
| Physicians are the richest profession in the US, and limit their
| supply by weaponizing the ACGME/AMA.
|
| Hospitals/clinics make so much money. We own one, and while it
| was slow to start, the profits are insane. Marketing is the
| hardest thing, once a patient comes in the door (and they don't
| have medicaid) its pure profit. Don't let anyone in healthcare
| let you think margins are slim.
|
| Pharma... we all know pharma.. (And pharmacists in 2023? Heck
| ML/AI will always be better than trusting that a pharmacist is on
| their game 100% of the time)
|
| Insurance, I have no idea how they waste so much money and have
| slim margins. Anyway they are weirdly allies most of the time
| because they will adjust a $400 bill down to $125. But they also
| suck with how expensive premiums are... again. what the heck is
| going on with their slim margins? Maybe its their ultra fancy
| buildings.
| izzydata wrote:
| Aren't there laws that require insurance companies and utility
| companies to have specific margins? They could in theory just
| print infinite money so they need to be reigned in by
| governments.
| paulddraper wrote:
| Correct.
|
| Insurance companies must pay 80% of all premiums directly to
| reimbursement. The remaining 20% is for administration,
| marketing, and profit.
|
| But that's a control for premium prices...it doesn't really
| say anything about the costs that doctors charge.
| thedougd wrote:
| Yes.
|
| https://www.healthcare.gov/health-care-law-
| protections/rate-....
| jmole wrote:
| So the only way to grow profits is by increasing the base
| cost of service.
| lotsofpulp wrote:
| An insurance company can also increase the number of
| customers.
| amluto wrote:
| And this is a _bad law_.
|
| What do you think happens when a company has limited
| margins? Hint: almost all companies try to make a profit
| (which is fine). If the margins are unrestricted, the
| company can cut costs to increase profit, which is a good
| thing. If the margins are limited, the company must _raise
| revenue_ to increase profit. For an insurance company (or a
| utility, and California has exactly the same broken rule
| for private utilities), this means raising rates or
| premiums.
|
| It gets worse. If an insurer raises rates, they are
| required to spend 80% of that money! They are required to
| be inefficient! If the insurer reduces their outflows by 5%
| by doing a good job, they lose 5% of their profits by law.
| So they are basically required to do a bad job.
| hospitalJail wrote:
| >they are required to spend 80% of that money
|
| I know someone that worked for BCBS and they had the
| nicest parking garage and a park on top of the building.
| Always renovations being done. I believe they even bought
| buildings nearby in the dense part of the city. I also
| think this person talked about getting a bonus.
|
| They had some high tech security along with low tech
| security. It was pretty impressive at the time. 24/7
| security, got to use their parking garage to for some
| sports game on a sunday.
| lotsofpulp wrote:
| Or a competing insurer takes their customers by offering
| lower premiums. There is a reason the health insurance
| business earns anemic profit margins, even though they
| can legally earn more.
| efsavage wrote:
| I don't think it's a _bad law_* as much as it's an
| _incomplete law_. I don't know what the complete version
| looks like, but it would include both customer cost
| controls and reward innovation-based efficiency gains.
| Alternatively, some places have taken the approach that
| these are mutually exclusive and just generally removed
| profit from the picture entirely by socializing it.
|
| * Health care costs were growing out of control before
| these laws, which seem to have slowed that trend short-
| term but not long-term as the industry pivoted.
| amluto wrote:
| IMO the most effective consumer cost control is
| competition. An actual, non-corrupt, free market where
| customers are not locked in and there are more than just
| a handful of providers generally results in low prices.
|
| We do not have this in healthcare. Providers form cartels
| - at least in Northern California, this is so bad that
| the state AG is investigating (not very effectually) [0].
| Customers generally can't even tell what a provider
| charges, so there is no price competition. There aren't
| many insurers, and they compete on so many
| incomprehensible dimensions that customers can't usefully
| choose. (And the most useful thing customers can look at
| is the network, but see the above issue with provider
| cartels.) Pharmacy benefits are highly corrupt and
| incomprehensible.
|
| [0] We have Sutter Health, UCSF, Stanford, and Kaiser.
| There is very little in the way of independent providers
| left. Sutter Health in particular has aggressively merged
| with any available competition.
| izzydata wrote:
| Wouldn't a free market eventually lead to all these
| insurance companies combining into 1-2 even more mega
| insurance companies until there is no competition again?
| At least if all their profits are capped there is no
| reason to merge.
| ochoseis wrote:
| The ACA caps insurer profitability at 20% by requiring 80% of
| premiums to go towards healthcare costs. Administrative /
| operational / marketing costs and profit come out of the
| remaining 20%. So, if you're an insurer who wants to increase
| nominal profits, then you're ok with spiraling healthcare
| costs.
|
| https://www.healthcare.gov/health-care-law-
| protections/rate-...
| [deleted]
| AnthonyMouse wrote:
| > So, if you're an insurer who wants to increase nominal
| profits, then you're ok with spiraling healthcare costs.
|
| Not just okay, but actively incentivized to cause it,
| because then you get 20% of a bigger number.
|
| Laws like that are some of the most expensive of the
| perverse incentives created by naive idealists (or cynical
| opportunists, since the lobbyists for the medical providers
| know _exactly_ what that would do).
| lotsofpulp wrote:
| In reality, there is sufficient competition such that the
| 7 largest publicly listed health insurance companies have
| 4% or less profit margins, and one has 6%.
|
| I always find it funny when people on this forum act like
| a certain business is so powerful when it can only earn
| low single digit profit margins, yet tech company
| employees work for companies so powerful they can earn
| 20%+ and 30%+ profit margins for years and years.
|
| https://www.macrotrends.net/stocks/charts/UNH/unitedhealt
| h-g...
|
| https://www.macrotrends.net/stocks/charts/ELV/elevance-
| healt...
|
| https://www.macrotrends.net/stocks/charts/CVS/cvs-
| health/pro...
|
| https://www.macrotrends.net/stocks/charts/CI/cigna-
| group/net...
|
| https://www.macrotrends.net/stocks/charts/HUM/humana/prof
| it-...
|
| https://www.macrotrends.net/stocks/charts/CNC/centene/pro
| fit...
|
| https://www.macrotrends.net/stocks/charts/MOH/molina-
| healthc...
| AnthonyMouse wrote:
| That's their profit margin, not including the
| administrative overhead that counts against the 20%.
| lotsofpulp wrote:
| I do not think health insurance company shareholders are
| interested in paying employees extra for no reason and
| earning less profit for themselves.
| AnthonyMouse wrote:
| Health insurance company executives are though, aren't
| they? Their compensation is the "administrative
| overhead."
|
| And a lot of the administrative overhead is proportional
| to expenses. Commissions are commonly a fixed percentage.
| How much it's worthwhile to spend on fraud prevention is
| in proportion to the size and amount of claims. So when
| premiums and claims costs go up, actual administrative
| costs go up, but shareholders and executives still prefer
| that to making less profit and compensation once you take
| lowering claims costs off the table as a way to make more
| money.
