There must be a pony in here somewhere.

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Painboy
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Re: There must be a pony in here somewhere.

Post by Painboy » 26 Jul 2017, 00:42

Mo wrote:
25 Jul 2017, 23:04
Painboy wrote:
25 Jul 2017, 22:28
Mo wrote:
25 Jul 2017, 22:12
Painboy wrote:
25 Jul 2017, 21:53
Mo wrote:
25 Jul 2017, 21:45
Painboy wrote:While I certainly don't like dealing with hospitals or insurance company bullshit the ire I have for them is pretty tepid. They both are just playing by the fucked up rules passed by the government. Any companies that may have tried being "nice" likely got pushed out of business long ago.
How so, the in-network out-of-network bullshit is part of the "free market" portion of health care. There are distortions to that market due to tax benefits and the like, but that shit is on them.
They wouldn't have to play these games if these institutions could make money straight up instead of constantly having to bury their prices to see a profit.
The nature/cost of health care means that direct payer models wouldn't exist for all but basic and preventative care for the bulk of the market.
Health care isn't some magic pixie land that is immune to market forces. It's only different from other industries due to the ridiculous amount of regulation and market busting rules that has been draped over it in one form or another over the past 100 years.

To sum up, don't hate the player, hate the game.
Indirect payer markets are frequently going to be jacked up. And you'll tend to see indirect payer markets in industries where the costs are very high*. Health care tends to have an urgency that's less relevant in other markets, which increases search costs by consumers. If I don't like the price offered by my local barber, spending a few days or even weeks looking for a more reasonably priced option isn't a big deal. Not so much if I need a stent.

There are also plenty of very free market industries with very screwed up economics from a market efficiency POV. Like the real estate broker commission has remained 6% for my entire life, despite greater efficiencies in the market, lower search costs, low barriers to entry** and relatively little regulation in the market. Or if we go down to the lower end of the market, how is the glasses industry still super screwed up by Luxottica and why did we need the internet to give us a Wrby Parker level disruption? Same goes for the mattress industry. A lot of that is based purely on the specific weirdness of the market dynamics related to the products.

* Lasik is a popular example for free market health care, but even back in the day when it was expensive, it was $8K. That's less than a complication free birth and 100% voluntary
** When I lived in CA, there was a joke that a person wrote a check at the supermarket and the clerk said, "Can I see your real estate license? The shopper said, "Don't you mean my driver's license?" and the clerk responded, "No, not everyone has a driver's license"
I'm not talking about how expensive healthcare would or wouldn't be under different market conditions. I'm talking about the tactics used by the industry to make it's money. That was what the complaint was about as I understood it. If these institutions could make a decent profit while not acting as they currently do, it's likely they would. The fact that not one company seems to be able run a profitable business model without these tactics points to perverse incentives due to regulation and other cartel like rules. The only choice is to nickle and dime everyone they can else go under.

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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 26 Jul 2017, 10:13

I don't think elimination of indirect payment is either possible or desirable. What you want to do is make people feel the payment in proportion to its actual cost. To me, the oft repeated thing from the left that "you'll never see another hospital bill" is just crazy talk. I get that the people at the point of payment would prefer that situation, but that doesn't mean it's smart for the system as a whole. People will totally go nuts here in the US if they don't have to pay for anything at point of transaction. That has to be one of the lessons from Oregon medicaid expansion.

The hospital / provider model is a kind of a joke here and I don't mind beating up on them one bit. They have fought in the public sphere every attempt by insurers (who are always the bad guy) to cut costs, they lobby actively to restrict providers by service and by nationality etc. Meanwhile the median payment they receive runs from 1.5x to like 4x what anyone else anywhere gets paid for identical services internationally. They can't possibly be on the verge of perpetual bankruptcy at the prices they actually get from insurers and the wages they are being paid.

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Re: There must be a pony in here somewhere.

