Saturday, November 28, 2009

Discovering medical prices and the problem with paying cash

Walecia Conrad has written a pretty good summary of the problems of price discovery in medical care services. She mentions several approaches, including online services, calling physician offices, and checking payor (insurance) sites.

None, of course, are satisfactory. I hope she'll dig a bit deeper into price discovery. There are two places she could learn from. One is the problem with discovering how much a medication costs in different forms through different vendors with different coverage plans. Good luck on that one.

The other topic is more amenable to digging. She almost got into it, but perhaps had to set it aside for another day. Ms. Conrad mentions that cash fees for medical services are usually much higher than the negotiated fees insurance companies provide (this is very relevant to health care reform of course).

What she missed is why.

My own recollection, for I no longer deal with this issues, is that payor (insurance) reimbursement is based on a fraction "list price". So imagine that Blue Scythe pays 50% of list price. If costs+margin means a services costs $50 physician must then set "list price" to $100 so they get $50 from Blue Scythe. The "list price" must be validated as a customary charge, so it must show up on bills -- including bills for people who pay cash.

This means people paying cash are providing a huge margin, but this is an unwanted embarrassment for most practices. In my day we wanted to charge people paying cash less, not more.

I think there may be ways around this now. My knowledge is at least fifteen years old! Still, this an area that deserves some journalistic effort.

Friday, November 27, 2009

Lagrangian finance and age of wonders

I had a relatively decent physics education for a non-major, but I'm pretty sure it didn't include discussions of the Lagrangian and its use in Newtonian mechanics. So I loved this brilliant exposition of the use of the Lagrangian.

Subtracting potential from kinetic energy? It feels like a measure of how much of a budget is unspent, how much is left to drive deviations from a trajectory...

That feels like finance. There ought to be applications of the Lagrangian to the world of financial modeling.

Once upon a time, that's where the thought would have ended. An idle speculation. Today, though, the answer is a few keystrokes away: google.com/search?q=lagrangian+finance.

73,800 hits. Yeah, looks like there's an application or two.

We don't truly grok the web. Not yet.

Wednesday, November 25, 2009

Left Behind: Ludd, Beck and the non-tribal roots of tea party rage

It's easy to mock the Palinistas, the Beckians, and the very vanilla Tea Partiers.

Easy, but wrong. They have good reason to be afraid. Their future looks grim. They are also, I think, the misleading face of something bigger.

Misleading, because the melanin-deficiencies of the Beckians makes it too easy to think of their roots purely in terms of the white underclass. I think there's something bigger, more interesting, and more important going on than the historic passing of one particular tribe.

The world is becoming increasingly complex and, for many people, inaccessible. How smart do you have to be to learn and absorb the multiple manifestations and implications of modern mortgage contracts, American health care benefits, mobile phone plans and scams, mortgage derivatives and exotic financial instruments, iPhone synchronization, Facebook and Twitter privacy policies, dysfunctional security procedures, OpenID, Oauth and 200 passwords, modern India, China, tribal Pakistan, your flaky modem, and, for most non-Mac owning Americans, virus infested XP boxes with unpredictable behaviors?

A lot smarter than me.

Most of humanity is being Left Behind by an increasingly incomprehensible world of increasing complexity. We can function in it, we can even prosper in it, but our world is beginning to resemble the world of pre-industrial man. That is, a world of powerful and mysterious forces that may, without obvious reason, aid or smite a mere mortal.

I suspect, in their marrow, the Beckians, like the Luddites before them, feel this. It adds to their fear and anger. This will be something to watch.

See also:

My Saint Paul Minnesota speeding ticket – emergent solutions to emergent consequences

A few weeks back I got my first ticket in over 12 years, for speeding on a notoriously deceptive stretch of highway 35E (it even has a Wikipedia reference under speed limits). For a week or two around the time I was dinged that stretch of road showed caught cars every time I passed.

There were, of course, lots of mitigating factors, but the biggest one was that I’m really dependent on cruise control and mine broke about a month ago. Probably from overuse.

Once upon a time, if you had an average income, a speeding ticket was an painful annoyance. Then it began to dramatically increase insurance costs. Later, as the world became more risk-adjusted and networked, speeding ticket questions began to show up on applications for life insurance, foster care, and I suspect, many more forms.

So the secondary costs of a modern speeding ticket are much higher than the list price. I decided to poke around rather than pay immediately.