| [deleted]
| lotsofpulp wrote:
| >Health insurance company executives are though, aren't
| they? Their compensation is the "administrative
| overhead."
|
| Yes, and considering they health insurance company
| executives are not all the richest people in the US,
| there must exist some pressure to contain their
| compensation.
|
| >once you take lowering claims costs off the table as a
| way to make more money.
|
| This is a pretty big assumption. Surely,
| UHC/Elevance/CVS/Cigna/Humana risk losing clients if they
| let their costs go up compared to competitors, and hence
| their premiums go up, and then a competitor offers their
| customers lower premiums.
| AnthonyMouse wrote:
| > Yes, and considering they health insurance company
| executives are not all the richest people in the US,
| there must exist some pressure to contain their
| compensation.
|
| Sure there is. But they're also not poor, so there must
| be some pressure to keep shareholders from paying them
| minimum wage.
|
| And if they make the shareholders more money, the
| shareholders will be willing to pay them more. If the way
| they do that is by making the same margin on a higher
| cost base, that also _allows_ the shareholders to pay
| them more. So the incentives all line up to have higher
| medical costs.
|
| > Surely, UHC/Elevance/CVS/Cigna/Humana risk losing
| clients if they let their costs go up, and hence their
| premiums go up, and then a competitor offers their
| customers lower premiums.
|
| But their competitors have the same incentives.
|
| Suppose you could lower your costs. One thing you could
| do is keep charging the same amount of money and just
| make more money, but now that's prohibited. So already we
| have a disincentive to lower costs right there. Maybe we
| don't care about this one, but this one is often
| _combined_ with the second one, and the incentive to
| achieve the cost reduction is what enables them to do the
| one we actually like.
|
| Which is to lower prices to try to get more customers. So
| let's say they lower their premiums by 20% and that gets
| them 10% more customers. If their absolute profit per
| customer stays the same, now they're making 10% more
| money -- great. But now their absolute profit per
| customer isn't allowed to stay the same. It has to go
| down by the 20% their costs went down. Meanwhile the
| lower premiums only got them 10% more customers, so
| they're losing money on net. Why would they do that?
| gruez wrote:
| There are actual figures that don't include admin
| overhead and are only claims paid out vs premiums
| collected. It's called medical loss ratio, and just from
| eyeballing the charts it looks like it's around 85% for
| insurance companies as a whole.
|
| https://www.oliverwyman.com/our-
| expertise/insights/2023/mar/...
|
| https://www.oliverwyman.com/our-
| expertise/insights/2022/mar/...
| AnthonyMouse wrote:
| That's basically what you'd expect to see if they're
| using the 80% as a target. They're not going to hit it
| exactly and it's politically disadvantageous to come in
| on the wrong side of the line, or for that matter to come
| in exactly _on_ the line.
|
| Much more advantageous to raise premiums and therefore
| profits by 400% and then be able to say that they're at
| 15% vs. the permitted 20%, even though the 15% would be
| 60% if they'd kept claims from going up.
| jtbayly wrote:
| You haven't done anything but prove the GP's point.
|
| Their margins are necessarily low, so they _should_ want
| total medical costs to increase in order for their gross
| profit to increase. And in fact, just checking one of
| them from your links, it has:
|
| https://www.macrotrends.net/stocks/charts/HUM/humana/gros
| s-m...
| ochoseis wrote:
| There is certainly nuance but UHC's net income has grown
| from under $4B in 2010 to over $20B today.
|
| https://www.macrotrends.net/stocks/charts/UNH/unitedhealt
| h-g...
| lotsofpulp wrote:
| Nominal profits are more work to analyze since you have
| to figure out if UHC is selling to 5x as many customers
| in 2020 as they were in 2010, and then also adjust for
| inflation and a bunch of other stuff. It is simpler to
| just look at profit margin.
| lotsofpulp wrote:
| I agree with AnthonyMouse that a business might be
| incentivized, but only if the business has so much market
| share that they can singlehandedly drive those prices up.
| Or if there is collusion between all the businesses.
|
| But the fact that there are so many publicly listed
| companies, and they have such similarly low profit
| margins, indicates they have very little pricing power.
| DoreenMichele wrote:
| This write up reminds me of the origin story of GIS. Canada wrote
| some law or other and someone invented GIS to be able to actually
| comply with it.
|
| I wish them well. Health care in the US has problems, opaque
| pricing being only one of them.
| kadoban wrote:
| How much of this is just to bury everyone in useless data,
| similar to how in discovery for lawsuits, one tactic is to just
| send hundreds of boxes of paper in the hopes that nobody will
| find the actually bad stuff?
| jimnotgym wrote:
| These kind of tales make me very happy to live in the UK with the
| NHS.
|
| Not perfect...but surely better than this?
| yardie wrote:
| I've been under the care of both. As an American I can say our
| system isn't that bad. You see the trick is to always be
| healthy, don't ever get sick.
|
| /s
| tiffanyg wrote:
| Because our (US) system is at Monty Python levels of absurdity.
|
| We waste more money with this "system" than most other countries
| spend as a total, and with worse outcomes on average [1].
|
| Fundamentally, there are two factors, IMO, that have been
| _conclusively_ proven (repeatedly, and for decades - much more
| strongly, recently) to be incompatible with delivering quality
| healthcare with some level of efficiency:
|
| 1) For-profit entities (particularly, publicly-traded / with
| "fiduciary responsibility" to shareholders)
|
| 2) Administrative burden / bureaucracy (partly stemming from all
| of the competing private entities, partly stemming from
| essentially impossible efforts to effectively regulate these
| entities and the created "market")
|
| The manner in which the US system evolved, tying insurance to
| employment through basically existing tax policies, and the move
| by companies to take advantage of this to attract workers (IIRC),
| created a massive landscape of entrenched interests that works
| exactly like such ecosystems work. It is a "teergrube" - an
| absolute tarpit - where any attempt to fix problems ultimately
| fails.
|
| The administrative situation is out of control, which means fraud
| (particularly with the turn towards "digital crime" of everyone
| from traditional organized crime networks to high schoolers) and
| waste are impossible to effectively control, adding to an already
| absurd situation where ever-increasing money is spent on
| marketing, lobbying, administrators / clerks, etc. Meanwhile, we
| desperately need more doctors, nurses, etc. AND, these
| professionals are now increasingly being politicized by
| "exploiters". A great many healthcare professionals are quitting,
| and those remaining are often trying to move away from areas that
| often MOST need their services!
|
| It's amazing to watch (from the inside, so far) a country that
| built such "soft-power" might ... such a dominant "marketed /
| exported 'culture'", have those same tools (used, in any
| scenario, intentionally or not) turn against itself (/ be turned
| against it) - sowing the seeds of collapse in all sorts of
| systems, top-to-bottom.
|
| There isn't a face or palm big enough for the facepalm this BS
| deserves.
