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Expanding the market region

by 6:29 am. It has 0 Comments.

The Petersen-Kaiser Family Foundation Health System tracker has a really interesting graphic on the average price paid for full knee replacements in metropolitan statistical areas in 2016 by large group insurers.  There is wild variation:

One of the first things I think about here is the possibility of regional trade. St. Louis is, on average, a little ($1,200) less expensive than Kansas City, Missouri for the same procedure. Cincinnati is, on average, a little ($1,800) cheaper than Columbus Ohio. Dallas is about $6,000 cheaper on average than Fort Worth. New York City is about $16,000 more expensive than the Philadelphia suburbs centered on Montgomery County, Pennsylvania.

It might not be worth sending someone from St. Louis to Kansas City for a knee replacement once travel, hotel and upkeep costs are factored in. It might be worth spending $2,000 to send someone 35 miles from Fort Worth to Dallas to save $6,000. It might be worth spending $10,000 to send someone two hours south in order to cut their knee open in Montgomery County instead of in Manhattan.

There are a couple of major challenges to expanding the geographic market region for health insurance. The first is that most plans are required to have network adequacy of so many surgeons within so many miles. Urban areas will often use a ten mile radius. In large metro areas, there are dozens of surgeons in a plan. For instance, within 5 miles of my former employer’s headquarters in the narrowest Exchange network (UPMC Partners) there are 70 orthopedic surgeons. Many can do a knee replacement if needed.

Benefit design is another challenge. The least expensive metro area in the Peterson/KFF tracker is Louisville at $22,606 as the average amount paid. Most benefit designs will see the patient already maxed out. High Deductible Health Plans (HDHP) will have hit their limit $15,000 ago, and deductible plus co-insurance plans will have very low to no cost sharing on the last dollar of spending. In New York City, patients will have reached their out of pocket maximum under almost any plausible plan design. There is no economic reason for people to decide that going to a hospital two hours away makes sense as they don’t see any gains. If they are already capping out their out of pocket expenses, the incentive then is to go “easy” which usually would mean close by, familiar and expensive.

Some insurers and large companies (Walmart) use a center of excellence approach where they routinely fly people across the country for very high cost procedures with all patient costs covered (including travel, living expenses and deductibles). This is effectively a preferred tier network design and that might be the way to encourage expanding the competition regions for some procedures with large price variation. The deal could be a person pays $4,000 for surgery in New York City or $0 plus nothing for a hotel room for a partner in suburban Philadelphia.





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On the Road and In Your Backyard

by 5:00 am. It has 7 Comments.

Good Morning All,

This weekday feature is for Juicers who are are on the road, traveling, or just want to share a little bit of their world via stories and pictures. So many of us rise each morning, eager for something beautiful, inspiring, amazing, subtle, of note, and our community delivers – a view into their world, whether they’re far away or close to home – pictures with a story, with context, with meaning, sometimes just beauty. By concentrating travel updates and tips here, it’s easier for all of us to keep up or find them later.

So please, speak up and share some of your adventures and travel news here, and submit your pictures using our speedy, secure form. You can submit up to 7 pictures at a time, with an overall description and one for each picture.

You can, of course, send an email with pictures if the form gives you trouble, or if you are trying to submit something special, like a zipped archive or a movie. If your pictures are already hosted online, then please email the links with your descriptions.

For each picture, it’s best to provide your commenter screenname, description, where it was taken, and date. It’s tough to keep everyone’s email address and screenname straight, so don’t assume that I remember it “from last time”. More and more, the first photo before the fold will be from a commenter, so making it easy to locate the screenname when I’ve found a compelling photo is crucial.

I found this post as a draft from mid-April so if I already published it, forgive me!

Which reminds me, one fantastic reader mentioned to me a small fundraiser she was part of for a school in Cambodia. Terrible me, I lost the link. I’d like to run a monthly fundraising thread for select causes, and that was what I had planned to lead with.  Mystery reader, please send me that info so I can share it with everyone! I know we can build those classrooms with 10 minutes of donations from our great readership. Can you imagine – we will build classrooms that will change the lives of generations!