Google and the rest were not helpful. This search topic turns up mostly misinformation (it will be interesting to see if this post helps!). The searches did bring up ads for various legal services, and my first instinct was to pay for some professional advice. The more I looked, however, the less savory that industry seemed. In the end I decided to “contest” the ticket. This is the story of what I saw of the system, and how an “emergent” solution was developed to the secondary costs of speeding tickets.

There’s a common myth that when you contest a ticket you appear before a judge along with the accusing officer. At this time you can supposedly argue about radar technologies and so on, but if the officer doesn’t show up your citation will be waived. That’s not how it works in Saint Paul.

You phone a number (no web) on the ticket and you’re given a hearing date with an administrative official. You can change the date; I had to due to a travel conflict. If you run late there’s an extra $5 late fee. (I think you can “appeal” this decision and end up in a real courtroom, but I didn’t go that far.)

The hearings take place on 15 West Kellogg, in the city court house. It’s an imposing structure with a vast ceiling and black marble columns bearing the names of dead warriors. It reminded me of a scene from the movie Brazil.

I joined about ten others sitting in a mildly gloomy room. There’s a display showing names and appointments, on which my name did not appear. Turns out that’s for the court, not for traffic citation. Most everyone else there seemed to know what to do; at around 8am a set of metal windows crash upwards and you cue up for a hearing slot.

Despite being last in line I was called in at my appointed time. I’d rehearsed my responses, but this was the complete discussion: “The speeding was an accident, I have a good record …” “You mean you were accidentally speeding?” “Yes". “Give me your license”.

The system, it turns out, has developed a solution to the problem of the increasingly heavy consequences of a speeding ticket. The solution was that I agreed to pay $188 (I don’t know how the total was calculated, it might be more than the ticket price) and the citation, for the moment, no longer exists. If I get another ticket in the next year it will restored and I will have to pay both. So local government gets at least the money the ticket would have generated, and if I make another mistake they get double the money. On the other hand, I don’t bear the secondary consequences of a modern citation.

An emergent solution to a modern dilemma. Fascinating.

Plus ca change – Non. Twenty years of a solstice letter.

I’ve been writing a “solstice letter” for over 20 years.

During that interval a few things have changed. The first letter would have been written with WordPerfect 3 on a Panasonic* 8086 with a 20MB hard drive. Today my local storage total is roughly 2TB, or about 100,000 times larger. I had email then; I used Norton Commander’s superb MCIMail client with MCI’s pre-internet modem-based mail service. Today I use Gmail.

Oh, and now we have the web.

I’m more interested, however, in what’s not changed. After many years of experimentation I’m back to authoring in a word Processor (Word:Mac) and distributing as a PDF from one of my personal servers. I’d love to have a great web based authoring solution, but there isn’t one. I’d love to have a universal open file format, but there isn’t one.

In this area, progress is only measurable by microscope.

* The most over-engineered device I’ve every purchased. You could park a car on it. Panasonic was threatening to wipe out Compaq in those days, until Congress intervened to block Japanese computer exports. That “saved” US computer manufacturing until Taiwan took it away, and forced Japanese manufacturers to focus on laptops. Adjusting grossly for inflation, it was cheaper than a comparably “higher end” machine would be today. But I digress …

Sunday, November 22, 2009

The shocking truth - the birthers are almost right ...

The birther crackpots are still stumbling about. They'll never figure out the real story -- though it's been staring them in the face all along.

Of course Obama wasn't born in America, but he wasn't born in Kenya either. You see, he wasn't born at all ...

It does explain a lot.

529 plans can be rebalanced twice in 2009

I was surprised to see this when I visited our kids 529 plans to make a contribution. I assume this extra rebalancing is to compensate for funds damaged by the crash of 2010 ...
The Treasury Department and the IRS recently announced that for 2009 only, 529 plan account owners will be allowed to change Investment Options two times per year. This means that you can reallocate your investment to different investment options in your plan up to two times this year...
I've never done any rebalancing. I didn't realize that we are normally allowed to do that once a year. Something else to learn about!
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Lipid guidelines: Sometimes the emperor really is starkers

A year ago I had to review guidelines for managing elevated blood lipids. I concluded that the guidelines were incoherent and silly. It wasn't a problem of science, it was a problem of logic.

Today, reading a JAMA editorial by Gaziano and Gaziano (brothers), I see that medicine has caught up with me. The risk calculator approach makes sense, though the models may have problems.

It's a cautionary tale of the limitations of expert panels. I suspect a lot of practicing physicians thought the guidelines were dumb, but they weren't making policy.

Hey, someone has to give me credit!