|
| [1] https://jamanetwork.com/journals/jama/article-
| abstract/27526... - only providing one of a parade of articles
| examining the issue in the past decade, especially
| BaseballPhysics wrote:
| > We waste more money with this "system" than most other
| countries spend as a total, and with worse outcomes on average
| [1]
|
| Oh sure, if you don't measure what is obviously the most
| important outcome: _freedom_
| notsound wrote:
| I value the freedom to not die because medical care is too
| expensive over the freedom to profit off of the sick.
| mtgx wrote:
| [dead]
| redandblack wrote:
| How come medicare "system" become the defacto standard
| hospitalJail wrote:
| We own a clinic and medicare pays decent enough.
|
| Medicaid isnt enough to run a business. Its like break even
| if you are super efficient.
|
| Private insurance is sooo cash money. If someone with private
| insurance wants us to get access to a pool for therapy, you
| got it.
|
| All 3 are good for us owners.
|
| None of it is good if you pay taxes.
| zo1 wrote:
| It's funny how people casually throw out how something has "
| _conclusively_ " been proven and yet it's a hot debated
| contentious issue that 50% of people don't agree with.
|
| Well gee, zo1, if it's been " _conclusively_ " proven then it
| should be trivial to convince them to change their mind, right?
| Perhaps it hasn't been as "conclusively" proven as we've been
| led to believe.
| cycomanic wrote:
| It might be 50% in the US (although studies show that even in
| the US most (>60 % IIRC) people favor some form of public
| healthcare if asked in non-polarizing terms), but if you look
| at worldwide statistics countries that have publically funded
| healthcare have typically better outcomes at lower costs,
| which might not be "proven" in the strictest sense, but is
| pretty strong evidence.
| 0cf8612b2e1e wrote:
| The bar for conclusively proven relies upon the public to
| agree? Have you met the public?
| coding123 wrote:
| Lol
|
| Cardiac Services ---- 44.8% of billed rate
|
| This screams pads and buffers. As in, the administrator adds
| random line-items to things as long as the name of the service is
| "similar enough" so that they can justify whatever amount they
| want in the end.
|
| It reminds me of the auto industry. I've been replacing
| transmission selonoids, serpentine belts, brakes, fluids, etc...
| last 3 years ( I bought a dodge ram 3500 and if you don't do
| these things yourself you end up owing the cost of the truck 3
| times over during its lifetime).
|
| And I have to say, when I replace something it costs me 45
| minutes + part cost. The repair shop instead lists it as
| "Transmission Flush Service" and charges $1500 when in reality
| it's running the engine for a minute with the pan off, then
| refilling it with about $200 in new transmission fluid.
|
| Again, the repair shop is banking on no one wanting to fix their
| car. I can say the same thing about healthcare and specific
| supplements instead of getting superfluous EKGs and other "med
| junk science" or worse actually dangerous drugs that the doctor
| is getting paid to prescribe to you. However even I would get a
| cast put on by a doctor, just as I would have my break calipers
| replaced and my tires rotated simply because that service is much
| more highly competitive, and regular. I would also, of course opt
| for a heart transplant just as I would buy a new cummins engine
| if mine went out. (The joke about ram is that the engine is the
| only thing that will hold up, while the rest of the truck falls
| apart all around it 4 times over)
| crooked-v wrote:
| Insurers paying a negotiated X% of the original bill is a
| common feature of the bizarre US health care market. This has
| all the knock-on effects you would expect, like the original
| bill being then massively inflated so that the healthcare
| provider doesn't go out of business when they're only paid
| 44.8% of it.
| [deleted]
| Sevii wrote:
| There is so much data because of insurance. Insurers are in the
| business of declining claims. They have discovered that the best
| way to decline claims is to create byzantine rules while
| offloading all the work to comply with those rules to healthcare
| providers. The only way to fix it at this point is to nationalize
| the system or to exclude all routine care from the insurance
| system. Something like a legal ban on deductibles smaller than
| 20k/year would work.
| lotsofpulp wrote:
| Per federal law (ACA), health insurers in the US are required
| to spend 80% to 85% of revenues on healthcare expenses. Their
| profit margins are 2% to 6%. Therefore, the higher the revenue,
| the higher the profit.
|
| Where is the incentive to deny legitimate claims?
| paulddraper wrote:
| > Where is the incentive to deny legitimate claims?
|
| Because they want to be competitive and gain customers.
|
| Which would you sign up for? Insurance that costs $800/month
| or $1200/month?
| yardie wrote:
| Competitive? In every job I've had it was basically the
| same 3-4 HMOs: Aetna, Bluecross, Cigna, and United
| Healthcare. If you are getting employer provided
| healthplans, as most Americans are, those are your options,
| 4. With so few options you aren't choosing the most
| competitive, you're choosing the lease worst.
| lotsofpulp wrote:
| That is because the messed up pre-tax benefit the US
| gives to big businesses so they have (another) advantage
| over small businesses, so you are buying from whoever
| your employer chooses to let you buy from.
|
| Ideally, everyone in the US would have to buy health
| insurance from healthcare.gov, and can choose whoever
| they want with zero input from their employer.
| paulddraper wrote:
| Humana, Kaiser, Oscar.
|
| But yes, there is an intense economy-of-scale that
| produces relatively few insurance companies.
|
| (Maybe eventually only one.)
| ADuckOnQuack wrote:
| The incentive is probably to get their profit margin up to
| the maximum 15-20% https://www.propublica.org/article/cigna-
| pxdx-medical-health...
| [deleted]
| lotsofpulp wrote:
| For sure, and that is where the government should be
| handing out heavy penalties. There supposedly is an appeals
| process, but obviously not enough auditing is being done:
|
| https://www.healthcare.gov/appeal-insurance-company-
| decision...
|
| Although, even with those fraudulent denials, Cigna's
| profit margins are suffering:
|
| https://www.macrotrends.net/stocks/charts/CI/cigna-
| group/net...
|
| Wonder if they went into too much debt to buy Express
| Scripts.
| banannaise wrote:
| Is that real profit or profit after a bunch of accounting
| sleight of hand? Are they cutting their "profit" by taking
| heavy debt burdens via leveraged buyouts or other schemes,
| pulling way more than 20% off the top for their shareholders
| and then making it look like much less?
| lotsofpulp wrote:
| I trust the financial figures filed with 10-K reports and
| the US SEC enough to not worry about that. If one does not
| trust those figures (for multiple different companies
| employing tens of thousands of people each), then further
| conversation cannot be had.
| thomascgalvin wrote:
| There are separate charge codes for _everything_ , and all of
| those codes need to be reflected in the pricing data.
|
| There's a price to slap on a bandaid.
|
| There's a price to give someone a Tylenol.
|
| Hell, W61.61XA is the medical code for "Bitten by duck, initial
| encounter." Presumably, this means there's also a code for
| "Bitten by duck, again."
|
| Medical billing is _broken_ , and it's no surprise that the
| amount of data is overwhelming.
| ivalm wrote:
| A friend of mine started a substack of all the kind of broken
| ICD10 codes, as recited by chatgpt:
| https://icdstories.substack.com/
| iambateman wrote:
| "Bitten by a duck, initial encounter" needs to be Bon Iver's
| next single.
