There must be a pony in here somewhere.

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Re: There must be a pony in here somewhere.

Post by Mo » 03 Nov 2019, 04:24

Switzerland’s is at 1% and has worked for a while.
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There must be a pony in here somewhere.

Post by JasonL » 03 Nov 2019, 06:12

Mo wrote:Switzerland’s is at 1% and has worked for a while.
TIL the Swiss wealth tax is a canton tax not a national one. It’s progressive marginal with Geneva having nearly 1% at the top line at like $10.1 million but median canton being half of that. Cantons get compliance by not being fussy with valuations. Real estate is contentious so the value at like 30% under market value. All of their political drama seems to be in valuation practices which vary by canton.

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Re: There must be a pony in here somewhere.

Post by Hugh Akston » 07 Nov 2019, 15:08

Addressing homelessness to reduce healthcare spending
In 1986, Congress enacted a law to bar hospitals from turning away patients who are unable to pay. Any hospital with an emergency room that participates in federal health programs must evaluate and stabilize every patient who comes through the door, including those who are uninsured, indigent, addicted to drugs, or mentally ill.
Sitting in a vacant studio apartment on the second floor of one of the complexes, Brenner shows me data on a patient named Steve, a 54-year-old with multiple sclerosis, cerebral palsy, heart disease, and diabetes. He was homeless before UnitedHealth got him into an apartment. In the 12 months prior to moving in, Steve went to the ER 81 times, spent 17 days hospitalized, and had medical costs, on average, of $12,945 per month. In the nine months since he got a roof over his head and health coaching from Brenner’s team, Steve’s average monthly medical expenses have dropped more than 80%, to $2,073.
The data he saw there illuminated a gross imbalance in health-care spending: A tiny sliver of patients accounted for a large part of spending. In Camden, 1% of patients made up 30% of the cost. Brenner spotted patients who went to the ER hundreds of times a year, including a handful of individuals who cost the system millions of dollars each. “Like, for 1% of the spending here, we could open up 10 primary-care offices all over the city,” Brenner says.
By early next year the company expects to house 350 homeless Medicaid patients whose annual health-care spending, while they’re on the streets, exceeds $17 million. The goal is for them to “graduate” within a year to paying their own rent. (Most get a disability check; those who don’t get help from MyConnections to apply.)

Insurers, including UnitedHealth, generally try to reduce costs by restricting medical care. They require prior authorization for expensive procedures, deny claims for care deemed inappropriate, and limit the drugs available on prescription plans. This is partly why the industry has a bad reputation—the perception that insurers are middlemen that profit by withholding needed care without adding value. It’s behind the argument Senators Bernie Sanders and Elizabeth Warren make for replacing private insurance with “Medicare for All.”

Brenner aims to reduce expenses not by denying care, but by spending more on social interventions, starting with housing. How to do it is still largely uncharted. “I don’t think we’ve figured any of this out,” he says. “We’re at a hopeful moment of recognizing how deep the problem is.” A trip to any big-city ER reveals the magnitude of the challenge.
Homeless patients have few good options when they’re ready for discharge. Sometimes the hospital pays to send them in taxis to city shelters, which are often full when they arrive. Some go to behavioral health centers for further treatment of mental illness or substance-use disorders. Others go to a respite center run by a nonprofit called Circle the City, where they get medical care along with a bed in a shared dormitory. There are never enough beds to meet demand.

Some people who no longer require hospital care stay at Valleywise simply because more appropriate quarters aren’t available. “There’s a couple of patients who live upstairs that have been here for months and months and months, because we can’t find a place, a safe place, to put them,” Jordan says.
Torres and his colleagues bring a reservoir of patience deeper than what the homeless typically encounter. Much of the U.S. social safety net conditions assistance on certain behaviors, in an effort to inspire or force people to change. In homeless shelters, people are often required to earn privileges such as a locker or a larger space, eventually to be rewarded with placement in a group home or further housing assistance. Many programs are predicated on first kicking drug habits or adhering to medication. If people act out, they may end up back on the streets. “It’s a little like playing Sorry,” Brenner says. “You go back to the beginning and start over again.”

Brenner, by contrast, advocates a model known as Housing First, which recognizes that getting off the streets is often a necessary first step for people to adhere to treatment for addiction or mental illness—not the other way around. Many of the patients he’s concerned with have experienced early trauma, which has lasting health consequences. Exposure to adverse childhood experiences is a strong predictor of problems such as chronic illness, obesity, smoking, substance abuse, and, not incidentally, health-care spending.
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Re: There must be a pony in here somewhere.