PS. There are now serious proposals to put every male over 50 or so on a statin. That's because they're so safe and cheap. The last time we did something like this it was women and estrogen. It took 10 years to learn that was a very bad idea.

Saturday, November 21, 2009

Sparta and the disturbing flexibility of human culture

I remember a cartoon of Spartan life that I learned as a child. I don't recall thinking about it much further until this week's IOT programme on Sparta.

Spartan culture is as alien to modern American life as the sacrificial cultures of the Aztecs, but it endured for hundreds of years. Men did not live with women. Children were removed from their mothers at age 7 and raised in a harsh military environment including routine sexual abuse. Contrary to some stories, it appears they did not routinely visit their mothers after that time.

The Spartans practiced active eugenics, exposing unwanted children (though some were apparently rescued by others). They enslaved, oppressed, tortured and murdered their "Helot" kin for centuries. Spartan women, paradoxically, may have had more freedom and a better life then Spartan men. Birth rates were low -- perhaps the earliest evidence that educating women leads to lower birth rates (aka "demographic transition").

This culture was not a passing thing. It appears to have been stable for centuries. Presumably, humans could do it again.

Update 11/22/09: On reflection, if you could get past losing your male children at aged 7, this might not have been such a bad arrangement for Spartan women. Exercise, education, freedom, limited exposure to Spartan men ...

Chrome OS - the Parental Controls

I'm going to forget I read that Google imagines Chrome OS machines will sell for $400. That's clearly a ploy to sedate Microsoft.

I'll stick with my original expectation, that moderately crummy Google branded Chrome OS machines will sell for under $180 with battery.

If that happens then Chrome OS laptops will be huge in K-12 education, 23 years after I mercifully failed to sell a rural school district on a student Newton OS mini-laptop education model.

Huge, that is, if Google gets Parental Controls right. I ain't giving my kids Chromebooks unless I get full control over what they get to and what they do.

If we don't see Parental Controls emerging in Google App domains within the next six months, the Chrome OS may be missing an essential function.

When to accept an Apple OS update

I mostly agree with this Macintouch post ...
Snow Leopard
.... In my experience with Tiger & Leopard, a really usable version isn't available until around the .4 timeframe. My guess is the same will be true with SL. I play with a SL partition every now and then (whilst I test things like SoftRAID - great!), but I need a system that works.
SL ain't there yet, and once again, Steve Jobs and company thank us all very much for paying to be beta testers."
Apple's point OS updates, like 10.5 to 10.6, are dramatic; even those like 10.6 that add few marketed features.

Six months, or a .4 release, is a good rule of thumb. We're now at 10.6.2, I expect 10.6.4 after April 2010.

If you buy a system released after a point OS release, and stick with Apple or very mainstream products, you can probably get by with a .3 release.

If you have an older system that's still supported, you may need to wait for .5 or .6.
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Google's failures - and recent improvements

Good list of Google's more prominent failures. They are far from perfect, as any heavy duty Google user knows.

Time for me to update my Google Quick, Sick and Dead list. Here's the current list, I use pretty much everything except Android. I'm surprised to see that there have been more promotions than demotions over the past 10 months ...

The Quick
  • Search and Scholar
  • Android
  • Google Reader
  • Google Reader Comments and Shares
  • Gmail
  • Google Contacts
  • Google Mobile Sync
  • Chrome browser
  • Chrome OS
  • Picasa and Picasa Web Albums
  • Calendar
  • Maps
  • Earth
  • News
  • Browser toolbars
  • Translate
  • Gmail Tasks (promoted)
  • Custom search engines (promoted)
  • YouTube (promoted)
  • Mobile (promoted)
  • Google Talk (promoted)
  • Books (because they keep trying)
The Sick
  • Google Voice (iPhone web app frozen in time)
  • Google Sites
  • Google Apps
  • Google Video Chat (demoted)
  • Blogger (demoted)
  • Shopping
  • Google Checkout
  • Google Base
  • Orkut
  • Desktop
  • iGoogle
  • Knol (all-but-dead)
The Dead
  • Google Notebook
  • Google Page Creator
  • Google Browser Sync
  • Google Video
  • Google Groups (demoted)
  • Google Web Accelerator
  • Google Name Verification (Knol)
  • Google Gears
Update 12/4/09: I've added a few more items, such as Google Gears in the Dead category.
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Fans of Glenn Beck

By their fans ye shall know them ...
Glenn Beck - Salon.com

... every person in the last 2 years that I have introduced to the WN [White Nationalist] Philosophy have come largely from Alex Jones, Glen Beck and the Scriptures for America founder Pastor Pete Peters ... Baby steps are required for people like these, but the trio Beck, Jones, Peters are the baby food that feeds potential Nationalists… Glenn Beck is not far behind as his Mormon background indicates to me as most Mormons I have met are not friends of Jews like the Church was years ago...
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Twilight of the mail

It's been a couple of months, so I went through my home paper mail. As usual there were about 3 items of interest, 3 periodicals for the bathroom, and a 2 journals for the office.