| bradgessler wrote:
| Here's the full list of codes for "Bitten by ____, _____
| encounter"
|
| https://www.icd10data.com/ICD10CM/Codes/V00-Y99/W50-W64/W61-
|
| The hierarchy looks like this:
|
| W61.6 Contact with duck
|
| = W61.61 Bitten by duck
|
| == W61.61XA ...... initial encounter
|
| == W61.61XD ...... subsequent encounter
|
| == W61.61XS ...... sequela
|
| = W61.62 Struck by duck
|
| == W61.62XA ...... initial encounter
|
| == W61.62XD ...... subsequent encounter
|
| == W61.62XS ...... sequela
|
| = W61.69 Other contact with duck
|
| == W61.69XA ...... initial encounter
|
| == W61.69XD ...... subsequent encounter
|
| == W61.69XS ...... sequela
|
| There's codings like this for parrots, macaws, chickens,
| turkey, etc.
|
| Hell there's an entire section for alligators and crocodiles at
| https://www.icd10data.com/ICD10CM/Codes/V00-Y99/W50-W64/W58-
| that includes crushing, bites, etc.
| [deleted]
| kderbyma wrote:
| Beagle Boys health records probably have a lot of W61.6... on
| their files.
| guidoism wrote:
| Ducktales?
| tanseydavid wrote:
| >> There's codings like this for parrots, macaws, chickens,
| turkey, etc.
|
| Yeah, but how much do they cost? </sarc>
| flangola7 wrote:
| Clarifying, encounter means a visit with a provider.
| pixelatedindex wrote:
| Thankfully, W61 is a non-billable code family... hope it
| stays that way! I do wonder what all the billable code
| families are, maybe I should find out.
| coding123 wrote:
| I wonder if bitten by duck is more expensive that bitten by
| chicken.
| btown wrote:
| Not even ironically, this all smells of insurers wanting
| sufficient data to raise rates on different types of
| farmers and breeders. It might be scandalous if they didn't
| collect the data and then were biased against, say, chicken
| farmers. But if they do collect the data, they can say they
| analyzed it, whether or not they did, to support any kind
| of tactic they desired.
| lotsofpulp wrote:
| You are smelling something that is not there because, in
| the US, health insurers are only allowed a few factors to
| determine someone's premium.
|
| https://www.healthcare.gov/how-plans-set-your-premiums
|
| > Five factors can affect a plan's monthly premium:
| location, age, tobacco use, plan category, and whether
| the plan covers dependents.
| chimeracoder wrote:
| > I wonder if bitten by duck is more expensive that bitten
| by chicken.
|
| They're diagnosis codes, so they're mostly irrelevant for
| determining cost. You don't get charged for "having the
| flu" - you get charged for the various services or
| treatments you received in the course of your illness.
|
| Diagnosis codes do factor into claims reimbursement
| _indirectly_. For example, some services can be done either
| as treatment or for preventive purposes, and insurance is
| legally required[0] to cover the latter at no cost to the
| patient, whereas insurers can require that the patient pay
| for the former. But that 's pretty indirect - by and large,
| the payment agreements between insurers and in-network
| providers apply to services rendered, which doesn't really
| factor in diagnoses codes (assuming that the service was
| appropriate for the diagnosis in the first place). That's
| assuming fee-for-service: capitation is a whole other
| model, although in that case it's still typically
| determined independent of the diagnosis, because the whole
| point of capitation is to minimize care delivered.
|
| But getting bitten by a duck vs. a chicken is unlikely to
| cause any difference in the price you pay, unless:
|
| (a) the injuries from the duck bite were significantly
| different from the injuries from a chicken bite, or
|
| (b) one was considered an occupational exposure and the
| other wasn't (in which case worker's compensation would be
| billed for it).
|
| [0] well, until March of this year, when a judge in Texas
| overturned that clause of the ACA
| chimeracoder wrote:
| Those are ICD codes, which are not the same as billing codes.
| ICD represent _diagnoses_ , not services rendered.
|
| ICD codes also are somewhat procedural in their generation -
| that is, there's a whole grammar to how they're formed. For
| example, you'll have something like "contact with", then a
| whole number of different animals, and then each of those
| will have three different varieties (initial encounter,
| subsequent encounter, sequela). So it does end up with very
| funny lists, like the one you posted, but:
|
| (a) most of those codes are never used, and
|
| (b) just because it's _assigned_ just means that it 's a
| "grammatically valid" combination, not that it has any
| particular clinical relevance.
|
| The goal is to assign granular and hierarchical codes at the
| outset, to allow for more robust analysis later, at least in
| theory.
|
| But again, all of that is irrelevant to billing, because
| while ICD codes are typically submitted along with the
| billing info (along with a whole other slew of data), ICD
| codes are not the actual code that's billed - there's a whole
| separate list of codes used for billing.
| marcus0x62 wrote:
| That's really interesting, because I had a customer that
| did nothing but provide medical billing services, and about
| 15 years ago when the industry was moving from ICD-9 to
| ICD-10, that customer seemed _really focused_ on their
| billing coders learning ICD-10.
| chimeracoder wrote:
| > That's really interesting, because I had a customer
| that did nothing but provide medical billing services,
| and about 15 years ago when the industry was moving from
| ICD-9 to ICD-10, that customer seemed really focused on
| their billing coders learning ICD-10.
|
| I mean, sure? You can't bill for a service without a
| diagnosis code that justifies the service. Anyone who
| does medical billing is going to need to be able to
| format that data. But ICD codes are not the codes that
| insurers are billed for - billing codes are completely
| separate and not even determined by the same party.
| baishtar wrote:
| That's to ensure that the service provided (procedure
| code) matches the diagnosis.
|
| For example, the procedure (HCPCS) code "71045"
| corresponds with the procedure "RADIOLOGIC EXAMINATION,
| CHEST; SINGLE VIEW" for billing purposes.
|
| If you were to match that up with the diagnosis code
| (ICD10) S80.211 for "Abrasion, right knee" there would be
| a mismatch between the diagnosis and the procedure. This
| happens all the time due to human error and often results
| in insurance denials, which sadly take a long time to fix
| since now you have to get MORE HUMANS involved.
| maweaver wrote:
| But why? I could understand from a treatment perspective the
| type of animal mattering (but even then initial vs subsequent
| encounters?). From a billing perspective, wouldn't it make
| sense to have animal bite exam fee, with possible additional
| charges for bandaging, stitches, rabies shot, etc based on
| doctor's discretion?
| tsbischof wrote:
| It partly arises as a mechanism to pay per case, not just
| per visit. For example, if we put all payment for a breast
| cancer treatment into the first visit, there is now an
| incentive to either complete the treatment (ideal) or keep
| the patient from coming back (less ideal). You can use
| these follow-up codes to measure rates of return visits,
| which can be related to quality of care metrics.
