What do you propose - that I file a lawsuit against AT&T and T-Mobile? They'll no doubt have the jurisdiction transferred to some court halfway across the country, no doubt citing some provision in my contract that allows this. Then they'll probably try to dismiss it. I don't have the luxury of taking a year off of work to write legal briefs, or the money to fly out to deposition corporate shills and show up in courtrooms who knows where. It would be a hardship for me to try to spend a week in small claims court if that were even a legal option.
Generally speaking consumers react to these sorts of things by complaining to the government. You know, it is actually their job (FTC, FCC, etc) to regulate these things...
I'm a T-mobile customer, and I don't want the merger to go through. If I wanted to be an AT&T customer I'd have signed on with AT&T. I picked T-Mobile because their plans are cheaper, are more flexible, their phones are better (in my opinion), and they have less of a tendency to try to extort $800 out of you when somebody on your plan messes up.
If they get bought I suspect that they won't get around to dismantling 4G coverage for my phone before my contract ends. If they try to get rid of my plan I'll leave without an ETF. If they significantly scale down 4G coverage I'll claim failure to perform and leave without an ETF. At that point I'll figure out what my best option is and go with it, but most likely it won't be AT&T unless they REALLY get their act together.
Yeah, but those science books from 10 years ago are SO out of date. You know, the ones that talk about how lightning is just a form of electricity, that fronts form when differing air masses collide, and that the earth is round.
There is little reason for books to be replaced more than once every 10 years even at the college level, unless you're talking graduate-level classes (and graduate level classes don't really benefit as much from textbooks anyway). How much has Physics 101 changed in the last 10 years?
Well, I guess you could offer everybody $200k/yr but that would seem a tad expensive. How else would you propose to pay people a reasonable wage?
I'd note that when lawyers lose time for one reason or another and a court seeks to make somebody else pay for it that their hourly rate is taken into account. It only seems that normal people are considered to have time worth nothing.
And in the end I'd have the parties be the ones paying for it (well, the loser anyway). My solution for court costs is that the parties agree in advance on the amount at stake. Then the state sets aside a fund for fees for each side based on the amount at stake. Both sides pay for their side of the litigation out of those funds, and it would be illegal for anybody to accept a witness fee or fees for legal services from one of the parties directly (ie the fees of both sides are completely capped at the same amount). Firms that engage in other legal services (preparing contracts / etc) would be forbidden from appearing in court, except as parties of course. Then the loser of the case becomes indebted to the state in the amount of the total court costs for the trial (including the jury, operational costs, etc). The state can collect as with any other public debt like tax delinquency. I'd also have the court directly pay any damages/etc and collect them in a similar way. Parties shouldn't have to get involved in that kind of tit-for-tat stuff, and then there is no disputing who owes who what.
Oh, I'm under no illusions that any of this will ever happen, so it is a bit silly to spend too much time arguing about it.:)
Yup. Why even have a jury if they don't have any political role in the proceedings?
The whole reason juries were required in the constitution was as a check and balance against the power of government. If the government passed a horribly unjust law, then they would have trouble convincing 12 ordinary people to go along with it.
The real problem is that the nature of the economy is such that most people can't afford to spend a lengthy time on a jury. Serious trials take weeks to complete. I can't miss work for weeks. Oh, sure, they "can't fire me" and in fact my employer would pay me for my entire period of service. However, when I got back the expectations would be that I'd still complete all my projects on time despite having a month less time to do it. I can't even work harder, since most projects are collaborative and inevitably anybody else who is only helping out will just do what they can to not be found at fault and let the project be late. Sure, I can find a better employer, but most people can't, and the reality is that this is what most employers are like (in the professional world). If you're really behind at the end of the year then you're more likely to be let go the following year. Not a word of jury service will be mentioned when they let you go - you just will have "not worked out" or whatever.
The only reform I can think of is that jury members should be paid their normal salary plus a 10% bonus for jury service (and all of that from the state - the employer pays nothing). The employer of the juror should be paid compensation for the loss of opportunity - it should be more than a token amount. Then people are less likely to have hard feelings about jury service. The cost of operating a court is already enormous, and should be considered the cost of justice. Now, I'm also in favor of reforming how court costs (both of the court and the parties) work out, but that is really a separate matter. Reforming how the costs work would defray the impact to taxpayers of having to pay jurors more than $10/day or whatever your local jurisdiction offers.
Obviously they're not very well coordinated either. With all the plate-scanning technology and cameras floating around, I'm sure they could have tracked him without the GPS.
Part of me is tempted to try to create an open-source database where anybody who wants to can just set up a camera and upload faces, license plates, locations, and timestamps to some central repository. I suspect that the people that you'd prefer not to have access to this sort of thing already have it. What would society look like if EVERYBODY knew the location of EVERYBODY all the time?