Also folks, should you have good, not-so-large causes, especially ones involving animals or education in developing areas, please let me know via email or the contact form. I won’t promise to run everything, but I think we need to use our generosity for more than just politics and our standard animal causes.

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Tuesday Morning Open Thread: Bidding Wars

by 4:57 am. It has 28 Comments.

I hope this viewing party is well stocked, because if I know corgis, their temporary “royal” will most definitely pit one admirer against another for a share of doggy attention.
 
Speaking of bidding wars…

To update a notorious quote from a certain Senate Majority Leader for the age of social media: If these Repubs insist on fornicating pigs, we can at least make them own it. Per Ars Techica:

The US Senate is scheduled to vote Wednesday, May 16 on whether to reverse the Federal Communications Commission’s repeal of net neutrality rules.

Republican senators were hoping to avoid the vote, but Democrats are using a Congressional Review Act (CRA) resolution to force the full Senate to vote. The CRA resolution would nullify the FCC’s December 2017 vote to deregulate broadband and kill net neutrality rules and would prevent the FCC from taking similar actions in the future.

“By passing my CRA resolution to put net neutrality back on the books, we can send a clear message to American families that we support them, not the special interest agenda of President Trump and his broadband baron allies,” Sen. Edward Markey (D-Mass.) said in an announcement today.

Republicans are pushing for weaker broadband regulations and have tried to discourage Democrats from pursuing the CRA vote…

FCC Chairman Ajit Pai announced last week that his repeal of net neutrality rules will take effect on June 11.

There are 50 senators, including one Republican, who have pledged to vote to prevent the net neutrality repeal. That may be enough to get the resolution through the Senate Wednesday because of the cancer-related absence of Sen. John McCain (R-Ariz.).

Democrats face longer odds in the House, where Republicans hold a 236-193 majority. President Trump could veto the resolution if it makes it through both chambers of Congress.

Congress isn’t the only obstacle in the way of Pai’s net neutrality repeal. The FCC must defend the repeal in court against a lawsuit filed by about three dozen entities, including Democratic state attorneys general, consumer advocacy groups, and tech companies…


Late Night Open Thread: 24-Carat Ingratitude

by 2:10 am. It has 26 Comments.

Much more of a symbolic protest than an actual boycott, of course; if not to the Repubs, where are a bunch of bloodthirsty economic parasites gonna go?

…As national Republicans scramble their resources for a high-stakes midterm election year, some of the party’s biggest and most reliable donors have quietly withheld their support for Senate and House Republican groups out of frustration with the new tax law, CNN has learned…

…[S]ome of the Republican Party’s powerhouse donors in fact feel deeply stung by the law and have made their displeasure known to party leaders by keeping their wallets shut, according to multiple sources familiar with the situation, who spoke with CNN on condition of anonymity. Although some of the donors have not sworn off contributions to individual campaigns or even the Republican National Committee, all have so far withheld contributions to the House and Senate Republican campaign arms — which are key players in the 2018 midterm elections — as a way to send a message over the law.

The donors who have boycotted, all of whom are leaders of prominent hedge funds, include Paul Singer, of Elliott Management; Citadel’s Ken Griffin; Warren Stephens of Stephens Inc.; Cliff Asness of AQR; Bruce Kovner, formerly of Caxton; and Third Point’s Daniel Loeb. Combined, their donations accounted for more than $50 million to Republican groups during the 2016 election cycle; Singer ranked among the top 10 donors of either party, while Griffin and Stephens ranked in the top 20.

Collectively, they have bristled at what they view as favored treatment for corporations under the law. While the corporate tax rate was slashed from 35% to 21%, hedge funds are largely taxed at the top individual rate, which ticked down from 39.6% to 37%…

Although Singer has donated six figures to the Republican National Committee this year and has given directly to the campaigns of Reps. Martha Roby and Claudia Tenney, he has uncharacteristically not donated to groups supporting House and Senate Republicans. Stephens’ only engagement has been maxing out to a few congressional campaigns in Arkansas, his home state. Griffin has not donated to any federal campaigns or committees this year, according to FEC data, although a source familiar with his thinking said donations to congressional candidates and national Republicans are forthcoming.