| sandworm101 wrote:
| >> I could understand from a treatment perspective the type
| of animal mattering
|
| Rabies, which is not just animals but also predators
| (snakes) that eat animals with rabies. There is even a
| disease called "seal finger" that is linked to seal bites.
| And bats, all sorts of nasty stuff can come from bats.
| paulmd wrote:
| because CDC wanted to collect epidemiological data on _how_
| those bites were happening, instead of having single
| generic "animal bite" code. If there is a sudden rise in
| duck bites in a future decade, we can start asking about
| whether there's a reason behind that, or something we
| should be doing to control duck populations, or something.
| That's what CDC is there to do.
|
| It's extraordinarily difficult to capture this information
| after the encounter... the patient is gone, the provider is
| working from notes/memory, and now it's this additional
| specific burden. How are you supposed to run an
| epidemiological study on the prevalence of duck bites if
| everyone involved has vanished into the ether? If you're
| going to capture it, it has to be rolled into the diagnosis
| codes and captured during the encounter. Also, you really
| want to capture the contemporaneous narrative including any
| misdiagnoses/etc - the CDC wants to know how much that is
| happening too!
|
| really those low-level codes are kinda just there, they're
| not really used in practice, and most billing systems would
| care about the higher levels of the hierarchy anyway. The
| part insurance cares about is "cleaning and stitches after
| small wild animal bite", not the levels of the coding
| scheme that indicate that it's a duck bite.
|
| (but you can see how it is potentially useful to shake some
| of these details out - is it a large animal, or a small
| one? a pet or a wild animal? a wild bear bite and a pet
| duck bite are two very different scenarios for the
| provider+insurer!)
|
| It's also really more about things like "gunshot wound from
| stranger" vs "gunshot wound from partner" vs "gunshot wound
| from LEO" where there is obvious value in capturing what is
| going on. Jokes aside, nobody is _super_ concerned about
| duck bites, it 's just a funny example of how detailed the
| coding system _can_ be (not _must_ be... at least yet).
|
| The real travesty is the idea that the same action using
| the same materials in the same facility can be billed 2
| different ways based on two different ICD codes, not that
| ICD codes include the diagnosis data. It shouldn't matter
| if it's a duck or a cat, it's a superficial clean-and-
| bandage, that's what procedure coding (CPT) is supposed to
| capture. If there's major variations in how you perform a
| procedure based on how the patient presents, such that cost
| is substantially impacted... that is a deficiency in CPT
| and needs to be fixed independently, not forcing everyone
| to track CPT+ICD for eternity.
|
| ~~CPT itself incorporates a huge amount of nuance and sub-
| coding for this exact reason.~~ Simple example but we'd
| spit out CPT codes like "MRI with contrast-enhancer" vs
| "without", "MRI 3-tesla" vs "1.5T" vs "Open", "CT 64-slice"
| vs "40-slice", etc. If you're not capturing some aspect of
| the procedure you need to take it up with the CPT people,
| not make it everyone else's problem.
|
| edit: superfun memory this just triggered, in fact this
| imprecision in CPT coding actually does lead to different
| things having the same CPT code and operators have to
| select from a picker of these possibilities that are
| specific to their organization's coding/billing systems.
| Forgot about that, awesome!
|
| Medical data systems are the absolute worst
| 88913527 wrote:
| Well, it employs a lot of people to have this complex
| billing. And whoever argued the need for it got to do some
| major empire building, maybe scored a promotion.
| brendanyounger wrote:
| Medical billing is a dreary business. Check out
| https://www.reddit.com/r/CodingAndBilling/. It's not
| clear that anyone is _trying_ to build an empire out of
| this. More likely, they're trying to build a bigger trash
| heap to climb on top of.
| nradov wrote:
| No one got a promotion out of it. The USA adopted the WHO
| ICD code system for diagnoses on billing claims because
| it was good enough, and much easier than defining a whole
| new code system. Some of the codes are never used, but so
| what.
| Ylpertnodi wrote:
| [flagged]
| mensetmanusman wrote:
| Bitten by a communist just yesterday. I wonder how it is
| coded.
| squeaky-clean wrote:
| Looks like it's W50.3XXA if it was accidental. Or
| Y04.8XXA if it was intentional. If you were the communist
| and bit yourself on the upper right arm it would be
| S40.871A or S41.151A depending on how deep the bite went.
| shubb wrote:
| Because these are world health organisation 'international
| disease classification' codes that are designed for
| population health study and happen to be used for insurance
| billing in the US.
|
| There are requirements for some data to be reported to
| federal and international organisations. For instance,
| these codes are also used on death certificates I think, so
| they can track whether a lot of people are dieing of flu
| (primary cause) after contact with duck (qualifier) and
| there is a bird flu outbreak.
|
| There are many coding systems - semi-standard extensions of
| ICD used to identify very specific types of cancer or the
| ontology based SNOMED which is rarely used as intended but
| none the less is becoming the standard.
|
| These codes are used for billing in the US to some extent
| but also for lots of other things, they are just a
| standardized set of codes that hospital IT systems use to
| talk about what is wrong with patients so they can somewhat
| interoperate - and they are forced to use them by
| government because the vendors prefer walled gardens over
| interoperability.
| gowld wrote:
| But if an app developer in a different industry doesn't
| know the history behind it then a must be worthless.
| shubb wrote:
| They are funny though, I just thought people might like
| to know the context
| ElFitz wrote:
| That's how it usually goes.
|
| I've lost count of all these times a freshly onboarded
| dev, replacing the old one, decided the systeme was
| needlessly complex, nothing made sense, and it'd be
| easier to just rebuild everything from the ground up.
|
| Only to end up with a similarly complicated nonsense,
| because the complexity actually was in the domain, and he
| knew nothing of it.
| paulddraper wrote:
| > From a billing perspective, wouldn't it make sense to
| have animal bite exam fee, with possible additional charges
| for bandaging, stitches, rabies shot, etc based on doctor's
| discretion?
|
| That is FFS (fee-for-service) billing. And indeed that does
| not use the diagnosis code, except for reporting purposes
| and documentation that the treatments were
| appropriate/necessary.
|
| The diagnosis code would be used if billing in a DRG
| (diagnostic-related groups) model, which is an overall fee
| for overall treatment related to the condition -- exam,
| stitches, etc.
| valleyer wrote:
| Because, like it or not, a doctor's discretion can
| sometimes be self-serving. The more treatments a doctor
| gives, the more they get paid, and there is an enormous
| information imbalance between doctor and patient. (As in,
| they went to medical school, and you didn't.)
|
| Unfortunately, some doctors are willing to take advantage
| of this.
| natosaichek wrote:
| It's kinda ridiculous that because it costs x billion in
| doctors overcharging, we'll spend 100x on administration
| to control costs. Cutting off one's nose to spite one's
| face and all that.
| tristor wrote:
| I always preferred "The cure is worse than the disease."
| for a metaphor describing US healthcare billing.
| willcipriano wrote:
| Nobody actually wants to control costs. From doctors to
| hospitals to insurance companies, everyone but consumers
| benefit from high prices.
