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I firmly believe that "single payer" would get a lot more support if people stopped talking about it in grandiose themes and noble vignettes and started talking about it in real terms. All the liberals I know are in heavy favor of "single payer" without any of them knowing what the fuck it is.

HERE'S WHAT THE FUCK IT IS.

I've got a medical facility - Al's Medicine. Al's subcontracts to Betty the Biller and Cindy the Client Specialist. I operate in a state where my medical facility is covered by Medicaid. We also take private (employer-provided) insurance, which is underwritten by the following insurance firms: Q, R, S, T, U, V, W, X, Y and Z.

Al's must sign individual contracts with Q, R, S, T, U, V and W. These contracts are "take it or leave it" binding: they say that for ICD code 1, Q will pay Al's $7.50 but for ICD code 1.000000001, Q will pay Al's $0.00 because fuck you, Al's. Note that Q might pay Joe's $6.50 or $9.50 or pi.ie^2 for ICD code 1. Q is entirely within its rights to do so. Al and Joe, on the other hand, are contractually forbidden from discussing their rates for ICD Code 1. If Q gets wind that Al and Joe know what the other are getting, they can drop both because fuck you, Al and Joe. Also know that Joe might not get anything for ICD Code 1 because Q has decided that all of Q's contracted healthcare clients can drive 75 miles to Al's for those services because fuck you, Joe. Also know that Q can tell Al's they'll pay $7.50 for "services" verbally and in writing, but when the actual contract comes through the actual number listed is $2.25 because fuck you, Al's. Also know that they won't tell you what ICD codes they'll pay for, they'll just say "services" and let you resubmit your bills over and over and over again until you find the ICD code that pays out the most because fuck you. Also know that the ICD code they choose to pay for can and will also change because fuck you.

A few other notes: Al's might have to provide, for example, rhogam shots to prevent babies from dying from blood type incompatibiliy. These rhogam shots might cost Al's $28 but Q is going to pay $7 because fuck you, Al's. If you ever wondered why hospitals charge you $40 to hold your baby it's because they're trying to claw back the $21 the insurance company isn't paying for medicine they're required by law to administer (for example). Also note that your involvement, gentle consumer, starts when you get an "explanation of benefits" from the insurance company listing all the outrageous charges the doctor hit you with. It will provide no explanation. It will show how generous they were in all their disbursements and then show you that your doctor's office is going to bill you STILL MORE MONEY because they're such bloodsuckers.

This is where Betty Biller and Cindy Client Specialist come in. Betty makes 10% by pickaxing all the money she can get out of Q. Betty's whole job is knowing what Q pays out on. Betty knows which ICD codes Q pays out what on, and can turn your "normal child checkup" into 42 different codes that pay the maximum rate Q has contracted to pay. She is literally a medical billing bounty hunter. Betty is the back office side while Cindy talks to you, the client - here's what's coming, here's what it means, here's how to get your insurance to pay for this ahead of time, here's how to get preapproval for that.

For those keeping track at home, billing specialists outnumber doctors 2:1 in this scenario.

Multiply times insurance companies R, S, T, U, V and W, who all have their own rates, all have their own codes, all have their own geographic exclusion areas, and probably have seven or eight sub-plans so that it's not actually "V" it's V.a, V.b, V.c, V.d, V.e, V.f and so on. Suddenly, Betty and Cindy look positively useful and you will pay them gladly because the act of billing for care takes three to four times as many man-hours as actually providing that care. Betty and Cindy make good livings and their existence is entirely parasitic on the insurance companie's deliberately opaque, byzantine and antagonistic reimbursement practices.

Not Y and Z, though. Y and Z contract through Medicaid. Medicaid has no patience for that bullshit. They will pay the following amounts on the following ICD codes. Anybody who contracts through Medicaid bills those codes and gets that money. It is known. Y knows, Z knows, Al knows, Joe knows, and all of Al and Joe's clients can fuckin' look it up. And when Medicaid's reimbursements lag behind the real world, it gets turned into a bill that goes to the legislature that raises the rates for everyone.

Al's, in fact, might get better reimbursements out of Y and Z (because of medicaid) than they get out of Q, R S, T, U or V.

Unfortunately you as a patient don't get your insurance through Y and Z because you make more than the poverty level for your county. You get whatever insurance your job provides, which might be V.c, might be Q, might be nothing because you drive for Uber and fuck you.

As a provider, we get to choose who we contract with. We do not get to choose what those providers pay us. And if 50% of your clients work for Microsoft, you bloody well better be able to take V.c, despite the fact that they reimburse at exactly half what Medicaid reimburses at (which is funny, because all your Microsoft mommies make six figures). R, on the other hand, may decide that they'll never cover you because they have enough of your specialty in network, never mind that the nearest provider is a ferry ride away (because this way they don't have to pay for those services).