Asness donated $250,000 to the Congressional Leadership Fund last year, in addition to more than six figures to the NRCC — but has not given since Trump signed the tax law. Loeb has supported Mitt Romney’s Senate campaign in Utah and Roby’s reelection bid but has not opened his wallet for any national Republican groups. And Kovner has not donated this year to federal candidates or committees — after last year giving six-figure sums to the NRSC and Speaker Paul Ryan’s PAC…


Pop Culture Open Thread: Is This America?

by 10:28 pm. It has 54 Comments.

I generally don’t post on rap music, because it’s outside my skill set, but ‘This Is America’ seems to have expanded the discourse well beyond the usual this-summer’s-top-single effect…

What say all y’all?

(This quick video seems to be a useful explanation of some of the symbolism in the original.)


Repub Venality Open Thread: Jefferson Davis Beauregard III Lives Out His Authoritarian Dreams

by 9:14 pm. It has 73 Comments.

If “rule of law” meant anything other than “people with power should have a free hand to do what they like to people without power”, the rule-of-law people would be screaming themselves blue over this. As if we needed any further proof they’re acting in bad faith…

… Sessions has stepped into the immigration system in an unprecedented manner: giving himself and his office the ability to review, and rewrite, cases that could set precedents for a large share of the hundreds of thousands of immigrants with pending immigration court cases, not to mention all those who are arrested and put into the deportation process in future.

He’s doing this by taking cases from the Board of Immigration Appeals — the Justice Department agency that serves as a quasi-appellate body for immigration court cases — and referring them to himself to issue a decision instead.

Sessions isn’t giving lawyers much information about what he’s planning. But he’s set himself up, if he wants, to make it radically harder for immigration judges to push cases off their docket to be resolved elsewhere or paused indefinitely — and to close the best opportunity that tens of thousands of asylum seekers, including most Central Americans, have to stay in the United States. And he might be gearing up to extend his involvement even further, by giving himself the authority to review a much bigger swath of rulings issued in the immigration court system…

Immigration courts aren’t part of the judicial branch; they’re under the authority of the Department of Justice. Their judges are supposed to have some degree of independence, and some judges are certainly harsher on immigrants and asylum seekers than others. But their decisions are guided by precedent from the Board of Immigration Appeals, which is basically the appellate court of the immigration system and which also answers to the DOJ and the attorney general.

If the attorney general doesn’t like that precedent, he has the power to change it — by referring a case to himself after the Board of Immigration Appeals has reviewed it, issuing a new ruling, and telling the immigration courts to abide by the precedent that ruling sets in future…

In theory, Sessions’s office is supposed to make its decision based on amicus briefs from outside parties, as well as the immigrant’s lawyer and the Immigration and Customs Enforcement (ICE) prosecutor. But advocates and lawyers’ groups say they can’t file a good brief if they don’t know what, exactly, the cases Sessions is getting involved in actually are — and Sessions is withholding that information.

In one of the cases Sessions has referred to himself, the DOJ refused to provide a copy of the decision that Sessions is reviewing or any information about where the case came from and who the immigrant’s lawyer was. In another case, congressional staff happened to find the decision under review on a DOJ website days before the deadline for amicus briefs.

That opacity makes it basically impossible to know whether Sessions is planning to issue relatively narrow rulings or very broad ones. In the case in which the decision under review was discovered by congressional staffers, both the immigrant’s lawyer and the Department of Homeland Security (serving as the prosecution) asked Sessions’s office to clarify the specific legal question at hand in the review — in other words, to give them a hint of the scope of the potential precedent being set. They were denied…

Sessions and the Trump administration claim they’re trying to restore efficiency to a backlogged court system that poses the biggest obstacle to the large-scale swift deportation of border-crossing families and to unauthorized immigrants living in the US. But lawyers are convinced that Sessions’s diktats, if they’re as broad as feared, would just gum up the works further.

“If the attorney general were seriously concerned about the backlog, as opposed to a desire for quick deportations, he would be focused on transferring as many cases away from” immigration judges as possible, attorney Jeremy McKinney told Vox — not forcing them to keep cases on their docket that they would rather close, or that could be rendered moot by other decisions. It’s “not smart docket control.”