Maybe privacy is just something incompatible with the information age. Social taboos and such will just have to evolve to handle a society where everybody you know does stuff you'd prefer that they didn't and everybody knows it.
I dunno - if you're convinced the game is rigged then the only way to win is not to play. I plan to work until I die, or until you end up taking care of me (assuming inflation and crashes don't destroy the value of your savings)...
Ok, imagine if you required a cashier at Walmart to have a witness come over every time the drawer opened, and count the money three times. Actually the drawer would be in a separate room from the customer to reduce the risk of theft. Every sale takes 30 minutes. Security is improved, but nobody would want to shop at Walmart. To prevent odd losses of $20 a day the company puts itself out of business. It just doesn't make sense.
Well, it is the same thing on Wall Street, but with a bunch of zeros added. If you make every trader quadruple-check things every time they want to spend $50M that will slow things down. In the end the firm is likely to lose more in opportunity than the odd $10M in embezzlement here or there.
I know somebody who was involved with Wall Street, and he said that people there tend to lose any normal sense of the worth of money. When every time you make a phone call $50M changes hands and you get $1M of that it is kind of hard to have a perspective.
I'm sure the rate of waste/loss is the same as in any other industry. The problem is that since trillions of dollars are changing hands a few percent is like the economy of many medium-sized nations.
Uh, the shuttle isn't really capable of making significant changes in orbit - beyond what is possible with another launcher. In particular inclination changes are very expensive. Plus, these satellites are big so it isn't like the shuttle could carry a bunch on one flight.
The original concept behind the shuttle was launching something or taking pictures from polar orbit and de-orbiting on the swing back around the earth, landing back where it started (ie a suborbital flight that just barely makes it around the earth once). This is why it needed wings, since the launch facility would be a few hundred miles east of the orbital path. It never actually did this. In fact, I'm not sure what its cargo capacity to polar orbit would be, or how much it could return to earth with such an orbit (it takes more energy to get to polar orbit and that is more energy to bleed off on re-entry).
Then whoever develops the systems used for any kind of national healthcare system should create something better. Doctors in Zimbabwe can use codes from a 1960s-era mainframe if they want to.
Vast quantities of money get spent on the present ICD9 system, and in most cases people just work-around all the complexity by using a handful of more generic codes anyway.
That's because as far as I can tell nobody really uses them in this way.
I doubt most doctors would use separate codes for turtle bites, cat bites, dog bites, and termite bites. Most likely they'd just figure out what the code is for animal bite and use it for everything. Or maybe the code for "bleeding wound" or "puncture wound" or something.
Just because you give somebody 140k choices in a drop-down doesn't mean that they actually sincerely try to find the one that best fits. Unless picking the right option actually changes how much they get paid they're not going to bother.
Should the system used to drive insurance billing in a national-scale health system in the first world be based on a design that has to first start with the assumption that the user might be in Zimbabwe and could not afford a computer?
To take the turtle example, previously if you were interested in turtle accidents, you may have needed to look under "reptile" "turtle" "tortoise" or maybe even just "animal". For that matter some people call snapping turtles just "snappers", which of course is also a kind of fish. Now with standard coding it is easier to find quickly who is being hurt by turtles, how often, when, and where.
No, you still have to search for all that other stuff, because why would a doctor's office classify a problem as a turtle accident when they could just capture it as a "bite wound?" Or better still something even more generic.
I've seen more than a few ICD codes on billing forms and such. A typical office just has half a page of billing codes and the secretary just checks off the one that is closest. Now, if the insurance company would pay them $1k to fix a turtle bite but only $200 for a generic bite wound, then they might take the time to classify it (assuming they even realized the code is available and they treat enough turtle bites for it to be worth their time to check).
People approach these kinds of problems like a programmer, and they really need to stop and see how people really use these systems. If you want a practitioner to hunt through 140k codes then you need to give them some incentive to do so. Otherwise they'll pick the most generic term that gets them the money they want so that they can send in the form and get back to treating patients.
Humans just aren't good at doing table joins, and other things that make perfect sense if you're a programmer.
You really need to minimize the number of choices a user is presented with at any time - really no more than 10-20 and there can't be any ambiguity between them.
A hierarchical system is probably going to be better as a result. This way nuanced diagnoses are grouped together so that users can first determine if the person is sick vs dead, and then if a limb was removed or not, and then whether the limb is an arm or a leg, and only at the end you figure out if the pinky finger was removed at the first or second digit.
Even so, I think this is almost doomed from the start if the goal is to get to this level of granularity. If a guy is shot in the heart do you browse down through heart problems, gunshot wounds, and so on. If somebody died because of some genetic problem that caused them to have a heart attack is that under heart problems, genetic problems, or problems with blood vessels (which caused the heart attack), and so on.
The only reason that somebody would take the time with the current system to fish through all of that for a more specific code is if it somehow makes a significant difference in their compensation or whether they are compensated at all (which is often the case for a practitioner submitting to an insurance company).
