While the pitchfork argument may be appealing, the actual article makes a convincing case that it's just combinatorial expansion:

> As a result, the Transparency in Coverage rule requires insurance companies to do the math for patients and, in most cases, publish prices as dollar amounts. That’s helpful for patients, but it requires that a price be pre-calculated for every possible service.

... So, they could publish the rules engine instead of the combinatorial expansion of all possible inputs, but it sounds like the regulation did not specify that.

I work with petabytes of data. A petabyte of text is an insane amount of text. You need a billion X multiplication of basic data. That’s not just combinatrionics, it’s deliberate obfuscation.

4 tables, each with 1k rows and one of them with a 1K text column in it, joined together to give a cartesion product, will give you a petabyte of data. So it doesn't sound impossible (just absurd).

That's a very artificially bloated way of compounding the data in memory with lots of data duplication. From storing the example tables you used, you'd need to store 62.5 million times that to get a petabyte of data. It's an absurd amount of data.

even taking your contrived example, you have to store it in the stupidest way possible to get that level of storage - even assuming your 1K of text is incompressible, you only have 1K unique values. The most basic compression algorithms will make easy work out of compressing the crap out of it, leave alone the advanced compression algorithms used for any big data storage formats.

Hanlon's razor maybe applies. I have no way to know if they're trying to do what you say, but the article explains what's going on and it's not hard to see how a flawed schema and implementors going by the letter and not putting any effort into minimising the data volumes could result in this without any malice. Any individual company is presumably producing a fraction of the petabyte total and people are as astonishingly lazy with data sizes now as computers are astonishingly capable of handling them. I'm routinely seeing multi-gigabyte executables these days (don't get me started).

Also the article says the schema is published in github and CMS is responsive to feedback on it, so things will hopefully improve.

I thought this was a really good article. I wasn't expecting to read all the way through a blog about something that doesn't affect me in the slightest but I did.

The standard is excessively verbose. Instead of being able to represent a price of a range of procedure codes (as most of the rules engines define it), you have to list every single code individually when often the price is the same. How that standard was set is probably an interesting questions.

Hanlon's razor. Never attribute to malice what can be explained by stupidity.

The US healthcare system is a mess, but I don't think it's intentionally malicious. It is just a mash of a thousand different systems, creating one big stupid system.

They made a ridiculously complex and obscure system because it was insanely profitable. It's not really stupidity or maliciousness that's responsible, but simple greed.

Yea, we need a corollary to Hanlon: Never attribute to malice OR stupidity that which can be explained by greed.

Even a stopped clock is right twice a day. Stupidity can't explain why everything is wrong. The American healthcare system is so totally broken, and broken in ways which so consistently benefit the rich at the expense of everyone else, that I can't see any way it could come about by accident.

Never attribute to malice that which is adequately explained by stupidity. In this case stupidity is not adequate - obviously insurance companies know how to make this data usable, otherwise they couldn't exist. They have just chosen not to make the public format usable.

A little of column A, a little of column B.

If it’s stupidity, then I would assume they wouldn’t be making so much freaking money.

Healthcare software systems: the home office printers of software systems?

It's absolutely intentionally malicious, despite the individual employees not having much say... have you ever tried to bounce between calls to get information for an insurer from a hospital billing department? they can make vogons look efficient

I've spent hours trying to get an estimate for a inpatient surgery only to find out afterwards that the surgeon used a different billing code than the billing department gave me

then the insurance company won't cover it because it's not the billing code they cover, and the hospital won't change the billing code

I think there's plenty of malice in the system, for example https://www.propublica.org/article/cigna-pxdx-medical-health...

I agree, but is the design of the system malicious? I don't think so. It's just stupid, and exploited by malicious people.

There rarely are systems designed in a malicious way. Most malicious systems slowly get shaped actors to their advantage. In some cases (insider trading or corruption) the government steps in and stops the abuse by laws and regulation. In the healthcare system they aren’t doing this and are letting profit oriented players shape the system.

