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RealSimulD said:
Like if I’m Walmart, the hell I’m paying $150k for prostate IMRT. We can fly them all in and get treated at CARTI
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I think Attia asks this same question at some point. #133 - Vinay Prasad, M.D., M.P.H: Hallmarks of successful cancer policy - Peter Attia

Why do insurers impose pre-authorization requests and other requirements that make things difficult for doctors?

  • One, the insurer’s incentive is to make sure year-to-year variability of costs is predictable and that they can model that out and make sure their premiums go where they need them to go to ensure their profit revenues
  • Also, insurers don’t have enough skin in the game to keep costs down, so they really don’t care
    • Peter thinks it’s the employer that has the most skin in the game
    • “But the problem is they’re so disaggregated and so spread out that they can’t speak in a unified way and they can’t fight in a unified way.”
 
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RickyScott said:
I think Attia asks this same question at some point. #133 - Vinay Prasad, M.D., M.P.H: Hallmarks of successful cancer policy - Peter Attia

Why do insurers impose pre-authorization requests and other requirements that make things difficult for doctors?

  • One, the insurer’s incentive is to make sure year-to-year variability of costs is predictable and that they can model that out and make sure their premiums go where they need them to go to ensure their profit revenues
  • Also, insurers don’t have enough skin in the game to keep costs down, so they really don’t care
    • Peter thinks it’s the employer that has the most skin in the game
    • “But the problem is they’re so disaggregated and so spread out that they can’t speak in a unified way and they can’t fight in a unified way.”
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Transcript? It may just exceed my smarm tolerance
 
RealSimulD said:
I understand that

But how does negotiation work then? If you’re saying the company is paying the bills and the insurer is admin, the company has incentive to lower prices.
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RickyScott said:
They absolutely do have an in incentive to lower costs, but supposedly they are not very good at because of the all the hidden prices and Byzantine structure. Evercore etc are services that insurers contract with to help companies lower costs, but utilization is not nearly as much a problem as prices.
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The insurance company execs get bigger bonuses when they facilitate bigger payouts by the companies; this is strictly on the employer funded insurance/healthcare side. It’s a little perverse. As unreal as it seems, I think RickyScott is right and a lot of companies get fleeced for lack of better word.
 
TheWallnerus said:
The insurance company execs get bigger bonuses when they facilitate bigger payouts by the companies; this is strictly on the employer funded insurance/healthcare side. It’s a little perverse. As unreal as it seems, I think RickyScott is right and a lot of companies get fleeced for lack of better word.
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If they de-monopolized both the insurance industry and healthcare providers (looking at you, UPMC, Penn, etc), then b2b negotiations would be more efficient and lead to improved outcomes for those not currently in a monopolistic position. I'm not holding my breath. Regulatory capture is hard to overcome.
 
TheWallnerus said:
The insurance company execs get bigger bonuses when they facilitate bigger payouts by the companies; this is strictly on the employer funded insurance/healthcare side. It’s a little perverse. As unreal as it seems, I think RickyScott is right and a lot of companies get fleeced for lack of better word.
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Goldman Sachs and the New York teachers union are simply not going to exclude mskcc from their network. As was mentioned before, this had a major impact on car companies and constant threat to health of california state workers pensions.
 
OTN said:
If they de-monopolized both the insurance industry and healthcare providers (looking at you, UPMC, Penn, etc), then b2b negotiations would be more efficient and lead to improved outcomes for those not currently in a monopolistic position. I'm not holding my breath. Regulatory capture is hard to overcome.
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Have to start with price transparency. I never thought I would see the day that a tax payer supported “Public Nonprofit” mdacc would rather break both federal and state laws rather than disclose prices.
 
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RickyScott said:
Have to start with price transparency. I never thought I would see the day that a tax payer supported “Public Nonprofit” mdacc would rather break both federal and state laws rather than disclose prices.
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Correct, waaaaay more important than trying to deregulate anything. Some level of regulation is necessary for any public good, whether we are talking healthcare or the electric grid (ask Texas how deregulation of ERCOT worked out).
 
medgator said:
Correct, waaaaay more important than trying to deregulate anything. Some level of regulation is necessary for any public good, whether we are talking healthcare or the electric grid (ask Texas how deregulation of ERCOT worked out).
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Agree re: regulation and public goods, and of course any capitalistic market needs to be regulated. However, I would argue that healthcare is not a public good, as it is both practically excludable and consumable (as opposed to, say, national defense).
 
OTN said:
Agree re: regulation and public goods, and of course any capitalistic market needs to be regulated. However, I would argue that healthcare is not a public good, as it is both practically excludable and consumable (as opposed to, say, national defense).
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There is no such thing as a capatilalistic market without price transparency.
 