The reason for banning other types of exchanges is to reduce the impact that algorithmic and other short-sighted forms of trading have on the economy in general. Companies don't change their intrinsic value 400 times per day (at least not in any knowable way), so why should their stock prices change this often?
The financial system operates with unnecessary granularity, and this tends to cause behaviors that aren't good for the economy as a whole.
Actually, it would be nice if it could plan a trip and even suggest airports based on planned time of arrival and proximity of both the departure and arrival airports.
If I want to be at 123 Abc drive in LA at 4PM on Saturday, and I'll be leaving from my house, it would be nice to find out that I can avoid an 8-hour layover by driving to a different airport 20 minutes further away from my house, or whatever. Combining the two databases makes that possible.
The collecting asks/bids is called 'auction' and it is already available.
Yes - it is how every exchange works. Or at least, it is how all the ones I'm aware of work. Typically however they execute as soon as two orders meet and not at a fixed time interval.
The idea of market participants not knowing of each other's orders is called 'dark pool'. They do exists and people use them. If you want to trade this way, you can do it.
I wasn't suggesting that nobody know what the other orders are. Only that they be pooled for a day before they are executed.
Whoever goes to this 'corrupt' 'first-in, first-served, executed ASAP' exchanges does it voluntary.
I didn't say anything about the order of execution either. I'd execute all ASKs/BIDs at the same price, set to maximize volume on that stock for the day. Order would be highest BID and lowest ASK first, and first-in, first-served when there is a tie. Yes, I realize that this means that Joe Investor can see that Goldman placed an order to buy 50M shares at $10 and place an order to buy 100 shares at $10.01 and get ahead of them (assuming the day doesn't end before they do, and that they feel the extra cent is worth paying).
I'm not quite sure what makes my suggestion "corrupt." And it wouldn't be voluntary (well, participation would be voluntary, but running a different kind of exchange would either be forbidden, or it would be closed to participation by individuals who aren't wealthy, or by any fund containing money belonging to or in stewardship for individuals who aren't wealthy).
Really the only big change I'm proposing is that stocks only swap hands once a day at a single price, and that there be no advantage for being faster than the other guy by more than a day.
I'd probably devise a system where people can at least name that value themselves and pay a premium accordingly.
Free Market healthcare already does that, so why bother creating a new one?
Uh, where is this free market healthcare system you're referring to? I only have a choice of a few reasonably-priced plans offered by my employer. Many people don't even have that. Or, you can shop on the "free market" and pay a fortune for a very mediocre plan. Or, you can just wait until you're sick and find out just how kind and generous the medical establishment is by sending you bills totaling $100k for a procedure that no insurer would pay more than $10k for, and then acting like they're doing you a favor by knocking it down to $50k.
There is always room for experimental medicine
Not if insurance companies (or the Federal government) are paying for them, there's not. Or do you really believe that Medicare pays for experimental treatments?
Read the entire line: "However, it is extremely wasteful to treat every patient encounter as a clinical trial." Medicare shouldn't be paying for experimental medicine - the NIH should. Patient participation in experimental medicine should only be permitted if it actually furthers the goals of science, or if the patient or another private party is willing to foot the bill themselves. When doctors make whimsical decisions around whether a treatment is necessary, that IS experimental medicine. Routine treatment should be based on evidence.
Medicare was just an example - insurers in general control prices, and necessity of procedures.
If you want to have a free market you need a couple of things:
1. Effective patient choice. If a patient can't actually choose what doctor will do the work, then they have no negotiating power, and uncontrolled prices will rape them. A patient has no choice if they are unable to make a decision, or if the facility they are at only makes one doctor available to them (or all the doctors at a facility charge the same price), or if there is risk involved in transferring to another facility. All of these are often the case in acute care - so acute care is a very poor candidate for free market pricing.
2. Knowledge. If it is hard for a patient to compare the quality and cost of services from one facility to another, then there is little incentive for those facilities to improve either.
3. Free supply. The number of doctors is something which is controlled by the industry to ensure a shortage overall. A high level of regulation around licensing ensures that the industry controls carry the weight of law. To be a free market, then anybody should be able to set up a practice by following well-documented regulations, and any regulation on licensing those facilities and practitioners must be quick and fairly low-cost, and should not require certifications or diplomas issued by anybody but the state (again quickly and at low cost). Anything else just isn't a free market to begin with. Car repair is a free market because I can start my own garage with minimal fuss assuming I can convince people that I know how to fix cars. Maybe medicine shouldn't be a free market, but if so we shouldn't just pretend that it is.