And Sessions isn’t simply planning to issue these rulings and walk away. His office is planning to give itself even wider power over the immigration court system. A notice published as part of the department’s spring 2018 regulatory agenda says, “The Department of Justice (DOJ) proposes to change the circumstances in which the Attorney General may refer cases to himself for review. Such case types will include those pending before the Board of Immigration Appeals (BIA) but not yet decided and certain immigration judge decisions regardless of whether those decisions have been appealed to the BIA.”

In other words, even when a DOJ judge makes a ruling in an immigrant’s favor and ICE prosecutors don’t try to appeal the ruling, the attorney general’s office could sweep in and overrule the judge…

If the Attorney General believes this is an improvement over the current system, why is he so determined to keep the mechanisms secret?

I personally suspect Mr. Sessions’ ambitions have something to do with last weekend’s flurry of reports about “President” Trump screaming at Homeland Security Secretary Nielsen. If the blond chick can’t throw enough brown people out of “our country” fast enough, Judge Jeff assures Lord Smallgloves, then by Christianist Jeebus he’ll roll up his sleeves and git ‘er done. It’s not as if Trump calling him nasty names has deterred his zeal for enforcing the “Just Us” of Justice in the past…


Not Sure If This Is Penetration At All Levels Or Getting Schlonged? Florida Weather Edition!

by 8:26 pm. It has 26 Comments.

That’s one well endowed weather map if you know what I mean. And I think you do…

Here’s the rundown from Earther, but to be honest, I was just looking for an excuse to post the strangely suggestive weather map tweet…

We’re still a few weeks out from the official start of hurricane season, but tropical cyclones don’t care much for regulation. That’s why there’s a small chance one could spin up off the Florida Panhandle this week.

A large, low pressure area filled with clouds and thunderstorms has developed across the southeastern Gulf of Mexico, and it’s marching slowly northward toward the west coast of Florida. As it moves across warm Gulf waters and gathers strength over the next 48 hours, it has about a 30 percent chance of getting organized into a cyclone.

Over the next five days, those odds rise to 40 percent, according to the National Weather Service.

Weather Underground meteorologist Bob Henson told Earther that in all likelihood, any cyclone that does form would be classified a tropical or subtropical depression, with maximum sustained winds of 38 mph or less. But, he added, there’s a “small chance” of a named tropical or subtropical storm, one featuring wind speeds of 39—73 mph.

“I wouldn’t rule it out, it’s just on the lower side of the probabilities,” Henson said, noting that water temperatures are a bit marginal right now.

Regardless of how fierce the storm gets, Floridians are going to feel it. The entire Florida Peninsula could be in for heavy rainfall this week, with eastern Florida around Kennedy Space Center expected to see up to seven inches of precipitation. And that’s not necessarily a bad thing—central and South Florida are coming off a particularly dry dry season, with more than 30 percent of the state in moderate to severe drought as of May 8.

Stay dry!

Open thread.


Totally gonna kill that nonexistent thing…

by 5:58 pm. It has 155 Comments.

Today in WTF:

Also, Trump’s wife had surgery this morning and will be hospitalized for the rest of the week. About half an hour ago, Trump tweeted that he was headed over to visit her at Walter Reed.

Can you imagine the media meltdown if any other president had loafed around the White House live-tweeting Fox News all day while his wife went under the knife? Especially if said president was in the middle of a massive sex scandal?

I get that everyone pretty much assumes the Trumps hate each other’s guts and that we all knew he was a gross philanderer from way back. Still, it’s amazing how quickly the Beltway press acclimated themselves to these circumstances, and yet they struggle to adjust to the fact that the president is a mind-blowingly corrupt, incompetent liar.

They are still covering the JOB aspect of Trump’s presidency as if he were a normal president, but the personal life angle — they were able to skippidy-doo-dah right over that. Hmmm. Not sure if I should be grateful or annoyed. (About being spared media hand-wringing about the Trumps’ fucked up family dynamics, I mean.)


Monday Afternoon Open Thread

by 4:21 pm. It has 152 Comments.