The problem with healthcare as an "industry", in my opinion, is that it can create both supply and demand completely on its own.
No other industry can actually create both demand and supply, up to infinity, in the magnitude that healthcare can.

Sure, Apple can persuade all of us that we need one iPhone. But persuading me that I need two iPhones? That's gonna be tricky.
An unregulated healthcare can however persuade the average person that she/he needs another diagnostic procedure (even it's totally pointless).

There are different ways how to regulate that. One is state intervention, the other is that the market itself regulates it (the problem here being that the market will need to find a reason why to do so), the third way being total transparency.
 
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Palex80 said:
The problem with healthcare as an "industry", in my opinion, is that it can create both supply and demand completely on its own.
No other industry can actually create both demand and supply, up to infinity, in the magnitude that healthcare can.

Sure, Apple can persuade all of us that we need one iPhone. But persuading me that I need two iPhones? That's gonna be tricky.
An unregulated healthcare can however persuade the average person that she/he needs another diagnostic procedure (even it's totally pointless).
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All true, but imagine buying an iPhone and not knowing how much it costs/you paid.
 
There's certainly a transactional component as others have mentioned here, but I think we are way oversimplifying this insurance process 🙂. The majority of cancer patients are seniors who are Medicare or Medicare Advantage. These aren't transactional relationships. Medicare Advantage plans are heavily incentivized to exclude the MSKCCs of the world. The Medi Advantage plans are basically paid a certain amount per senior by CMS and they keep what they don't spend. Some of the biggest healthcare profits come on the Medi advantage side, which is why there is such a strong push to get seniors into these plans. They absolutely don't want 1000% of Medicare MSKCC, MD Anderson, City of Hope, and all of the other NCI designated centers ****ing with their bottom line. At the same time, they can't completely exclude those entities because they have to give patients the illusion of choice. It's very much a balancing act that differs by region and is ultimately driven by actuarial science.
 
Reaganite said:
There's certainly a transactional component as others have mentioned here, but I think we are way oversimplifying this insurance process 🙂. The majority of cancer patients are seniors who are Medicare or Medicare Advantage. These aren't transactional relationships. Medicare Advantage plans are heavily incentivized to exclude the MSKCCs of the world. The Medi Advantage plans are basically paid a certain amount per senior by CMS and they keep what they don't spend. Some of the biggest healthcare profits come on the Medi advantage side, which is why there is such a strong push to get seniors into these plans. They absolutely don't want 1000% of Medicare MSKCC, MD Anderson, City of Hope, and all of the other NCI designated centers ****ing with their bottom line.
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Same logic as to why they contract with optum and evilcore to deny igrt/imrt etc as often as possible
 
Neuronix said:
Eh, it depends on how many particles you're looking at.

View attachment 358587
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RickyScott said:
Put a photon detector in one of the slits and the interference pattern disappears! True for elecltons as well. Look at it and the wave dissapears.(no longer superposition) Very disturbing. What counts as an observer- a cat a flea on the cat etc? Solvay conference in 1920s concluded with the Copenhagen interpretation of quantum mechanics.
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Lamount said:
Observing a photon/electron (and/or any form of matter) as a particle will eradicate wave-like properties and vice versa. This "observation" phenomenon (whereby the wave function collapses upon making a measurement) exists throughout experimental quantum physics... though surprisingly, it is not explained by the mathematics of quantum physics.

From my perspective, the only satisfying explanation is the "many worlds" hypothesis.
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communitydoc13 said:
Bothers me.

Like @TheWallnerus said, one photon at a time will create the interference pattern.

Like @RickyScott said, block one slit to know where the photon/electron is and there is no interference pattern.

What doesn't bother me....

Quantum suicide and immortality - Wikipedia

en.wikipedia.org en.wikipedia.org

What @Lamount said.
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one more

 
OTN said:
What a terrible waste of time, energy, and effort.
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It throws off mets too.

Other proton centers will give the same schedule/recommendations at tumor boards based upon the great mayo experience. I saw it happen with the MDA (thanks, Ben Smith) proton APBI reports.

So it's not like these places just have an in-house protocol. Others replicate it and advocate for it.
 
BobbyHeenan said:
It throws off mets too.

Other proton centers will give the same schedule/recommendations at tumor boards based upon the great mayo experience. I saw it happen with the MDA (thanks, Ben Smith) proton APBI reports.

So it's not like these places just have an in-house protocol. Others replicate it and advocate for it.
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I don't understand why all we have is phase II data these days. Couldn't they have done this in a truly randomized fashion? We have good data which shows that non-randomized phase II data is often not replicated in phase III trials. Why aren't we performing the highest-quality clinical trials we can? Where the hell did "non-inferiority" come from all the sudden? Why did they make me take all those biostats classes in 1st year of med school if we were just going to ignore their basic tenants?
 