There really is no band-aid solution to the healthcare crisis. There are lots of things that do need to change. A few that I'd start with would include:
1. Publication of price lists. Every practitioner or facility must publish a price list prominently. The prices on the list are what get charged to everybody. Negotiating different rates with different payers is forbidden, and not collecting the full fee from some patients is forbidden. They can either accept patients at the published price, or not. Suddenly the guy without insurance pays the same amount as Medicare or Aetna or whatever.
2. Single-billing/accountability. You go to the hospital, the hospital sends you a bill for whatever was on the price list. You pay the bill, you're done. Doctors are either employees or sub-contractors of the hospital, and dividing the spoils is their own internal problem to figure out. If somebody messes up, the hospital is 100% liable to the patient, and then internally they can all fight over whose fault it is. More-or-less this is how insurance companies treat the situation anyway - a typical large-procedure explanation of benefits that I've seen tends to just go down the list and disallow most of the charges on it just paying a certain amount to the doctor and to the hospital based on what was done. Individual payers end up having to haggle with 87 different providers and never really know when the next bill will come. You can't really have a published price-list system if nobody knows what lists they have to check.
3. Published quality metrics. On the price list you have a column that indicates success rate for each procedure. Obviously these need to be standardized. Maybe have columns for % whose condition required no further intervention for n years, and % of patients who had serious complications. This requires auditing to work.
These kinds of steps would actually improve the whole system regardless of how we ultimately reform it. All are necessary for a free market to work effectively, and they would improve the current system and provide more information for the design of a single-payer system. I am under no illusions that they alone would entirely fix the problem. However, if you want shopping for health care to resemble shopping at Walmart you need to make the experience more like shopping at Walmart.
So, I'll be the first to agree that conventional medical research is a pretty torrid state of affairs. However, I'm not convinced the alternative world really has that much to offer either. Rarely are their claims backed by double-blind placebo-controlled clinical trials. When they are the results are usually inconclusive, but occasionally we find out something useful.
A big part of the problem is that there isn't enough money in alternative therapy to fund trials. The other problem is that there are just fundamental ethical limitations on experimenting on humans in general.
I'm all for having the NIH or whatever fund clinical trials on popular therapies, but somebody is coming up for the latest Oprah cure for cancer every other week, so there has to be some kind of filter around what you test.
The problem is that everybody and their uncle has a bottle of pills that sells for $50, a powerpoint deck explaining in all kinds of medical detail how it works, and a list of 100 people who swear that it works great for them. What very few have is any real evidence that they're right.
The only problem with expectation maximization is that if I wrote an algorithm that spat out "the patient just has a cold" I'd probably be right a good portion of the time. If it only output 20 diagnoses I'd probably be right 95% of the time.
The problem with medicine is people that aren't in the top 20 get almost no care. Or, they get care for one of their symptoms that is in the top 20.
There is always room for experimental medicine, and there should always be a budget for doing it. However, it is extremely wasteful to treat every patient encounter as a clinical trial.
Should insurers pay for a procedure that costs $100k, and has a 10% chance of extending life by a year? How about one that costs $1M but has a 2% chance of extending life 20 years (and a 98% chance of death in two months)? You'll always find somebody who had it done and lived, and they'll say the surgeon saved their life (which is true). Then EVERYBODY will expect to be one of that 2% and will insist on having a surgery which is only effective if we're willing to spend $2.5M/yr/patient to extend life.
Nobody goes into the OR saying, "yeah, I'll be the guy who doesn't make it."
Ultimately insurance or socialism is about putting a price on life - it just isn't fashionable to talk about it. I'd probably devise a system where people can at least name that value themselves and pay a premium accordingly. The problem is that discussing the value of life is a bit of a social taboo so you'll never see it happen.
Well, this is why a doctor is still on the hook to interpret the results.
Most doctors will probably just ignore it. In my experience the average doctor has the average treatment they're comfortable with when a patient comes in with a given set of circumstances. They get paid the same for the visit whether it takes 5 minutes or 50 minutes, and 99.999% of the time ruling out a rare ribosome disorder is time wasted. For 99.999% of the population that works out just fine, but if you happen to have a rare ribosomal disorder you're pretty much out of luck as every doctor you turn to will first start treating you for some common malady that is hard to diagnostically confirm.
In the real world, House would be driving a used car, even if he could miraculously diagnose problems correctly (which of course is unrealistic to begin with). He just wouldn't have enough patients to bill. The money is in extracting $100/day from every other patient in the hospital regardless of outcome.
Yup, and now think about the kinds of people getting ahead at work. Is it because they really write better code or offer better support or whatever than the next guy, or are they better at schmoozing? So, do you think that the doctor that has some big long title next to his name is likely to be different.
I've met some good doctors and some bad doctors in my life. You just work with what you have sometime. If you need to see 5 doctors quarterly chances are you can't really manage with each of them being in a different state.
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Uh, I'm a customer and I oppose the merger.