Post by Jennifer » 07 Nov 2019, 15:13

FWIW, I've read of other programs in various cities (IIRC Salt Lake City is one) that decided the cheapest and easiest, not to mention most effective, way to "solve the homelessness problem" is just to give homeless people homes with no strings attached.

(I remember being appalled to read of one Atlanta-area homeless shelter with a daily curfew of three in the afternoon. There is essentially no paid work you can get if you have to be "home" from three p.m. until sometime the next morning. And then people have the gall to wonder why people who fall into homelessness have such a hard time getting out?)
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Re: There must be a pony in here somewhere.

Post by JasonL » 07 Nov 2019, 15:31

The glaring statistic is half of US health spending is incurred by 5% of the population. That is stunning to me every time I encounter it. I always knew it was a top heavy distribution, but that's absurd. And it's international, not a feature of our system per se. The form of the system determines if Quality Adjusted Life Year calculations result in people screaming at HMOs or screaming at the government, but it's the same problem.

Until I started working with a homeless shelter, I never really made the connection to high frequency users and the homeless. They have constant referral streams from hospitals. They try to allocate showers among their population to spread around the positive health effects of having at least one shower in a week (or month). This is a big extension of the ideas they are grappling with.

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Re: There must be a pony in here somewhere.

Post by Mo » 08 Nov 2019, 08:24

JasonL wrote:The glaring statistic is half of US health spending is incurred by 5% of the population. That is stunning to me every time I encounter it. I always knew it was a top heavy distribution, but that's absurd. And it's international, not a feature of our system per se. The form of the system determines if Quality Adjusted Life Year calculations result in people screaming at HMOs or screaming at the government, but it's the same problem.
Is it really that absurd or unusual? It seems like pretty standard Pareto principle stuff. It’s true in most markets that heavy users are a small proportion of the relevant population.
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Re: There must be a pony in here somewhere.

Post by JasonL » 08 Nov 2019, 08:59

I get 20% using 80%. I don't think we normally infer that runs all the way to 5% using 50%. I mean, in part because we talk about health policy as though total costs are a thing controlling the lives of the population at large and we are looking for a solution to ease total costs and such - there's nothing anyone can do in in the middle of the distribution that matters to total costs. There's no policy regulating expenses at the median consumer that matters at all to total costs. That's like trying to balance the budget by cutting NPR funding. It's all that 5%.

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Re: There must be a pony in here somewhere.

Post by Jadagul » 08 Nov 2019, 15:09

If the Pareto principle is scale invariant, that would imply that 4% of people use 64% of resources, which is more extreme than what you're citing.

(Obviously it can't be completely scale invariant. That would imply there was one person using like six percent of all health care spending. But in a lot of ways it's less extreme than the surface read of the Pareto principle.)

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Re: There must be a pony in here somewhere.

Post by Eric the .5b » 08 Nov 2019, 16:36

If the most expensive 5% are costing 50%, how could 4% use 64%?
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Re: There must be a pony in here somewhere.

Post by Jadagul » 08 Nov 2019, 16:44

That's what I said!

Jason said that even knowing the Pareto principle, it's surprising that 5% of people use 50% of resources. I pointed out that a naive extrapolation of Pareto would give something even more extreme than that.

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Re: There must be a pony in here somewhere.

Post by thoreau » 08 Nov 2019, 16:46

64% used by 4% was an extrapolation of the 80-20 rule: If 20% of the people use 80% of the resources, then of that 80%, 80% of that (i.e. 64% of the total) will be used by 20% of the 20% (4% of all users). It is interesting that this extrapolation gives numbers that aren't "too" far off from 50% of resources being used by 5% of the population.
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Re: There must be a pony in here somewhere.

Post by Mo » 08 Nov 2019, 18:00

Jadagul wrote:If the Pareto principle is scale invariant, that would imply that 4% of people use 64% of resources, which is more extreme than what you're citing.

(Obviously it can't be completely scale invariant. That would imply there was one person using like six percent of all health care spending. But in a lot of ways it's less extreme than the surface read of the Pareto principle.)
Wasn’t that the case in Iowa and what killed their insurance marketplaces? The one hemophiliac that cost $1M a month and wrecked the insurance marketplace.


http://www.businessinsider.com/hemophil ... are-2017-6
his voice is so soothing, but why do conspiracy nuts always sound like Batman and Robin solving one of Riddler's puzzles out loud? - fod

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Re: There must be a pony in here somewhere.