Post by Aresen » 26 Jul 2017, 10:18

JasonL wrote:
26 Jul 2017, 10:13
They can't possibly be on the verge of perpetual bankruptcy at the prices they actually get from insurers and the wages they are being paid.
Actually, the amount of cash flow has nothing to do with the ability to manage funds. In fact, I would guess that the greater cash flow gives them less incentive to control costs to the point where they are not looking at the effectiveness of the way they spend money.
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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 26 Jul 2017, 10:20

Aresen wrote:
26 Jul 2017, 10:18
JasonL wrote:
26 Jul 2017, 10:13
They can't possibly be on the verge of perpetual bankruptcy at the prices they actually get from insurers and the wages they are being paid.
Actually, the amount of cash flow has nothing to do with the ability to manage funds. In fact, I would guess that the greater cash flow gives them less incentive to control costs to the point where they are not looking at the effectiveness of the way they spend money.
Let me reframe - they can't possibly be priced so low it's impossible to run a profitable business given the obscenely higher prices they charge than anyone else anywhere.

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Painboy
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Re: There must be a pony in here somewhere.

Post by Painboy » 26 Jul 2017, 10:53

JasonL wrote:
26 Jul 2017, 10:13
I don't think elimination of indirect payment is either possible or desirable. What you want to do is make people feel the payment in proportion to its actual cost. To me, the oft repeated thing from the left that "you'll never see another hospital bill" is just crazy talk. I get that the people at the point of payment would prefer that situation, but that doesn't mean it's smart for the system as a whole. People will totally go nuts here in the US if they don't have to pay for anything at point of transaction. That has to be one of the lessons from Oregon medicaid expansion.

The hospital / provider model is a kind of a joke here and I don't mind beating up on them one bit. They have fought in the public sphere every attempt by insurers (who are always the bad guy) to cut costs, they lobby actively to restrict providers by service and by nationality etc. Meanwhile the median payment they receive runs from 1.5x to like 4x what anyone else anywhere gets paid for identical services internationally. They can't possibly be on the verge of perpetual bankruptcy at the prices they actually get from insurers and the wages they are being paid.
Yes but those rules that they lobbied for were passed by the government. As long as the government continues to pass rules that favor one method over another the healthcare companies are going to lobby for rules that favor how they currently do business. Otherwise they risk being cut out by a competitor who is lobbying for legislation that favors them.

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thoreau
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Re: There must be a pony in here somewhere.

Post by thoreau » 26 Jul 2017, 11:04

JasonL wrote:I don't think elimination of indirect payment is either possible or desirable. What you want to do is make people feel the payment in proportion to its actual cost. To me, the oft repeated thing from the left that "you'll never see another hospital bill" is just crazy talk. I get that the people at the point of payment would prefer that situation, but that doesn't mean it's smart for the system as a whole. People will totally go nuts here in the US if they don't have to pay for anything at point of transaction. That has to be one of the lessons from Oregon medicaid expansion.

The hospital / provider model is a kind of a joke here and I don't mind beating up on them one bit. They have fought in the public sphere every attempt by insurers (who are always the bad guy) to cut costs, they lobby actively to restrict providers by service and by nationality etc. Meanwhile the median payment they receive runs from 1.5x to like 4x what anyone else anywhere gets paid for identical services internationally. They can't possibly be on the verge of perpetual bankruptcy at the prices they actually get from insurers and the wages they are being paid.
This.

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fyodor
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Re: There must be a pony in here somewhere.

Post by fyodor » 26 Jul 2017, 11:25

Painboy wrote:
26 Jul 2017, 00:42
Mo wrote:
25 Jul 2017, 23:04
Painboy wrote:
25 Jul 2017, 22:28
Mo wrote:
25 Jul 2017, 22:12
Painboy wrote:
25 Jul 2017, 21:53
Mo wrote:
25 Jul 2017, 21:45


How so, the in-network out-of-network bullshit is part of the "free market" portion of health care. There are distortions to that market due to tax benefits and the like, but that shit is on them.
They wouldn't have to play these games if these institutions could make money straight up instead of constantly having to bury their prices to see a profit.
The nature/cost of health care means that direct payer models wouldn't exist for all but basic and preventative care for the bulk of the market.
Health care isn't some magic pixie land that is immune to market forces. It's only different from other industries due to the ridiculous amount of regulation and market busting rules that has been draped over it in one form or another over the past 100 years.