As an insurer, you get to decide who you contract with. You can pick the providers that are the stupidest, that will accept the lowest rates, that have the lowest conflict rate of you arguing over charges. And you get to discuss this with the HR reps of companies large and small, none of which have any background in medicine, medical billing, accounting or statistics. To no one's surprise, they choose on price.

But the poor people? They pay what the state says they pay, the insurance companies collect what the state says they collect, and they contract with the providers the state says they contract with.

THEY STILL MAKE MONEY.

They're still private insurance companies, privately managing your health care, privately paying out private doctors. It is not "socialized medicine." It is not "universal healthcare." It is not the National Health Service. The healthcare industry is something like a tenth of the US economy; you're never getting that. But you go single payer and all of a sudden things go from back-room knife fights between Q, R, Betty and Cindy to state-mandated pricing and state-mandated coverage.

My future is tied to health care. I've got more in a medical practice than you have in your house.

And I'm a big booster of single payer.

And so's Aetna, who in this example is R.

by: kleinbl00

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kleinbl00  ·  link  ·  parent  ·  post: Pubski: June 5, 2019

IMPOSTER SYNDROME

Had Veen and 'bootz out last week. Veen for ten days, 'bootz for three. Did much hosting. Had many "what do I do with my life" conversations. Drank astonishingly little alcohol. Spent a few hours showing veen how to take apart a watch; apparently the parts Elgin I bought last year is hella more hammered than even I knew 'cuz my screwdrivers looked brand new for the past two years but as soon as I had to get the dial off that thing I'd snapped two blades.

Veen asked if I ever experienced "impostor syndrome" when it came to watchmaking. It's a fair question. After all, two years ago I knew virtually nothing. Thing of it is, though, it's an extremely shallow field. Immersing myself in it for a year and a half has me revealing manufacturers and history my instructors never knew, manipulating small parts my instructors can't manipulate and knowing by heart industry statistics that lifelong watchmakers are completely incredulous about.

I learned as an acoustical consultant - a trade that requires a mechanical engineering or physics degree and several years experience with esoteric empirical knowledge - that the way you prove your worth in a gnostic field is by slagging on others. The normies don't know so if you piss all over everyone else they assume you're pissing with reason. And watchmakers piss all over everyone. As a group their shit doesn't stink and if you ask 'em questions they'd best put your ass in its place. Their Facebook groups are largely about how stupid customers are, how stupid vendors are, and how horrible everyone is to their preciousssssss.

Here's the thing, though. A mechanical watch movement has between 50 and 250 parts, from the most basic to the most fiddly chronograph. Yeah there are watches with more but really, it's a bunch of gears ("wheels") and axles ("pinions") and other jargon and they only interact mechanically. The engine your Toyota has 5-600 parts and that's just the mechanical shit. A fuckin' fuel injector is like 30 parts and for it to work you've got fluid mechanics, electromechanics, electronics and thermodynamics. Not only that but your average "watchmaker" has no idea how to do anything other than fix the mechanical bits and polish what's there. It's a specialist field where nearly everything else is farmed out to other specialists. And I've been spending the past year neck deep in the "other specialists" shit - I've mixed three seasons of television while also earning sixty college credits in the past year while also spending maybe 300 hours (and $28k or so) in pursuit of "watchmaking" (which is what we call "being a watch mechanic"). I know more about watches and their repair than a few manufacturers I know.

But my daughter was whiney on Sunday. There was a little drama. She insisted she wasn't whining. I let her know (during the hug-it-out period) that if I'd used her tone of voice when I was a kid I would have been shouted at, possibly spanked and sent to my room without any supper and that sometimes I have a hard time when she does stuff I wasn't allowed to do, even if the stuff I wasn't allowed to do didn't really make sense. She asked why my parents were so mean. I said I didn't know. She asked if I told them to stop being mean and I said "I didn't know they were mean, they were the only parents I had" and she said "but you aren't mean" and I burst into uncontrollable tears.

And I mean, she doesn't know. She has no more insight into my suckitude than I had into my parents'. But I had a pretty good idea by 3 that my relationship with my parents was dissimilar to my peers. And whereas every picture I have of myself as a youth is of a haunted-eyed little spooky kid, my daughter is happy to the point of mania in photos. The great thing about kids is they love you unreservedly and worship everything you do (until they become teenagers, anyway). The terrible thing about kids - for me, anyway - is that you're never, ever worthy of it.