What do you propose - that I file a lawsuit against AT&T and T-Mobile? They'll no doubt have the jurisdiction transferred to some court halfway across the country, no doubt citing some provision in my contract that allows this. Then they'll probably try to dismiss it. I don't have the luxury of taking a year off of work to write legal briefs, or the money to fly out to deposition corporate shills and show up in courtrooms who knows where. It would be a hardship for me to try to spend a week in small claims court if that were even a legal option.
Generally speaking consumers react to these sorts of things by complaining to the government. You know, it is actually their job (FTC, FCC, etc) to regulate these things...
I'm a T-mobile customer, and I don't want the merger to go through. If I wanted to be an AT&T customer I'd have signed on with AT&T. I picked T-Mobile because their plans are cheaper, are more flexible, their phones are better (in my opinion), and they have less of a tendency to try to extort $800 out of you when somebody on your plan messes up.
If they get bought I suspect that they won't get around to dismantling 4G coverage for my phone before my contract ends. If they try to get rid of my plan I'll leave without an ETF. If they significantly scale down 4G coverage I'll claim failure to perform and leave without an ETF. At that point I'll figure out what my best option is and go with it, but most likely it won't be AT&T unless they REALLY get their act together.
Yeah, but those science books from 10 years ago are SO out of date. You know, the ones that talk about how lightning is just a form of electricity, that fronts form when differing air masses collide, and that the earth is round.
There is little reason for books to be replaced more than once every 10 years even at the college level, unless you're talking graduate-level classes (and graduate level classes don't really benefit as much from textbooks anyway). How much has Physics 101 changed in the last 10 years?
Well, I guess you could offer everybody $200k/yr but that would seem a tad expensive. How else would you propose to pay people a reasonable wage?
I'd note that when lawyers lose time for one reason or another and a court seeks to make somebody else pay for it that their hourly rate is taken into account. It only seems that normal people are considered to have time worth nothing.
And in the end I'd have the parties be the ones paying for it (well, the loser anyway). My solution for court costs is that the parties agree in advance on the amount at stake. Then the state sets aside a fund for fees for each side based on the amount at stake. Both sides pay for their side of the litigation out of those funds, and it would be illegal for anybody to accept a witness fee or fees for legal services from one of the parties directly (ie the fees of both sides are completely capped at the same amount). Firms that engage in other legal services (preparing contracts / etc) would be forbidden from appearing in court, except as parties of course. Then the loser of the case becomes indebted to the state in the amount of the total court costs for the trial (including the jury, operational costs, etc). The state can collect as with any other public debt like tax delinquency. I'd also have the court directly pay any damages/etc and collect them in a similar way. Parties shouldn't have to get involved in that kind of tit-for-tat stuff, and then there is no disputing who owes who what.
Oh, I'm under no illusions that any of this will ever happen, so it is a bit silly to spend too much time arguing about it. :)
Yup. Why even have a jury if they don't have any political role in the proceedings?
The whole reason juries were required in the constitution was as a check and balance against the power of government. If the government passed a horribly unjust law, then they would have trouble convincing 12 ordinary people to go along with it.
The real problem is that the nature of the economy is such that most people can't afford to spend a lengthy time on a jury. Serious trials take weeks to complete. I can't miss work for weeks. Oh, sure, they "can't fire me" and in fact my employer would pay me for my entire period of service. However, when I got back the expectations would be that I'd still complete all my projects on time despite having a month less time to do it. I can't even work harder, since most projects are collaborative and inevitably anybody else who is only helping out will just do what they can to not be found at fault and let the project be late. Sure, I can find a better employer, but most people can't, and the reality is that this is what most employers are like (in the professional world). If you're really behind at the end of the year then you're more likely to be let go the following year. Not a word of jury service will be mentioned when they let you go - you just will have "not worked out" or whatever.
The only reform I can think of is that jury members should be paid their normal salary plus a 10% bonus for jury service (and all of that from the state - the employer pays nothing). The employer of the juror should be paid compensation for the loss of opportunity - it should be more than a token amount. Then people are less likely to have hard feelings about jury service. The cost of operating a court is already enormous, and should be considered the cost of justice. Now, I'm also in favor of reforming how court costs (both of the court and the parties) work out, but that is really a separate matter. Reforming how the costs work would defray the impact to taxpayers of having to pay jurors more than $10/day or whatever your local jurisdiction offers.
Obviously they're not very well coordinated either. With all the plate-scanning technology and cameras floating around, I'm sure they could have tracked him without the GPS.
Part of me is tempted to try to create an open-source database where anybody who wants to can just set up a camera and upload faces, license plates, locations, and timestamps to some central repository. I suspect that the people that you'd prefer not to have access to this sort of thing already have it. What would society look like if EVERYBODY knew the location of EVERYBODY all the time?
Maybe privacy is just something incompatible with the information age. Social taboos and such will just have to evolve to handle a society where everybody you know does stuff you'd prefer that they didn't and everybody knows it.