To sum up, don't hate the player, hate the game.
Indirect payer markets are frequently going to be jacked up. And you'll tend to see indirect payer markets in industries where the costs are very high*. Health care tends to have an urgency that's less relevant in other markets, which increases search costs by consumers. If I don't like the price offered by my local barber, spending a few days or even weeks looking for a more reasonably priced option isn't a big deal. Not so much if I need a stent.

There are also plenty of very free market industries with very screwed up economics from a market efficiency POV. Like the real estate broker commission has remained 6% for my entire life, despite greater efficiencies in the market, lower search costs, low barriers to entry** and relatively little regulation in the market. Or if we go down to the lower end of the market, how is the glasses industry still super screwed up by Luxottica and why did we need the internet to give us a Wrby Parker level disruption? Same goes for the mattress industry. A lot of that is based purely on the specific weirdness of the market dynamics related to the products.

* Lasik is a popular example for free market health care, but even back in the day when it was expensive, it was $8K. That's less than a complication free birth and 100% voluntary
** When I lived in CA, there was a joke that a person wrote a check at the supermarket and the clerk said, "Can I see your real estate license? The shopper said, "Don't you mean my driver's license?" and the clerk responded, "No, not everyone has a driver's license"
I'm not talking about how expensive healthcare would or wouldn't be under different market conditions. I'm talking about the tactics used by the industry to make it's money. That was what the complaint was about as I understood it. If these institutions could make a decent profit while not acting as they currently do, it's likely they would. The fact that not one company seems to be able run a profitable business model without these tactics points to perverse incentives due to regulation and other cartel like rules. The only choice is to nickle and dime everyone they can else go under.
I'm going to second hating the game not the players mainly cause I just don't see any point in hating the players. What does that get you? A lot of hot air, best I can tell. Understanding the game gets you an understanding for why players do what they do and possibly an understanding of what can be changed to make them play differently.

That said, I want to quibble with one thing. Being able to "make a decent profit" by playing it straight is no guarantee that slimy tactics would be eschewed, not if slimy tactics still make you an even better profit.
Your optimism just confuses and enrages me. - Timothy

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Re: There must be a pony in here somewhere.

Post by nicole » 26 Jul 2017, 11:32

The players wrote the rules of the game.
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Re: There must be a pony in here somewhere.

Post by JasonL » 26 Jul 2017, 11:42

That particular set of players never gets enough shade in my view and fixing "the cost of American healthcare" means explicitly cutting their wages by good margins. Like HMOs aren't ideal but they should work better at cost containment than they do. The reason they don't is provider behavior, while saying "the cost of things isn't our business we are Healers", totally actually fight tooth and nail to preserve high costs and exclude competition.

You ever see that whole Aetna CA vs Big Hospital group thing? FFS. Docs wanted some absurd 40% hike in payment, Aetna said nope we'll cut you, docs went to direct mail to patients about losing your doctor and took out ads showing asthma kids dying because Big Insurance doesn't care. Die in a fire dude.

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Re: There must be a pony in here somewhere.

Post by fyodor » 26 Jul 2017, 11:42

nicole wrote:
26 Jul 2017, 11:32
The players wrote the rules of the game.
Well if you mean the industry, well no, not really. As Painboy has been pointing out, the government writes the rules. The industry may have told them what to write, but so what. The industry isn't who's responsible to the population. Well, they're responsible to their customers, but that's different. I dunno, I really don't relate to complaints about industry behavior, it makes no sense to me. People are gonna do what they can get away with. At the same time, I can sure tire of complaints about politicians' behavior too (at least when it's complaints about typical behavior, so a certain shitshow largely excepted). Still, at the least the politicians are "our" responsibility, and, as slimy as they are, they will bend to enough pressure to change said rules.

Anyway, short answer is the government writes the rules. Public policy is what we should be concerned with. (Not that we never are.)
Your optimism just confuses and enrages me. - Timothy

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Re: There must be a pony in here somewhere.