I am blowing off the rest of my schooling. Jewelry class for the past 10 weeks has been bang-on-shit-with-a-hammer class and I have received exactly zero instruction. I crafted a silver cup from a sheet using nothing but a hammer - it looks like a Riedel stemless champagne flute. I coated it in Japanese enamel to see what the colors look like. And it looks amateurish and silly because I received zero instruction in enameling. I have some interesting parts from that class, but everything I made I made without any input or insight from anyone while also being sniped by everyone around me (because jewelers are like watchmakers but with less schooling). And I cleaned out my bag, and I'm going to take the F (I'm yearning for that F - I'm eager to have it sit there - so that the instructor knows we're enemies now), and I'm going to pursue my own thing because where I'm going I don't need roads. I set micro-pave last year without knowing the first thing about it and while it looks like hammered shit, the next one won't and if you set out to learn how to do micro-pave the first thing you do is apprentice in Antwerp and get yourself a $2500 microscope.

But I've got a Valjoux 7750 that's misbehaving and when you look up the symptoms the Internet tells you to "take it in for service" and what they don't tell you is that at the price point of that 7750 the "servicepeople" are going to swap the movement and I'm wondering if I fucked it up by wearing it in beat-on-shit-with-a-hammer class. See, I know beyond a reasonable doubt what I know about fixing watches. But when the internet tells me I have no idea how to wear a watch I'm perfectly willing to believe them because I'm fucking white trash and I know it down to my very bones.

This washed across my transom this morning. You don't need to click on it. It's a puff piece about a jeweler opening a new boutique. They're spending about $1.3m and creating ten jobs. Woo hoo. News piece. I built a birth center with about $350k and our payroll now has nine people on it. We're setting up a Vaccines for Children program and it's going to be three phone calls, one contractor and three SKUs purchased. We'll be up in a month. Shit's trivial. Sure as fuck isn't worth making an international trade magazine.

My daughter spent her weekend putting together "scent packs" - her idea of play is to pick herbs, wrap them in paper, put together a merchandising display and haul it into class in an egg carton so that she can dominate a pinecone economy she created. Yeah. My daughter is getting others to hoard pinecones for her by selling artisanal herbs out of my garden. Told my wife this wasn't something all the kids had come up with, like we thought, but my daughter's idea and she said "well it's not surprising, she is the daughter of two entrepreneurs, after all." I immediately said "well, one entrepreneur and one loser who wastes a lot of time and money on useless knowledge." She was quiet for a minute and then said

"That's you talking, not me."

I spent $1300 so that Christie's could teach me the history of jewelry design. It's not a course for jewelers, it's a course for bored old rich ladies. I tell you what, though - ain't nobody in there gonna say that you should feel bad for owning gold jewelry because it's mined illegally in the Amazon for use in iPhones. When I'm done I hope to have a rich old lady's understanding of jewelry as propagated by Christie's because it's hella more useful to me than an angsty community college assistant's understanding of jewelry as propagated by indignant environmental movies. After all, jewelry makers call byzantine chain "idiot's delight." Jewelry sellers call it ten grand.

George Friedman recommended the works of Herman Wouk yesterday. This passage caught my eye:

    Even more instructive was the character Armin von Roon, a German general and aristocrat, whom Pug Henry met in Germany, and who wrote an operational analysis of the war that Henry translates into English. Wouk explains German strategy in detail and unapologetically. He argues powerfully that Germany was forced into a war it didn’t want and lost it only because of the ruthless cunning of Roosevelt. I didn’t agree with it, and I thought he was falsifying history, yet Wouk’s emulation of a brilliant German general explaining his country was, in my view, Wouk’s moment of genius. It was not just that he explained it but, in that passage, he reminded me of something I learned in philosophy. I was taught that you must understand a philosopher as he understood himself. Wouk showed that you must understand a nation as it understands itself. You may take issue with philosophers of a nation, but only after you have disciplined yourself to understand them as they understand themselves. And when you do that you not only understand important things, but you learn to compel your soul to listen and learn, even from evil. From Wouk I learned the suspension of judgement without plunging into the abyss of relativism.

"Impostor syndrome" is, to me, the "abyss of relativism." I know what I know about the outside world because I can vouch for that knowledge. I fought for it, I tested it, I verified it, I expanded it into corners it was never meant to illuminate. The inside world is, has been and shall always be a dark and dismal failure because my n will never be greater than one.

I have no doubts that I will be able to create and sell luxury timepieces. And I have no doubts that I will feel uncomfortable wearing one for as long as I draw breath. And that's pretty much where I am this Wednesday.

Cheers.