We know the periodicals and journals are going to move to some form of "ePad" in the next year or two. At that time I will get valued paper mail less than six times a year -- mostly from family over 80.

I get nothing at work.

Of course there's a trick. Emily gets all the bills and the Netflix DVDs, but fairly soon vendors will stop mailing paper. We're fed up with broken Netflix DVDs, so that will end within a few months time. (Suck it Netflix.)

Paper mail is going the way of paper news.
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Friday, November 20, 2009

Health IT Standards - what I would do

I almost never blog about anything that's work related. For example, if you visit my blog page you'll see a "label cloud" with 360 posts on Economics, but I'm no economist.

This post, written as a private citizen, is different. I'm going to write about something that I really do know quite well. It's a sufficiently obscure topic that there are probably only a handful of people who know it as well as I, and I doubt any of them have been invited to participate in the Health and Human Services IT standards process.

I wasn't invited, but I feel a moral obligation to contribute anyway. I can't see a good way to do that, so I'll post my contribution here. Sometimes these posts travel in odd ways.

My unusual expertise is in combining the realms of healthcare "accounting" (ICD-9-CM, HCPCS, CPT) and the realms of industrial ontology (gritty knowledge representation) such as SNOMED. I've been personally grinding these pieces together for over twelve years in various software systems. I know them rather better than I'd like.

The accounting systems matter. Their idiosyncrasies distort health care statistics, change people's insurance, impede and break computerized decision support, dictate care and determine how most clinicians define disorders. They are fashioned in obscure dark rooms, and they alter health care as surely as technical accounting dictates corporate software development.

They matter so much that they are deeply embedded and almost impossible to displace. ICD-9 was obsolete 30 years ago, but it staggers on. ICD-10-CM is a merely improvement that will cost many fortunes to implement.

On the other hand, SNOMED, a language for healthcare, is a very rich tool. Buggy, yes. Imperfect, yes. Even so, it's a powerful tool for anyone who wants to provide cost-effective decision support that will make all health care providers smarter and faster.

So why don't we implement things like SNOMED now? Are there technical issues? Well, there are some technical challenges, but they're not too big. The real problem is the deadweight of ICD-9, CPT and all that layers upon them, such as vast "medical necessity" (LRMP, medical coverage) databases. Since payment is closely bound to ICD and CPT coding, the easiest route to legal maximization of reimbursement is to stay close to ICD and CPT.

I don't think we have the energy to move America quickly to better health care standards like SNOMED CT. Maybe we do, but this kind of change is very hard. Even so, I think we can do it gradually. The trick is to keep the current system in place, while incrementally building up an alternative approach.

For example, consider the "coverage determination" database. This is a reasonably complex set of tables that define relationships between ICD-9-CM (aka "ICD" in the US) codes and CPT codes (AMA owns CPT btw). The tables express rules such as "we will pay for procedure X (CPT) if a patient has condition Y" (ICD).

I think those tables would be simper, and more internally consistent, if the rules were expressed using SNOMED CT. Medicare (CMS) could then publish rules in both SNOMED and, through things called "mappings", ICD-9-CM and CPT too. The transaction systems would still use the ICD and CPT codes of old, but developers could represent the rules internally using SNOMED, thereby facilitating SNOMED use in their clinical systems. This alone would remove a very large hurdle.

State governments could encourage clinicians to include SNOMED CONCEPTIDs (codes) in a new class of public health and/or payor transactions. This would be entirely optional, but transactions could have come with small payments and regulatory rewards.

We could express new ARRA reporting requirements in SNOMED as well as in the traditional ICD and CPT code sets. Again, accept either data set.

Lastly, we could accelerate implementation of SNOMED-founded ICD-11, perhaps even foregoing ICD-10-CM plans and doing an early partial implementation of the full ICD-11 vision.

It's very hard to move things as deeply embedded as ICD-9-CM and CPT. This deadweight is heavy weight. We can't do it all at once, but we could take doable steps that would provide us with better decision support and more portable electronic health records.

We now return you to the regular amateur hour ...
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