I don't think the billing system is malicious. But at the end of the day, each "provider" is given incentives to bill. They get promotions based on this. So the maliciousness is a distributed system that does not get codified at all.

It's the exact same thing as cops getting incentives for speeding tickets. Then you start getting more speeding tickets for 5 over instead of 10 over.

The amount of human labor involved in the US healthcare system, that has nothing at all to do with medical professionals helping patients, is astonishing.

/r/MaliciousCompliance, in other words.

[email protected] for the post-Reddit fediverse

Not the same article but it has come up on here at least one other time with a lively discussion. Can't find it off hand though.

I've been a designer for a number of hospitals (tech, and physical, some systems) but never in the billing, however I can attest that billing codes are complete BS (billing codes are basically a number for the procedure/system/resources used such that they can say 'Code 10 == $10,000" to simplify it...

Hospitals are usually 'health *groups*' and they work just the same as insurance companies - they have actuaries that do all the calc to determine what they CAN charge for a procedure, not what its summary cost actually is...

When youre in a hospital GROUP you have more negotiating power with the insurance companies - so the exact same procedure in one group may be significantly different than what another group charges you....

HOWEVER - and this is important, and they wont ever tell you this - you can "haggle" with hospital billing departments... NEVER pay a hospital bill once you receive it.

ALWAYS call and ask for more details about the bill, with a line item receipt for every single action, drug, interaction 'encounter' and you will generally see your bill reduced significantly.

-

As example, I went to the ER with chest pains. waited 2 hours for an MD to come see me, he didnt even touch me, take a BP, EKG, etc - then 'prescribed' me some motrin (over the counter) and then billed me $1,500 for a 4 minute interaction.

I refused to pay this and they tried to drop it to $900 - and I told them, that if they can drop it from $1500 to $900 with just me protesting, then they needed to pay me for the two hours I waited to speak to the MD

They dropped the bill entirely.

Good Samaratin Hospital, Los Gatos CA.

While there are huge problems, I think the majority of the problem is people expect their health insurance plan to be like a prepaid maintenance plan.

If you crash your car today without insurance, you understand it won't be covered by getting insurance tomorrow.

Why people think they can finally get healthy "insurance" at 45 from company xyz, knowing they need this pill or that pill, and expect the new insurance company to pay for it I will never understand.

In the US, federal law requires the insurance company to offer any applicant insurance coverage and pay for necessary healthcare (after accounting for deductible/out of pocket maximums).

https://www.healthcare.gov/how-plans-set-your-premiums

>Five factors can affect a plan’s monthly premium: location, age, tobacco use, plan category, and whether the plan covers dependents.

> FYI Your health, medical history, or gender can’t affect your premium

https://www.healthcare.gov/appeal-insurance-company-decision...

I understand the law says so. My point is this makes no sense as an "insurance". It's basically a service plan now.

Yes, health insurance as expected by people has never made sense as "insurance".

Once an event goes from unlikely to likely, buying insurance for it turns into simply prepaying an amortized amount for future expenses. Not dissimilar to paying taxes for road maintenance.

Why wouldn't they expect it? If they need that medicine/treatment, they need it. If I don't have car insurance my organs won't shut down and I won't die. If I don't have medicine, they do and I will.

If you need medicine to live, you should pay for it. If you can't, the government should step in.

However, making me pay $400 a month for insurance in case I need stitches next month because I have to subsidize your medicine is annoying.

I want insurance in case something I don't know about goes wrong. You want something you know you need.

Right, but the government doesn't step in. I've voted for universal healthcare sorry supporting candidates at every local, state, and federal election.

I'm sorry that my illness is "annoying" you, but your anger is misplaced. Not that long ago I used to only have insurance for stitches too.

Your illness isn't annoying me. The fact that I need to pay for it via my health insurance premiums is.

If we want to pay for it via government mandate, fine. Raise taxes. That way during my lower earning years I dont need to artificially pay for it through health "insurance" that isn't really insurance.