OTN said:
I don't understand why all we have is phase II data these days. Couldn't they have done this in a truly randomized fashion? We have good data which shows that non-randomized phase II data is often not replicated in phase III trials. Why aren't we performing the highest-quality clinical trials we can? Where the hell did "non-inferiority" come from all the sudden? Why did they make me take all those biostats classes in 1st year of med school if we were just going to ignore their basic tenants?
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Biostat tenants as pertains to proton tx are about 25 years behind on rent, need evicted 😉
 
OTN said:
I don't understand why all we have is phase II data these days. Couldn't they have done this in a truly randomized fashion? We have good data which shows that non-randomized phase II data is often not replicated in phase III trials. Why aren't we performing the highest-quality clinical trials we can? Where the hell did "non-inferiority" come from all the sudden? Why did they make me take all those biostats classes in 1st year of med school if we were just going to ignore their basic tenants?
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It’s thinly veiled profiteering. Why even bring up the notion of stats.
 
Fpg1245 said:
Stats are for community based RO and PP to shame and ridicule them. For the academic big health machine…they have the luxury of picking what facts they’ll be using.
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Agree. An example prototype here is the ASTRO Choosing Wisely that IMRT had no proven benefit for whole breast RT. This “fact” just had to be repeated a few times by academics, and Paul Wallner, and it just became pure fact (sans quotation marks). In fact (irony intended), when an academic center and academician says it, it often launches past fact into truth. "The proton DVHs look so good, wouldn't a trial be unethical?" sounds truthful.
 
medgator said:
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The "cannot go backwards in technology" bulletpoint is the most insane of the 3. Literally what?

Imagine we built a bunch of nuclear power plants and they ended up costing way more than coal plants and half of them melted down, and the government said "meh, sorry, can't go backwards in technology" The Concorde travelled twice as fast as a 737, but it burned an insane amount of fuel and cost 10 times as much to operate and kept exploding after takeoff. Meh, can't go backwards in technology. Sorry :shrug:
 
Moonbeams said:
The "cannot go backwards in technology" bulletpoint is the most insane of the 3. Literally what?

Imagine we built a bunch of nuclear power plants and they ended up costing way more than coal plants and half of them melted down, and the government said "meh, sorry, can't go backwards in technology" The Concorde travelled twice as fast as a 737, but it burned an insane amount of fuel and cost 10 times as much to operate and kept exploding after takeoff. Meh, can't go backwards in technology. Sorry :shrug:
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Have you considered a proton fellowship? Could be your way out of getting the stuff out of storage? Reset/fresh start for you! Sounds like you might need a reset. Storage situation doesn’t sound good man.
 
Moonbeams said:
I know you're joking, but there was a low point my first year out where I was seriously contemplating a fellowship.
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Ok well teasing you a bit about protons but legitimally offering advice. It sounds like a funk and sometimes only way to get out is an atmosphere change. I know of people where the fellowship has helped them. It woukd suck to be a “fellow” for a year but it might give you a reset to be able to get a job in better locations. Many of them have research months so your time in clinic slaving away will go quick. You don’t sound happy about current situation? Just a thought. Something has to be done?
 
thecarbonionangle said:
Ok well teasing you a bit about protons but legitimally offering advice. It sounds like a funk and sometimes only way to get out is an atmosphere change. I know of people where the fellowship has helped them. It woukd suck to be a “fellow” for a year but it might give you a reset to be able to get a job in better locations. Many of them have research months so your time in clinic slaving away will go quick. You don’t sound happy about current situation? Just a thought. Something has to be done?
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The fear would be you go and spend a year in a cool place somewhere like NYC, coastal Florida, SoCal, etc and it's a good time and all but goes by fast and the next year the job market is even worse, you've got the fellow stigma on your C.V. that scares PP away, and you're going right back to the kinds of places you started at at potentially significantly reduced income. Maybe you have potentially opened up some kind of academic satellite gig in a more desirable location, but we know what that comes with.
 
Moonbeams said:
The fear would be you go and spend a year in a cool place somewhere like NYC, coastal Florida, SoCal, etc and it's a good time and all but goes by fast and the next year the job market is even worse, you've got the fellow stigma on your C.V. that scares PP away, and you're going right back to the kinds of places you started at at potentially significantly reduced income. Maybe you have potentially opened up some kind of academic satellite gig in a more desirable location, but we know what that comes with.
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I rather roll the dice on a new gig vs wasting money and time pursuing a fellowship.
 
RickyScott said:
Put a photon detector in one of the slits and the interference pattern disappears! True for elecltons as well. Look at it and the wave dissapears.(no longer superposition) Very disturbing. What counts as an observer- a cat a flea on the cat etc? Solvay conference in 1920s concluded with the Copenhagen interpretation of quantum mechanics.
Click to expand...

I did not get one thing done yesterday evening because of this post....

I've heard of this experiment... but assumed it was just over my head.