Post by Eric the .5b » 08 Nov 2019, 18:14

Jadagul wrote:
08 Nov 2019, 16:44
That's what I said!

Jason said that even knowing the Pareto principle, it's surprising that 5% of people use 50% of resources. I pointed out that a naive extrapolation of Pareto would give something even more extreme than that.
thoreau wrote:
08 Nov 2019, 16:46
64% used by 4% was an extrapolation of the 80-20 rule: If 20% of the people use 80% of the resources, then of that 80%, 80% of that (i.e. 64% of the total) will be used by 20% of the 20% (4% of all users). It is interesting that this extrapolation gives numbers that aren't "too" far off from 50% of resources being used by 5% of the population.
Sorry, I was unclear on this. I thought Jadagul was saying that using the principle meant you could extrapolate 4% using 64% from 5% using 50%.
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Re: There must be a pony in here somewhere.

Post by Jadagul » 08 Nov 2019, 20:13

Mo wrote:
08 Nov 2019, 18:00
Jadagul wrote:If the Pareto principle is scale invariant, that would imply that 4% of people use 64% of resources, which is more extreme than what you're citing.

(Obviously it can't be completely scale invariant. That would imply there was one person using like six percent of all health care spending. But in a lot of ways it's less extreme than the surface read of the Pareto principle.)
Wasn’t that the case in Iowa and what killed their insurance marketplaces? The one hemophiliac that cost $1M a month and wrecked the insurance marketplace.


http://www.businessinsider.com/hemophil ... are-2017-6
If Iowa is only spending $8M a month on health care, I want to know how they're managing that.

Like, yes, it's a spiky distribution, but it's not nearly as spiky as a scale-invariant Pareto distribution would have it.

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Re: There must be a pony in here somewhere.

Post by JD » 11 Nov 2019, 13:20

I found this piece by the Iowan father of a child with hemophilia (not the famous million-dollar-per-month one), in which he makes some points about why certain treatments cost so much and whether they would even exist absent the profit motive. It isn't perfect, but then the guy is a part-time college teacher and part-time programmer, not an economist.
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Re: There must be a pony in here somewhere.

Post by Mo » 11 Nov 2019, 17:20

At the same time, they also point to a different fact that cuts against the “indirect payments are evil”. Without an indirect payment system, state or private, the population that can afford it is so small (of an already small population) that there’s no chance you could ever sell it profitably in a direct payer market.

The thing where people get correctly upset about price gouging are super expensive genetics and insulin.
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Re: There must be a pony in here somewhere.

Post by Warren » 11 Nov 2019, 19:08

Mo wrote:
11 Nov 2019, 17:20
At the same time, they also point to a different fact that cuts against the “indirect payments are evil”. Without an indirect payment system, state or private, the population that can afford it is so small (of an already small population) that there’s no chance you could ever sell it profitably in a direct payer market.
I think if HDHPs with HSAs became the norm and everybody paid direct until they racked up serious medical expenses, it would work.
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Re: There must be a pony in here somewhere.

Post by JD » 11 Nov 2019, 20:21

Going through my company's insurance open enrollment today reminded me of just how weird the situation is. You're ostensibly given all these choices, but all they boil down to is "I want this particular policy" or "I don't want anything". Because, of course, you are not the customer, your employer is.
I sort of feel like a sucker about aspiring to be intellectually rigorous when I could just go on twitter and say capitalism causes space herpes and no one will challenge me on it. - Hugh Akston

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Re: There must be a pony in here somewhere.

Post by Mo » 12 Nov 2019, 07:13

JD wrote:
11 Nov 2019, 20:21
Going through my company's insurance open enrollment today reminded me of just how weird the situation is. You're ostensibly given all these choices, but all they boil down to is "I want this particular policy" or "I don't want anything". Because, of course, you are not the customer, your employer is.
The thing is your company is not the customer, they're the provider.
his voice is so soothing, but why do conspiracy nuts always sound like Batman and Robin solving one of Riddler's puzzles out loud? - fod

no one ever yells worldstar when a pet gets fucked up - dhex

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Re: There must be a pony in here somewhere.