I dunno - if you're convinced the game is rigged then the only way to win is not to play. I plan to work until I die, or until you end up taking care of me (assuming inflation and crashes don't destroy the value of your savings)...
Ok, imagine if you required a cashier at Walmart to have a witness come over every time the drawer opened, and count the money three times. Actually the drawer would be in a separate room from the customer to reduce the risk of theft. Every sale takes 30 minutes. Security is improved, but nobody would want to shop at Walmart. To prevent odd losses of $20 a day the company puts itself out of business. It just doesn't make sense.
Well, it is the same thing on Wall Street, but with a bunch of zeros added. If you make every trader quadruple-check things every time they want to spend $50M that will slow things down. In the end the firm is likely to lose more in opportunity than the odd $10M in embezzlement here or there.
I know somebody who was involved with Wall Street, and he said that people there tend to lose any normal sense of the worth of money. When every time you make a phone call $50M changes hands and you get $1M of that it is kind of hard to have a perspective.
I'm sure the rate of waste/loss is the same as in any other industry. The problem is that since trillions of dollars are changing hands a few percent is like the economy of many medium-sized nations.
Uh, the shuttle isn't really capable of making significant changes in orbit - beyond what is possible with another launcher. In particular inclination changes are very expensive. Plus, these satellites are big so it isn't like the shuttle could carry a bunch on one flight.
The original concept behind the shuttle was launching something or taking pictures from polar orbit and de-orbiting on the swing back around the earth, landing back where it started (ie a suborbital flight that just barely makes it around the earth once). This is why it needed wings, since the launch facility would be a few hundred miles east of the orbital path. It never actually did this. In fact, I'm not sure what its cargo capacity to polar orbit would be, or how much it could return to earth with such an orbit (it takes more energy to get to polar orbit and that is more energy to bleed off on re-entry).
Then whoever develops the systems used for any kind of national healthcare system should create something better. Doctors in Zimbabwe can use codes from a 1960s-era mainframe if they want to.
Vast quantities of money get spent on the present ICD9 system, and in most cases people just work-around all the complexity by using a handful of more generic codes anyway.
That's because as far as I can tell nobody really uses them in this way.
I doubt most doctors would use separate codes for turtle bites, cat bites, dog bites, and termite bites. Most likely they'd just figure out what the code is for animal bite and use it for everything. Or maybe the code for "bleeding wound" or "puncture wound" or something.
Just because you give somebody 140k choices in a drop-down doesn't mean that they actually sincerely try to find the one that best fits. Unless picking the right option actually changes how much they get paid they're not going to bother.
Should the system used to drive insurance billing in a national-scale health system in the first world be based on a design that has to first start with the assumption that the user might be in Zimbabwe and could not afford a computer?
To take the turtle example, previously if you were interested in turtle accidents, you may have needed to look under "reptile" "turtle" "tortoise" or maybe even just "animal". For that matter some people call snapping turtles just "snappers", which of course is also a kind of fish. Now with standard coding it is easier to find quickly who is being hurt by turtles, how often, when, and where.
No, you still have to search for all that other stuff, because why would a doctor's office classify a problem as a turtle accident when they could just capture it as a "bite wound?" Or better still something even more generic.
I've seen more than a few ICD codes on billing forms and such. A typical office just has half a page of billing codes and the secretary just checks off the one that is closest. Now, if the insurance company would pay them $1k to fix a turtle bite but only $200 for a generic bite wound, then they might take the time to classify it (assuming they even realized the code is available and they treat enough turtle bites for it to be worth their time to check).
People approach these kinds of problems like a programmer, and they really need to stop and see how people really use these systems. If you want a practitioner to hunt through 140k codes then you need to give them some incentive to do so. Otherwise they'll pick the most generic term that gets them the money they want so that they can send in the form and get back to treating patients.
Agreed - I've seen this sort of thing at work.
Humans just aren't good at doing table joins, and other things that make perfect sense if you're a programmer.
You really need to minimize the number of choices a user is presented with at any time - really no more than 10-20 and there can't be any ambiguity between them.
A hierarchical system is probably going to be better as a result. This way nuanced diagnoses are grouped together so that users can first determine if the person is sick vs dead, and then if a limb was removed or not, and then whether the limb is an arm or a leg, and only at the end you figure out if the pinky finger was removed at the first or second digit.
Even so, I think this is almost doomed from the start if the goal is to get to this level of granularity. If a guy is shot in the heart do you browse down through heart problems, gunshot wounds, and so on. If somebody died because of some genetic problem that caused them to have a heart attack is that under heart problems, genetic problems, or problems with blood vessels (which caused the heart attack), and so on.
The only reason that somebody would take the time with the current system to fish through all of that for a more specific code is if it somehow makes a significant difference in their compensation or whether they are compensated at all (which is often the case for a practitioner submitting to an insurance company).