It started raining yesterday afternoon and has been pouring off and on — mostly on — ever since. I like when it rains, but this deluge is ill-timed as it has disrupted our puppy potty training regimen. It turns out Mr. Badger doesn’t care for the rain, so on our round-the-clock trips outdoors, he presses himself into the door frame when it’s raining and refuses to budge.

At approximately 3 AM, I was standing outside in a steady downpour attempting to demonstrate via nonchalance that it’s perfectly fine to be rained on in the middle of the night. The dog was unconvinced and stuck to the door until I finally gave up and went back inside with him. He didn’t poop or pee in the house, though, so I guess it counts as a success?

Anyway, open thread.


White Evangelicals Celebrate Opening of US Embassy in Jerusalem

by 10:53 am. It has 456 Comments.

Live shot of Trump-voting evangelical Christians celebrating the opening of the embassy:

The event in Jerusalem features corrupt plutocrats, pandering politicians, nepotism hires and bigoted preachers. Israeli security forces have killed more than 40 Palestinian protesters so far.

A religious scholar who escaped a Jesus Camp upbringing explains the significance of this move to evangelicals who believe in dispensational pre-millennialism here. An excerpt:

While that may sound benign (or perhaps nutty) to the theologically uninitiated, they are referring to the “prophecy” of the conversion of the Jews, the second coming of Jesus, the final judgment, and the end of the world — the events referred to as the biblical apocalypse.

I doubt that President Trump could explain dispensational pre-millennialism. I doubt he knows the term. But his evangelical supporters know it. Some of his advisers are probably whispering these prophecies in his ears. Trump might not really care how they interpret the Bible, but he cares that white evangelicals continue to stand with him. Moving the embassy to Jerusalem is one way to affirm his commitment to these evangelicals — reminding them that he, Donald J. Trump, is pressing biblical history forward to its conclusion and that he is God’s man in the unfolding of these last days.

I may not believe it — anymore, at least. You may not believe it. Donald Trump might not even truly believe it. But millions do. That matters. Not only for American politics, of course. For the peace of Jerusalem. And for peace for the rest of us as well.

I’m not sure that’s true anymore — that millions are motivated by this nonsense. In my opinion, what really matters is defeating the hate, greed and ignorance that underlie it. That’s the only thing that matters.


Better or best

by 9:34 am. It has 79 Comments.

California will soon require new residential construction to have solar panels.

This is provoked the usual sturm and drang on Twitter.
Every expert that I’ve read has said that the solar panel idea is cost effective but sub-optimal. There are better choices to reduce carbon dioxide emissions in California than mandating residential solar. A professor up at RIT made a very relevant for health policy and health care reform point:

I am, by nature and inclination, a gradualist. In baseball terms, I’m move than happy to make a living playing good defense, and hitting for average, mostly singles with the occasional double while generating a good OBP by walking a lot. The optimizers, in baseball terms, are three true outcome players, home runs, strike outs and walks.  Much wider variance but in the right situations and environments, they can produce big results fast.  The downside is a lot more strike-outs.

Both perspectives are needed.  I think one of the more important questions to ask is “How would that actually work…..” as I downplay that question of “What could be….”

So by my nature, I’ll work within or at least nearby existing frameworks while I count on others to see what other frameworks are potentially plausible.  I’ll be happy that there is potentially a $1.5 million dollar hemophilia cure potentially coming to market as that is an improvement over a $3.5 million dollar 10 year net present value treatment instead of asking why that cure is so expensive.  I have productively spent that past several years thinking and talking about how to tilt the subsidy system in the ACA to get better deals for people.  I’ll be thinking about what happens when the underlying morbidity of the 138%-200% FPL risk pool is completely detached from the morbidity of the Silver plan buyers.

All of those are interesting questions that should be asked and probed but they are gradualist questions.  And I am more than okay with that, but it is a limitation that I have.





This post is in and has 79 Comments.

On the Road and In Your Backyard

by 5:00 am. It has 19 Comments.

Good Morning All,

This weekday feature is for Juicers who are are on the road, traveling, or just want to share a little bit of their world via stories and pictures. So many of us rise each morning, eager for something beautiful, inspiring, amazing, subtle, of note, and our community delivers – a view into their world, whether they’re far away or close to home – pictures with a story, with context, with meaning, sometimes just beauty. By concentrating travel updates and tips here, it’s easier for all of us to keep up or find them later.