Post by JasonL » 18 Nov 2019, 16:25

Related to some of Shem's comments about his belief E Warren is being tactical in her pandering regarding medicare for all:

There are a couple of visions of the "what do people really want to do with healthcare" question. In one version people simply want cheaper point of access healthcare and they will pay more in premiums to get it, you just have to get them over the hump by misrepresenting that they will pay anything more in taxes but once they have it they will like it so it won't matter when the curtain reveals their new lower disposable incomes. In another version, people legitimately have no interest in it if they have to pay a red cent more, which is what it actually looks like when you ask people what they are willing to pay. I'm actually not sure which story I believe.

The three major obstacles to large healthcare reform have always been 1) people in jobs with health plans tend to actually like those plans quite a bit ("if you have insurance, you can keep it"); 2) when asked neutrally about do they want national healthcare, everyone says yes but the minute you change the question to ask about how much people will pay, support evaporates almost immediately in all polls I've ever seen going back forever; 3) our doctors make 2-3X what everyone else's doctors make in income - how do you "control costs" without saying "sorry everyone who is doing this right now, you are now going to earn a third what you did yesterday". If you do say that what happens to the provider side?

The idea that the time is now hinges on people being so fed up with escalating premiums and out of pocket costs at the same time, they can get over all 3 of those hangups. I do think we are a bit close to that point, I do think we need to do something, but man the proposals on the table are going big and they are not attempting to work around that set of constraints at all except for lying about costs to Real Americans.

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Re: There must be a pony in here somewhere.

Post by D.A. Ridgely » 18 Nov 2019, 18:13

I'm not especially worried about the prospect of a shortage of doctors. The supply of qualified prospective medical students is far greater than the 'demand'; physicians have done a much better job of arbitrarily keeping their numbers well below what they'd be in some sort of market equilibrium and I'm unaware of any physician shortage in at least those Asian and Western nations I'd have no quality concerns about.

Yes, people who are happy with the status quo are happy with the status quo, but they're getting substantially lower disposable incomes already than they would if their employers were passing along whatever medical insurance costs they are bearing directly to their employees. That could, of course, be far more easily and preferably be fixed than by migrating to a socialized medical system, but the point remains.

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Re: There must be a pony in here somewhere.

Post by JasonL » 18 Nov 2019, 19:21

I think the doc compensation problem is the biggest problem, followed by nobody actually wanting to pay for it, followed by people being happy with employer plans and the choices therein.

People have expectations that emerge from their experiences. Large sudden expectation gaps on “what is your lifestyle as a doctor” will be very difficult to overcome, and further there is a cost structure associated with those anticipated returns. All the downstream effects will be very hard to sort out. Hospitals will close if you do this quickly.

You have to bend the curve I’d guess over at least a decade.

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Re: There must be a pony in here somewhere.

Post by D.A. Ridgely » 18 Nov 2019, 20:59

JasonL wrote:
18 Nov 2019, 19:21
I think the doc compensation problem is the biggest problem, followed by nobody actually wanting to pay for it, followed by people being happy with employer plans and the choices therein.

People have expectations that emerge from their experiences. Large sudden expectation gaps on “what is your lifestyle as a doctor” will be very difficult to overcome, and further there is a cost structure associated with those anticipated returns. All the downstream effects will be very hard to sort out. Hospitals will close if you do this quickly.

You have to bend the curve I’d guess over at least a decade.
I agree it would take time.

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Re: There must be a pony in here somewhere.

Post by Dangerman » 19 Nov 2019, 12:20

If you listen to the new EconTalk, it seems like you can keep doctor money flat and eliminate facility profit to create a shitload of savings. If you don't want to listen, look up the Surgery Center of Oklahoma.

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Re: There must be a pony in here somewhere.

Post by JD » 19 Nov 2019, 12:45

Dangerman wrote:
19 Nov 2019, 12:20
If you listen to the new EconTalk, it seems like you can keep doctor money flat and eliminate facility profit to create a shitload of savings. If you don't want to listen, look up the Surgery Center of Oklahoma.
Surgery Center of Oklahoma does accept private insurance, but the center does not accept Medicaid or Medicare.

Dr. Smith said federal Medicare regulation would not allow for their online price menu.
(https://kfor.com/2013/07/08/okc-hospita ... es-online/)

Well, son of a bitch. Thanks for mentioning SCoO, though!
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