I agree with your statement on the differences.
The reason for banning other types of exchanges is to reduce the impact that algorithmic and other short-sighted forms of trading have on the economy in general. Companies don't change their intrinsic value 400 times per day (at least not in any knowable way), so why should their stock prices change this often?
The financial system operates with unnecessary granularity, and this tends to cause behaviors that aren't good for the economy as a whole.
User: What is five plus three?
Cleverbot: Seven.
User: That's clever!
Cleverbot: What does 'réseau' mean?
User: Your guess is probably almost as good as mine...
Cleverbot: My guess is better.
User: Better in a five plus three way?
Cleverbot: In the way of two words being conjoined as one.
Actually, it would be nice if it could plan a trip and even suggest airports based on planned time of arrival and proximity of both the departure and arrival airports.
If I want to be at 123 Abc drive in LA at 4PM on Saturday, and I'll be leaving from my house, it would be nice to find out that I can avoid an 8-hour layover by driving to a different airport 20 minutes further away from my house, or whatever. Combining the two databases makes that possible.
The collecting asks/bids is called 'auction' and it is already available.
Yes - it is how every exchange works. Or at least, it is how all the ones I'm aware of work. Typically however they execute as soon as two orders meet and not at a fixed time interval.
The idea of market participants not knowing of each other's orders is called 'dark pool'. They do exists and people use them. If you want to trade this way, you can do it.
I wasn't suggesting that nobody know what the other orders are. Only that they be pooled for a day before they are executed.
Whoever goes to this 'corrupt' 'first-in, first-served, executed ASAP' exchanges does it voluntary.
I didn't say anything about the order of execution either. I'd execute all ASKs/BIDs at the same price, set to maximize volume on that stock for the day. Order would be highest BID and lowest ASK first, and first-in, first-served when there is a tie. Yes, I realize that this means that Joe Investor can see that Goldman placed an order to buy 50M shares at $10 and place an order to buy 100 shares at $10.01 and get ahead of them (assuming the day doesn't end before they do, and that they feel the extra cent is worth paying).
I'm not quite sure what makes my suggestion "corrupt." And it wouldn't be voluntary (well, participation would be voluntary, but running a different kind of exchange would either be forbidden, or it would be closed to participation by individuals who aren't wealthy, or by any fund containing money belonging to or in stewardship for individuals who aren't wealthy).
Really the only big change I'm proposing is that stocks only swap hands once a day at a single price, and that there be no advantage for being faster than the other guy by more than a day.
Free Market healthcare already does that, so why bother creating a new one?
Uh, where is this free market healthcare system you're referring to? I only have a choice of a few reasonably-priced plans offered by my employer. Many people don't even have that. Or, you can shop on the "free market" and pay a fortune for a very mediocre plan. Or, you can just wait until you're sick and find out just how kind and generous the medical establishment is by sending you bills totaling $100k for a procedure that no insurer would pay more than $10k for, and then acting like they're doing you a favor by knocking it down to $50k.
Not if insurance companies (or the Federal government) are paying for them, there's not. Or do you really believe that Medicare pays for experimental treatments?
Read the entire line: "However, it is extremely wasteful to treat every patient encounter as a clinical trial." Medicare shouldn't be paying for experimental medicine - the NIH should. Patient participation in experimental medicine should only be permitted if it actually furthers the goals of science, or if the patient or another private party is willing to foot the bill themselves. When doctors make whimsical decisions around whether a treatment is necessary, that IS experimental medicine. Routine treatment should be based on evidence.
Medicare was just an example - insurers in general control prices, and necessity of procedures.
If you want to have a free market you need a couple of things:
1. Effective patient choice. If a patient can't actually choose what doctor will do the work, then they have no negotiating power, and uncontrolled prices will rape them. A patient has no choice if they are unable to make a decision, or if the facility they are at only makes one doctor available to them (or all the doctors at a facility charge the same price), or if there is risk involved in transferring to another facility. All of these are often the case in acute care - so acute care is a very poor candidate for free market pricing.
2. Knowledge. If it is hard for a patient to compare the quality and cost of services from one facility to another, then there is little incentive for those facilities to improve either.
3. Free supply. The number of doctors is something which is controlled by the industry to ensure a shortage overall. A high level of regulation around licensing ensures that the industry controls carry the weight of law. To be a free market, then anybody should be able to set up a practice by following well-documented regulations, and any regulation on licensing those facilities and practitioners must be quick and fairly low-cost, and should not require certifications or diplomas issued by anybody but the state (again quickly and at low cost). Anything else just isn't a free market to begin with. Car repair is a free market because I can start my own garage with minimal fuss assuming I can convince people that I know how to fix cars. Maybe medicine shouldn't be a free market, but if so we shouldn't just pretend that it is.