| nradov wrote:
| Employers and other group buyers want to control costs.
| michaelmrose wrote:
| Actually if you think about it insurance is forced
| investment in a fund where the amount they make is driven
| as much by the amount they can get you to pay in as much
| as efficiency. It is only beneficial not to be so
| obviously egregious that nobody will touch you in an
| environment full of people who are tacitly collaborating
| to increase prices so that the pie gets bigger for
| everyone.
|
| Everyone is actually collaborating against you which is
| why in the US we only provide free health care for a
| small fraction of the populace but still manage to pay
| for THOSE folks as much as some other developed nations
| pay to cover their entire population.
| brendanyounger wrote:
| And why this has not been prosecuted as giant
| racketeering operation is beyond me.
| airstrike wrote:
| This has gradually changed with the emergence of "value-
| based healthcare", which is what we should be solving for
| (and building the right incentive structures for)
| chimeracoder wrote:
| > The more treatments a doctor gives, the more they get
| paid
|
| You could say this 30 years ago, but it's not really the
| case today. The majority of physicians are now salaried,
| not independent. And even for many of the ones in
| independent private practice, the amount they make is not
| necessarily tied anymore to the services they provide,
| due to the rise of capitation and other forms of bundled
| service agreements.
|
| Nowadays, it's actually statistically more likely that
| you receive care from a doctor who has an explicit
| incentive to _undertreat_ , because they receive a fixed
| amount of money per patient per year, and the costs of
| treatment come out of pocket directly with no additional
| reimbursement.
| coldcode wrote:
| This is the basis of all Medicare Advantage Plans, where
| the physician or their employer gets X$ a month per MAP
| patient and must pay for most of the cost of care. The
| insurance company gets to keep most of its share of what
| Medicare pays. Nice profit ensues for the insurance
| company.
| nradov wrote:
| Insurance companies that sell Medicare Advantage plans
| end up keeping only a tiny fraction of what they're paid,
| hardly "most". This is a low-margin, high-volume
| business. You can find the details in their published
| financial reports.
| valleyer wrote:
| I would love to see some data on this, if anyone knows of
| any. I'll just provide anecdata that of the doctors among
| my friends and family, more of them get paid by "wRVU"
| [0], which is basically a derivative of "how much
| treatment you give", than by salary.
|
| (I only happen to know this because they complain nearly
| incessantly about the wRVU system! I make no claim to be
| an expert on the topic.)
|
| [0] https://www.physiciansthrive.com/physician-
| compensation/wrvu...
| [deleted]
| mensetmanusman wrote:
| "I'd like to file a complaint. This is my fourth time being
| bitten by a duck not my second time. You have overcharged
| me!"
|
| This is possible in America today. Great job post ww2
| employer coverage side effects!
| arcticfox wrote:
| As others have explained, the subsequent encounter is for a
| follow-up visit, not a repeated duck attack.
| galleywest200 wrote:
| This is still silly.
| [deleted]
| Alupis wrote:
| It's not when you want statistics about all injury types,
| treatments, etc.
| boredpeter wrote:
| You don't need arbitrary codes to get statistics for
| something that can be typed in a description field.
| petsfed wrote:
| I've spent a lot time around people doing statistics for
| environmental science, especially regulatory compliance
| around accidentally killing birds and bats. The
| unfortunate reality for the statisticians is that every
| tech thinks they're Henry David Thoreau or something.
| Like, nobody cares if it was a particular large exemplar
| of a given species, or that it had magnificent plummage,
| just write down the species of the carcass and where it
| was located, and move on. Instead, there's so much
| variance from (mass produced and standardized) data sheet
| to data sheet that you can't even use hand writing
| recognition to automate the process of ingesting the
| data. Manually entering the data is somebody's whole job,
| because they've tried to automate it, and failed.
|
| The billing codes exist explicitly to limit the amount of
| independent thought that can be applied to something that
| is adequately summarized as "bit by a duck, third visit".
| marvin wrote:
| What if it was a lemur, though? Bet they don't have a
| code for that.
| vanattab wrote:
| Well the codes are just a standard way to enter the data
| so you don't have x reports of "duck bite" and y cases of
| "bitten by duck" or "mallard bite"
| owenmarshall wrote:
| Speaking as someone who has seen the inside of an EHR
| system, their data models, and what data _actually_ ends
| up stored there:
|
| lmao
| paulddraper wrote:
| You don't need to type arbitrary descriptions for
| something that can be a standardized code.
| [deleted]
| esaym wrote:
| Some ducks are poisonous, this is why the species needs to
| be known.
| JohnFen wrote:
| (Sorry, the pedant in me can't resist)
|
| If you get a toxin through biting it, it's poisonous. If
| you get a toxin through being bitten by it, it's
| venomous.
| ekelsen wrote:
| What ducks are poisonous?
| FireBeyond wrote:
| > Hell, W61.61XA is the medical code for "Bitten by duck,
| initial encounter." Presumably, this means there's also a code
| for "Bitten by duck, again."
|
| All this means is "first visit", as in "I need immediate
| attention for this", and "subsequent encounter" doesn't mean
| "another duck" it means "follow up for X, but it's already been
| 'counted' (and presumably the care is less acute)" (i.e. for
| statistical purposes, "X,000/year people bit by ducks".
| ochoseis wrote:
| While there is a mapping between them, ICD10 (diagnosis) codes
| and CPT (billing) codes have different purposes.
| pc86 wrote:
| My personal favorite is V97.33XD "Sucked into jet engine,
| subsequent encounter."
| NoMoreNicksLeft wrote:
| I'm having trouble being sympathetic with this one. Maybe he
| does deserve to have this claim rejected.
| chimeracoder wrote:
| > My personal favorite is V97.33XD "Sucked into jet engine,
| subsequent encounter."
|
| If you were sucked into a jet engine, you'd probably sustain
| serious injuries, so hopefully you'd have a followup visit
| with your doctor about it after the fact, rather than just
| one single visit.
|
| (Yes, I get that you're joking, but that's what "subsequent
| encounter" actually means.)
| none_to_remain wrote:
| There's at least one guy who got partially sucked into an
| engine but caught up on something before his head reached
| the blades.
| ryneandal wrote:
| This reminds me, I recently read of this happening in TX
| [1]. It was ultimately ruled a suicide. A horrible,
| scarring event for all in the vicinity without a doubt.
|
| 1: https://www.npr.org/2023/06/26/1184281638/airport-
| worker-eng...
| marcus0x62 wrote:
| If a person were sucked into a jet engine, they'd be turned
| into soup. Maybe they could be poured into a container and
| the doctor could subsequently encounter them in that state.
| arcticfox wrote:
| https://twitter.com/NavalInstitute/status/123054297912482
| 202...
|
| Here's a video of a guy getting sucked into a jet engine
| and surviving. Most, of course, do die.
|
| I don't quite understand why everyone is so bothered by
| the extensive ICD taxonomy; it clearly needs to be
| extremely extensive to cover even fairly common
| scenarios, and once you're past the point that things can
| be easily managed why not cover everything?