So please, speak up and share some of your adventures and travel news here, and submit your pictures using our speedy, secure form. You can submit up to 7 pictures at a time, with an overall description and one for each picture.

You can, of course, send an email with pictures if the form gives you trouble, or if you are trying to submit something special, like a zipped archive or a movie. If your pictures are already hosted online, then please email the links with your descriptions.

For each picture, it’s best to provide your commenter screenname, description, where it was taken, and date. It’s tough to keep everyone’s email address and screenname straight, so don’t assume that I remember it “from last time”. More and more, the first photo before the fold will be from a commenter, so making it easy to locate the screenname when I’ve found a compelling photo is crucial.

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Monday Morning Open Thread: Working Together, Joyously

by 4:55 am. It has 184 Comments.

Per the Washington Post:

… It was a change of scenery for James Shaw Jr., who wrestled an AR-15 from a gunman in a Waffle House in Tennessee last month, which authorities said likely stopped the spree that left four people dead.

The 29-year-old found himself in Florida on Saturday, trading the Waffle House for a Denny’s with some company — students from Marjory Stoneman Douglas High in Parkland.

“[T]he Most Legendary Breakfast ive ever had in my life,” Emma González said on Twitter afterward…

[Shaw] seems focused to keep going with his story beyond the drive.

“Thank you great meeting you all, let’s keep inspiring and bringing ppl together,” he wrote on Twitter to the students…

 
Bonus note:


Sunday Night Open Thread- There’s a Feral Bobcat On My Chest

by 10:13 pm. It has 126 Comments.

I lay down to take a nap this afternoon and had my phone with me by the bedside table (normally I turn the damned thing off or have it on a charger somewhere), so when Steve jumped up on my chest and started demanding food, I took the opportunity to take some pictures so you will know how my day starts EVERY. SINGLE. MORNING.

First, he walks into the room and announces his presence. That sometimes wakes me up, and I try to be very still and pretend I am still asleep and don’t hear him. Then I lie there hoping that playing possum works, but usually it does not, and since Steve is plus size, the next thing I hear is him defying all the laws of physics and and gravity projecting himself onto my bed. From there, he slowly climbs on top of my chest, and gets his face really close to mine, sometimes so close I can feel his whiskers. Like this:

The key to possum is not making eye contact and just not moving. So he’ll sit there and stare at me until his gaze penetrates my eyelids. Other times he will knead, start out slowly, increasing the pace and force and the amount of claw every few seconds until it feels like a bantamweight boxer is working out on the heavy bag. Sometimes even more aggressive measures are employed, like a swift “THWAP” to the face:

Notice the serious look on his face as he delivers a deft right hook. When I finally wake up, he stands on me triumphantly, declaring victory, letting me know what I have to do:

“Rise and shine, fatty. Home team needs breakfast.”





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Mother, don’t you recognize your son

by 6:02 pm. It has 196 Comments.

I was thinking of doing a post about songs that mention mothers and it got me thinking of Lady Madonna and that got me thinking of What I Got (because it’s the same tune) and that got me thinking about how I think one of the Sublime albums has the best title of all time and that got me thinking about seeing Cadillac Records and how everyone involved had a great name (you can’t beat Howlin Wolf or Muddy Waters for names and I Can’t Be Satisfied and Killing Floor aren’t bad name either)…and that gave me an idea for a post.

What’s the best title for an album ever?

For me, this is a slam dunk. Forty Ounces To Freedom.

What’s the best name for a band ever?

I know you all think I’m a dad rock kind of a guy but I’m going to get a little contemporary here and go with Hurray for the Riff Raff.

What’s the best name for a song ever?

I think when you get down to it you can’t beat some of the old blues stuff — I Can’t Be Satisfied, Dark Was The Night Cold Was The Ground, Stones In My Passway. I mean, that says it all, right? I also like Your Pretty Face Is Going To Hell, though.

Finally, how about songs about mothers?

I’ll go with the one in the title here. There’s one I like even better but it’s a little dark (though very upbeat!) because it begins with a hearse.


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