There really is no band-aid solution to the healthcare crisis. There are lots of things that do need to change. A few that I'd start with would include:
1. Publication of price lists. Every practitioner or facility must publish a price list prominently. The prices on the list are what get charged to everybody. Negotiating different rates with different payers is forbidden, and not collecting the full fee from some patients is forbidden. They can either accept patients at the published price, or not. Suddenly the guy without insurance pays the same amount as Medicare or Aetna or whatever.
2. Single-billing/accountability. You go to the hospital, the hospital sends you a bill for whatever was on the price list. You pay the bill, you're done. Doctors are either employees or sub-contractors of the hospital, and dividing the spoils is their own internal problem to figure out. If somebody messes up, the hospital is 100% liable to the patient, and then internally they can all fight over whose fault it is. More-or-less this is how insurance companies treat the situation anyway - a typical large-procedure explanation of benefits that I've seen tends to just go down the list and disallow most of the charges on it just paying a certain amount to the doctor and to the hospital based on what was done. Individual payers end up having to haggle with 87 different providers and never really know when the next bill will come. You can't really have a published price-list system if nobody knows what lists they have to check.
3. Published quality metrics. On the price list you have a column that indicates success rate for each procedure. Obviously these need to be standardized. Maybe have columns for % whose condition required no further intervention for n years, and % of patients who had serious complications. This requires auditing to work.
These kinds of steps would actually improve the whole system regardless of how we ultimately reform it. All are necessary for a free market to work effectively, and they would improve the current system and provide more information for the design of a single-payer system. I am under no illusions that they alone would entirely fix the problem. However, if you want shopping for health care to resemble shopping at Walmart you need to make the experience more like shopping at Walmart.
So, I'll be the first to agree that conventional medical research is a pretty torrid state of affairs. However, I'm not convinced the alternative world really has that much to offer either. Rarely are their claims backed by double-blind placebo-controlled clinical trials. When they are the results are usually inconclusive, but occasionally we find out something useful.
A big part of the problem is that there isn't enough money in alternative therapy to fund trials. The other problem is that there are just fundamental ethical limitations on experimenting on humans in general.
I'm all for having the NIH or whatever fund clinical trials on popular therapies, but somebody is coming up for the latest Oprah cure for cancer every other week, so there has to be some kind of filter around what you test.
The problem is that everybody and their uncle has a bottle of pills that sells for $50, a powerpoint deck explaining in all kinds of medical detail how it works, and a list of 100 people who swear that it works great for them. What very few have is any real evidence that they're right.
The only problem with expectation maximization is that if I wrote an algorithm that spat out "the patient just has a cold" I'd probably be right a good portion of the time. If it only output 20 diagnoses I'd probably be right 95% of the time.
The problem with medicine is people that aren't in the top 20 get almost no care. Or, they get care for one of their symptoms that is in the top 20.
There is always room for experimental medicine, and there should always be a budget for doing it. However, it is extremely wasteful to treat every patient encounter as a clinical trial.
Should insurers pay for a procedure that costs $100k, and has a 10% chance of extending life by a year? How about one that costs $1M but has a 2% chance of extending life 20 years (and a 98% chance of death in two months)? You'll always find somebody who had it done and lived, and they'll say the surgeon saved their life (which is true). Then EVERYBODY will expect to be one of that 2% and will insist on having a surgery which is only effective if we're willing to spend $2.5M/yr/patient to extend life.
Nobody goes into the OR saying, "yeah, I'll be the guy who doesn't make it."
Ultimately insurance or socialism is about putting a price on life - it just isn't fashionable to talk about it. I'd probably devise a system where people can at least name that value themselves and pay a premium accordingly. The problem is that discussing the value of life is a bit of a social taboo so you'll never see it happen.
Well, this is why a doctor is still on the hook to interpret the results.
Most doctors will probably just ignore it. In my experience the average doctor has the average treatment they're comfortable with when a patient comes in with a given set of circumstances. They get paid the same for the visit whether it takes 5 minutes or 50 minutes, and 99.999% of the time ruling out a rare ribosome disorder is time wasted. For 99.999% of the population that works out just fine, but if you happen to have a rare ribosomal disorder you're pretty much out of luck as every doctor you turn to will first start treating you for some common malady that is hard to diagnostically confirm.
In the real world, House would be driving a used car, even if he could miraculously diagnose problems correctly (which of course is unrealistic to begin with). He just wouldn't have enough patients to bill. The money is in extracting $100/day from every other patient in the hospital regardless of outcome.
Yup, and now think about the kinds of people getting ahead at work. Is it because they really write better code or offer better support or whatever than the next guy, or are they better at schmoozing? So, do you think that the doctor that has some big long title next to his name is likely to be different.
I've met some good doctors and some bad doctors in my life. You just work with what you have sometime. If you need to see 5 doctors quarterly chances are you can't really manage with each of them being in a different state.