| thfuran wrote:
| Sure, it's necessary to have some specificity so that
| providers and insurance companies can be reasonably
| informed about what's going on, but this stuff has a very
| real cost. Healthcare providers have entire departments
| of people dealing with coding. The more complex it gets,
| the more time consuming and expensive it is to correctly
| code things. At some point (I suspect well behind us),
| the added cost isn't worth the marginal benefit.
| skissane wrote:
| These codes were originally developed by the World Health
| Organisation to collect public health statistics, and
| statistics on causes of death - that's their original
| purpose, not insurance billing. A lot of codes which seem
| silly or pointless for insurance have more validity when
| keeping their original purpose in mind.
|
| There's an ICD-10 code for executions - Y35.5 - can you
| bill an execution to health insurance? I hope not, but as
| a possible value for a cause of death field in a death
| certificate database, it makes sense.
| thfuran wrote:
| Sure, there are other uses for the data. But the fact
| remains that generating it isn't free. And changing the
| coding in and of itself incurs significant administrative
| cost, so "we've come this far; we might a well just keep
| going" isn't really a compelling reason to expand ICD.
| skissane wrote:
| > Sure, there are other uses for the data. But the fact
| remains that generating it isn't free. And changing the
| coding in and of itself incurs significant administrative
| cost, so "we've come this far; we might a well just keep
| going" isn't really a compelling reason to expand ICD.
|
| The WHO expands and revises ICD all the time - and how it
| gets used by US health insurance isn't really a concern
| of theirs. The WHO has 194 member states and the US is
| only one of them. WHO intends the ICD to be used for
| collecting public heath and cause of death statistics,
| and if some countries want to use it for
| insurance/billing - that's their problem, not the WHO's
|
| The US uses its own modified version of ICD-10,
| ICD-10-CM, which adds even more codes. A lot of those
| added US-specific codes exist simply because some
| hospital - or bureau of vital statistics - somewhere in
| the US, was tracking that. Other countries have done the
| same thing - Australia has the ICD-10-AM, Canada the
| ICD-10-CA, Germany the ICD-10-GM, etc
|
| Just because a code exists doesn't mean you have to use
| it for any particular purpose. Indeed, most medical
| software packages permit disabling codes you don't want
| clinicians to be able to use. In an insurance system, a
| code like Y35.5 is likely marked as non-billable.
| thfuran wrote:
| Yes, but we're in a thread about health insurance. That
| that isn't the primary concern of the WHO is beside the
| point.
| skissane wrote:
| Yes, but the ICD isn't for health insurance, it is for
| international standardisation of mortality and morbidity
| statistics, so they can be compared between countries.
| That's its purpose and the reason for its existence
|
| The fact that the US chooses to use it for something
| which was not its originally intended purpose is the
| fault of the US, not the fault of the ICD. The WHO
| doesn't force the US health insurance system to use it,
| the US could invent its own totally unrelated coding
| system for that purpose and the WHO wouldn't care (so
| long as those codes can be converted to ICD codes for
| statistical analysis)
| cool_dude85 wrote:
| Do we get separate diagnosis codes for each verb? So, sucked
| into jet engine, walked into jet engine, fell into jet
| engine, pushed into jet engine, etc.?
| talldatethrow wrote:
| I'd hope all those fall under "made contact with jet engine
| internals" If you fell into a jet or were pushed into a jet
| are the same. You fell into it because you were pushed. If
| you were sucked into it, the push just came from the other
| side and you still fell into it.
| mensetmanusman wrote:
| Those are all 'died of Covid' now /s
| vsareto wrote:
| IIRC the "initial encounter" refers to the first visit between
| the patient and doctor about the duck bite, and "subsequent
| encounter" means a follow-up visit about the issue, not a
| second maiming by the duck.
|
| It makes for a fun first impression though
| thomascgalvin wrote:
| That does make more sense, but I refuse to let go of the
| image of a duck with a vendetta tracking some poor bastard
| down, and the stalwart medical coding technician who is
| dutifully documenting it all.
| paulddraper wrote:
| That is correct. Obviously, there's little value in
| distinguishing between the first and second occurrences of
| duck bites. Rather, the suffix describes which treatment it
| is.
|
| A - initial encounter (initial treatment)
|
| D - subsequent encounter (continued treatment)
|
| S - sequela (after the treatment plan is completed)
| gnfargbl wrote:
| The initial/subsequent encounter coding seems to refer to the
| encounter with medical personnel (for the specified issue), not
| the number of times the same issue has been encountered by the
| individual. Which is maybe a good thing for recipients of
| T18.5XXA.
| abeppu wrote:
| Ok, so it's _broken_. As a system of recording stuff is it also
| ... incoherent? Slapping on a bandaid or giving someone tylenol
| are _services_. "Bitten by duck" is a _cause_, and different
| people bitten by ducks could need different services, and
| people impacted by different causes could need the same
| services. If I have a laceration, I'm guessing that how I'm
| treated should depend on how deep/large/severe it is, rather
| than what kind of implement was involved? If they're equally
| sharp, dirty, etc, a kitchen utensil, non-powered tool,
| scissors, or other sharp implement may all result in the same
| slapped bandaid, right?
|
| https://www.icd10data.com/ICD10CM/Codes/V00-Y99/W20-W49/W27-
| https://www.icd10data.com/ICD10CM/Codes/V00-Y99/W20-W49/W26-
| adolph wrote:
| Yes, the cause or problem is needed as well as the procedure
| or treatment that was delivered to treat the problem. The
| treatment will be charged separately for professional (like
| MDs) and technical (like nurse, pharmacy). It also matters
| who is performing a procedure. An MD slapping the bandaid
| charges more than a PA, Nurse Practitioner or PharmD.
|
| https://www.icd10data.com/ICD10PCS/Codes
| skissane wrote:
| > Ok, so it's _broken_. As a system of recording stuff is it
| also ... incoherent? Slapping on a bandaid or giving someone
| tylenol are _services_. "Bitten by duck" is a _cause_, and
| different people bitten by ducks could need different
| services, and people impacted by different causes could need
| the same services.
|
| As others have explained, these are diagnosis codes; there
| are also procedure codes. Procedure codes are the primary
| thing billed for, the diagnosis code is just to justify the
| procedure - some doctors will perform (or falsely claim to
| have performed) medically irrelevant procedures as a form of
| billing fraud, and cross-checking the procedure and diagnosis
| is meant to prevent that.
|
| And the reason why there are so many diagnosis codes, is
| because their primary purpose is public health statistics not
| insurance billing; and ICD codes are global (although the US
| also adds its own US-specific ones.) Probably, somewhere in
| the world, some bureaucrat is tracking the public health cost
| of animal attacks by species, and those species-specific
| animal attack codes exist to enable them to do that.
| DoreenMichele wrote:
| I worked in health insurance. The code is supposed to make it
| easy to pay. It doesn't.