Post by nicole » 26 Jul 2017, 11:59

fyodor wrote:
26 Jul 2017, 11:42
nicole wrote:
26 Jul 2017, 11:32
The players wrote the rules of the game.
Well if you mean the industry, well no, not really. As Painboy has been pointing out, the government writes the rules. The industry may have told them what to write, but so what. The industry isn't who's responsible to the population. Well, they're responsible to their customers, but that's different. I dunno, I really don't relate to complaints about industry behavior, it makes no sense to me. People are gonna do what they can get away with. At the same time, I can sure tire of complaints about politicians' behavior too (at least when it's complaints about typical behavior, so a certain shitshow largely excepted). Still, at the least the politicians are "our" responsibility, and, as slimy as they are, they will bend to enough pressure to change said rules.

Anyway, short answer is the government writes the rules. Public policy is what we should be concerned with. (Not that we never are.)
Yes, and special interests capture public policy.
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fyodor
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Re: There must be a pony in here somewhere.

Post by fyodor » 26 Jul 2017, 12:15

nicole wrote:
26 Jul 2017, 11:59
fyodor wrote:
26 Jul 2017, 11:42
nicole wrote:
26 Jul 2017, 11:32
The players wrote the rules of the game.
Well if you mean the industry, well no, not really. As Painboy has been pointing out, the government writes the rules. The industry may have told them what to write, but so what. The industry isn't who's responsible to the population. Well, they're responsible to their customers, but that's different. I dunno, I really don't relate to complaints about industry behavior, it makes no sense to me. People are gonna do what they can get away with. At the same time, I can sure tire of complaints about politicians' behavior too (at least when it's complaints about typical behavior, so a certain shitshow largely excepted). Still, at the least the politicians are "our" responsibility, and, as slimy as they are, they will bend to enough pressure to change said rules.

Anyway, short answer is the government writes the rules. Public policy is what we should be concerned with. (Not that we never are.)
Yes, and special interests capture public policy.
And I addressed that, but, I'll leave it there.

ETA: Okay, I lied.

Y'know, if you personally know a doctor who's participating in an emotionally based smear campaign, feel free to tell him personally to die in a fire. (But will you refuse a glass of his or her non-oaked Chablis? :P )

Here's the difference. 51% of the people want their politicians to change public policy, it might actually happen.

51% of the population want smear campaign participating doctors to go die in a fire, guess what, they'll nary feel a lick of flame. And they'll still capture public policy. BFD all our complaints about them.
Your optimism just confuses and enrages me. - Timothy

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Re: There must be a pony in here somewhere.

Post by Mo » 26 Jul 2017, 13:24

I can hate farmers for whining for protectionism and Ag subsidies, so I can direct the same ire to medical providers.
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Re: There must be a pony in here somewhere.

Post by JasonL » 26 Jul 2017, 13:38

At least farmers don't usually go with "Prices? What are those? I'm just trying to feed people for the good of mankind over here. Unrelated - Moar Farm Bill pls."

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Re: There must be a pony in here somewhere.

Post by nicole » 26 Jul 2017, 13:52

fyodor wrote:
26 Jul 2017, 12:15
nicole wrote:
26 Jul 2017, 11:59
fyodor wrote:
26 Jul 2017, 11:42
nicole wrote:
26 Jul 2017, 11:32
The players wrote the rules of the game.
Well if you mean the industry, well no, not really. As Painboy has been pointing out, the government writes the rules. The industry may have told them what to write, but so what. The industry isn't who's responsible to the population. Well, they're responsible to their customers, but that's different. I dunno, I really don't relate to complaints about industry behavior, it makes no sense to me. People are gonna do what they can get away with. At the same time, I can sure tire of complaints about politicians' behavior too (at least when it's complaints about typical behavior, so a certain shitshow largely excepted). Still, at the least the politicians are "our" responsibility, and, as slimy as they are, they will bend to enough pressure to change said rules.