So the interference pattern disappears just by putting a detector there?

WTF.....
 
dieABRdie said:
I did not get one thing done yesterday evening because of this post....

I've heard of this experiment... but assumed it was just over my head.

So the interference pattern disappears just by putting a detector there?

WTF.....
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Yes, it is essentially the uncertainty principle. The more you try to figure out which slit by putting a detector, the less you know about the location. It is absolutely wild. Blew my mind back in college when i first learned it. There is so much about the quantum world we do not understand. You got a cat in a box.
 
Moonbeams said:
The fear would be you go and spend a year in a cool place somewhere like NYC, coastal Florida, SoCal, etc and it's a good time and all but goes by fast and the next year the job market is even worse, you've got the fellow stigma on your C.V. that scares PP away, and you're going right back to the kinds of places you started at at potentially significantly reduced income. Maybe you have potentially opened up some kind of academic satellite gig in a more desirable location, but we know what that comes with.
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I know of multiple fellows who got good jobs. Why do you think there is a stigma? Maybe back in day but that is doubtful now.
 
thecarbonionangle said:
I know of multiple fellows who got good jobs. Why do you think there is a stigma? Maybe back in day but that is doubtful now.
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I have been told by some in private practice that fellowships are a red flag because they suggest that someone came out of residency unable to practice independently and/or was damaged goods and nobody wanted to hire them. Perhaps I was told wrong and someone can comment otherwise. The only door I could see one opening would be an in into an academic system in a competitive market.

I find it hard to believe a PP that almost exclusively hires top tier residency grads would hire a WVU grad who did a fellowship at MDACC simply because they did a year to get MDACC on their CV.
 
dieABRdie said:
I did not get one thing done yesterday evening because of this post....

I've heard of this experiment... but assumed it was just over my head.

So the interference pattern disappears just by putting a detector there?

WTF.....
Click to expand...
Probably smartest group in history gathered (including madam curie) to make sense of this. 1927
I think niehls Bohr view won out that when you look at something it forces the wave function to collapse. This is a very real problem in quantum computing. If information leaks out to an observer, no more superposition and calculation ruined
rarehistoricalphotos.com

The Solvay Conference, probably the most intelligent picture ever taken, 1927 - Rare Historical Photos

The most famous conference was the 1927 Fifth Solvay Conference on Electrons and Photons. 17 of the 29 attendees were or became Nobel Prize winners.
rarehistoricalphotos.com rarehistoricalphotos.com
 
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Moonbeams said:
I have been told by some in private practice that fellowships are a red flag because they suggest that someone came out of residency unable to practice independently and/or was damaged goods and nobody wanted to hire them. Perhaps I was told wrong and someone can comment otherwise. The only door I could see one opening would be an in into an academic system in a competitive market.

I find it hard to believe a PP that almost exclusively hires top tier residency grads would hire a WVU grad who did a fellowship at MDACC simply because they did a year to get MDACC on their CV.
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I don't know that I would go so far as saying there's a stigma for people who did fellowships, but if someone did a brachy or proton fellowship and is willing to take a job that doesn't have either, it kind of makes me wonder why they wasted a year of their life...

The single most important aspect of getting a job is who you know. That doesn't mean who do you know that will vouch for you, it means who does your potential employer know who will vouch for you. I couldn't care less if "so and so's program director thinks they're great." Program directors have a vested interest in their residents' employment, they'll tell you everyone is great (though mega red flag if they say someone isn't). I want to know if people I trust would vouch for an applicant. If someone is a stellar person/resident at a hellpit with no connections, doing a fellowship with connections to a place they'd like to practice long term can absolutely help. The converse is true. If you're a dud who did residency at WVU, or a dud who did residency at MSKCC, you're still going to be a dud regardless of where you do your fellowship.
 
RickyScott said:
Probably smartest group in history gathered (including madam curie) to make sense of this. 1927
I think niehls Bohr view won out that when you look at something it forces the wave function to collapse. This is a very real problem in quantum computing. If information leaks out to an observer, no more superposition and calculation ruined
rarehistoricalphotos.com

The Solvay Conference, probably the most intelligent picture ever taken, 1927 - Rare Historical Photos

The most famous conference was the 1927 Fifth Solvay Conference on Electrons and Photons. 17 of the 29 attendees were or became Nobel Prize winners.
rarehistoricalphotos.com rarehistoricalphotos.com
Click to expand...

I’m no expert on this, but from the rabbit trails I’ve followed the conservation of information is a big deal. Just wild stuff.
 
thecarbonionangle said:
I know of multiple fellows who got good jobs. Why do you think there is a stigma? Maybe back in day but that is doubtful now.
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C'mon carbon, most fellowships are **** and you know it unless we are talking brachy. All continue to be UNaccredited, UNlike radiology
 
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