|
| We could do away with the codes. In addition to having to look
| up the codes, I read records all day, called and wrote
| providers for additional info, consulted my technical lead
| regularly to see if it was covered and once had to print the
| entire file and get it reviewed by the retired surgeon who came
| in once a week to read surgical reports on difficult cases.
|
| I'm underwhelmed with the value they provide and I paid claims
| as my job for 5+ years.
| swalsh wrote:
| I'm in healthcare analytics, the codes are for me.
| DoreenMichele wrote:
| We were drowning in data. It was a Fortune 200 company and
| every few years they completely overhauled their system for
| looking up state exceptions etc, which meant longstanding
| employees could no longer use it efficiently and new people
| still didn't magically _get it_ instantaneously and
| inevitably some important thing could no longer be accessed
| at all.
|
| It was all in-house, homegrown software, I tried more than
| once to suggest moving to GIS -- a map-based system -- for
| some things and was ignored.
|
| I'm curious how that works for you because I just have
| trouble imagining that actually works. Like what value does
| that provide that you cannot do some other way and which
| justifies the systemic cost burden?
|
| Please edify me a smidgen.
| mwerd wrote:
| Nuanced but important distinction: these are ICD-10 diagnosis
| codes. They are only loosely related to what is billed and
| would not show up in the pricing data referenced by the OP.
| paulddraper wrote:
| ICD-10 codes are used for DRG billing which is what most
| inpatient billing operates on. But aren't included in the
| data I think.
| marcus0x62 wrote:
| The nominal reason for the (seemingly insane) billing codes is
| the codes are based on ICD-10. The ICD (International
| Classification of Diseases) system was supposedly originally
| developed for epidemiological tracking.
| talldatethrow wrote:
| I wish instead of charging 100x for random things to pay for
| the hospital, they'd just charge per minute of room and per
| minute of doctor contact.
|
| I understand why you need to charge me $2000 to have an entire
| hospital ready in case I need stitches at 3am. But I get
| annoyed when you try to play it off as having to charge $85 for
| an aspirin. Just be upfront and say, we charge $100 a minute
| and this is going to take 15-20 minutes.
| colejohnson66 wrote:
| But then there's an incentive to be slow
| banannaise wrote:
| So then you also add a constant per patient, but then
| there's an incentive to be rushed. Gosh, it seems like
| profit incentive is a really bad way to run a healthcare
| system, doesn't it!
| SilasX wrote:
| Even systems without a profit motive will have to
| economize, and therefore will track resource usage and
| discourage waste. The NHS still has e.g. PSAs telling
| people not to go to the emergency room for non-
| emergencies.
| banannaise wrote:
| I like that you specifically chose "Bitten by duck" which you
| could say is itself a form of _billing_.
| m_0x wrote:
| I remember a comment (not sure if here at HN or at Reddit)
|
| Whenever a hospital staff gives you a medicine they put it
| first in your table then give it to you because that way they
| can bill you twice.
|
| Take it in a grain of salt because I can't verify it and I can
| be misremembering details.
| paulddraper wrote:
| Co-founder of rivethealth.com here.
|
| Take however complicated you think medical billing is and
| multiply 5x. For starters.
|
| ---
|
| You are using a bit of a mixed example with bandaids, aspirin,
| and duck bite.
|
| The simplest billing is FFS (fee for service). This associates
| a fee for each procedure/drug/product using a 5-digit CPT/HCPC
| code.
|
| For example, 29877 would be _Arthroscopy, knee, surgical;
| debridement /shaving of articular cartilage (chrondroplasty)_.
| Add a 50 modifier to make it bilateral (both knees). Add an AS
| modifier if billing for an assistant surgeon. Add a 26 if the
| bill is only for the professional (human services) portion. And
| so on.
|
| The in-network price will be based on the health organization
| (9-digit tax ID), the rendering physician (10-digit NPI), the
| insurance plan/network (no standardized format), and the place
| of service (2-digit code, e.g. 24 _Ambulatory Surgery Center_
| ).
|
| The price is further modified by a variety of adjustments, such
| as MPPR (multiple-procedure price reduction), MACRA, etc.
|
| W61.61XA (Bitten by duck, initial encounter) is a ICD10
| _diagnosis code._ That is, a diagnosis of a condition, not a
| service. While you will always have a diagnosis, it 's not
| relevant for FFS pricing. This is used in a whole other set of
| billing called DRG (diagnosis-related groups) typically used
| for inpatient care.
|
| And of course there are even more billing methods.
|
| ---
|
| This is all very, very complicated.
|
| A lot of it is essential complexity -- modern medicine is
| indeed very complex.
|
| And a lot of it is incidental complexity.
|
| Not unlike a certain software industry. /:
| lisasays wrote:
| _Medical billing is broken_
|
| Is it?
|
| Seriously - how do you _know_? More specifically: broken
| compared to _what_? What would you replace it with?
|
| Be specific, please.
|
| Keeping in mind that it's like, an extremely complex domain and
| all, you know.
| johntiger1 wrote:
| Yep, this seems like surface level complexity. Like adding a
| new/non-existing key to a dictionary, it shouldn't surprise
| us that there can be different codes for getting bitten by
| different things
| lmm wrote:
| Broken compared to what literally any other country in the
| world does? Personally I'd replace it with publicly funded
| healthcare, but even those countries that still feel the need
| to bill the victim have avoided the whole billing-insurance
| complex that the US has.
| EliRivers wrote:
| Can we bill it like my mechanic does? Parts and labour. I
| could see that some medical people would want to have their
| time considered more valuable, so how about bill for parts,
| and labour depending on minimum qualification to do it.
| karaterobot wrote:
| I read the article, and I understand that the cause of that size
| is an absurd amount of redundancy.
|
| However, I still can't conceive how it could be that big. A
| petabyte is a million gigabytes. Wikipedia, uncompressed, is
| about 42 gigabytes. So, every month there is the equivalent of
| about 24,000 Wikipedias generated just from pricing data? And
| it's all just text. Wow.
| oldgradstudent wrote:
| For reference, here is the Israeli Ministry of Health price list
| as of July 1st 2023:
|
| https://www.gov.il/BlobFolder/dynamiccollectorresultitem/moh...
|
| Edit: Direct link to an Excel spreadsheet.
| mkmk wrote:
| FYI The above is direct link to .xlsx file
| oldgradstudent wrote:
| Thanks, noted.
| kasey_junk wrote:
| It's interesting that so many commentators are blaming the
| insurers here. The whole article is about how insurers use rules
| engines and lookups to define these prices and that the data
| explosion was a result of the legislation requiring price lists
| instead of an open standard for describing rules and lookups.
| brendanyounger wrote:
| Having worked with this data extensively (tynbil.com) and
| talked to several payers and providers, I don't think any of
| this intentional. CMS did their best at guessing what format
| the payer data could be exported to (with little to no help
| from the payers themselves). None of the payers have exactly
| the same schema for defining these rates as they all have home-
| grown solutions developed over decades. That said, most
| insurers have gone out of their way to bury us in data. The
| result is messy and annoying, but not impossible to work with.
| It's the best we can expect in this imperfect world.
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