Anyway, short answer is the government writes the rules. Public policy is what we should be concerned with. (Not that we never are.)
Yes, and special interests capture public policy.
And I addressed that, but, I'll leave it there.

ETA: Okay, I lied.

Y'know, if you personally know a doctor who's participating in an emotionally based smear campaign, feel free to tell him personally to die in a fire. (But will you refuse a glass of his or her non-oaked Chablis? :P )

Here's the difference. 51% of the people want their politicians to change public policy, it might actually happen.

51% of the population want smear campaign participating doctors to go die in a fire, guess what, they'll nary feel a lick of flame. And they'll still capture public policy. BFD all our complaints about them.
I'm totally lost, I have no idea what the smear campaign stuff is referring to.
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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 26 Jul 2017, 14:09

It's a reference to my comment above about how the big hospital group in CA famously dealt with Aetna when they refused a large percentage payment hike. It is one of the events that contributed to the demise of HMO as a method of cost control and it was a front line in the HMO's are evil and want your kid to die wars of the 90s.

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Re: There must be a pony in here somewhere.

Post by nicole » 26 Jul 2017, 14:21

Oh okay. I mean it's not like smear campaigns are the only or the primary thing doctors are doing wrong. Like, the whole "we're a cartel that thinks we should control your access to goods and services" thing is a lot worse.
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Re: There must be a pony in here somewhere.

Post by Hugh Akston » 26 Jul 2017, 14:41

That reminds me that I have been meaning to recommend the recent Econtalk featuring Christy Ford Chapin and the evolution of the American health care system (is fucked). The AMA emerges as the surprising not-surprising villains.
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nicole
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Re: There must be a pony in here somewhere.

Post by nicole » 26 Jul 2017, 14:44

Hugh Akston wrote:
26 Jul 2017, 14:41
That reminds me that I have been meaning to recommend the recent Econtalk featuring Christy Ford Chapin and the evolution of the American health care system (is fucked). The AMA emerges as the surprising not-surprising villains.
Yep, I happened to be listening to that this morning at the gym and it's very apropos. Fuck doctors.
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Re: There must be a pony in here somewhere.

Post by fyodor » 26 Jul 2017, 14:55

JasonL wrote:
26 Jul 2017, 13:38
At least farmers don't usually go with "Prices? What are those? I'm just trying to feed people for the good of mankind over here. Unrelated - Moar Farm Bill pls."
The hypocrisy angle begins to skirt relevancy to me. People shouldn't buy that load.
Your optimism just confuses and enrages me. - Timothy

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JasonL
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Re: There must be a pony in here somewhere.

Post by JasonL » 26 Jul 2017, 15:35

If you perceive that the total cost of american healthcare is too high and you note that rates paid to providers are stunningly large compared to rates paid anywhere else in the world and you observe that the largest reason insurance has been unable to contain payments is the efforts of providers in both the political space and the scaring grandma space, I think it is entirely reasonable to ask questions when providers directly refute accountability for costs with "we shouldn't have to care about costs".

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Re: There must be a pony in here somewhere.

Post by Jennifer » 26 Jul 2017, 16:06

JasonL wrote:
26 Jul 2017, 15:35
If you perceive that the total cost of american healthcare is too high and you note that rates paid to providers are stunningly large compared to rates paid anywhere else in the world and you observe that the largest reason insurance has been unable to contain payments is the efforts of providers in both the political space and the scaring grandma space, I think it is entirely reasonable to ask questions when providers directly refute accountability for costs with "we shouldn't have to care about costs".
But a lot of defenders of the current American medical status quo will counter by arguing "Americans might pay more for medical procedures than anyone else in the world, but America is also the leader in developing new medical technologies -- without it, people will stop making new discoveries, and medical progress will stagnate." (Granted, the hospitals and/or doctors and/or middlemen like EmCare generally are not the ones making these new discoveries and producing these new inventions -- but defenders of the status quo tend not to make such distinctions. IIRC, that wretch of a Martin Shkreli tried using a similar argument to justify his buying the patent on that one lifesaving drug and then jacking up the price several thousand percent.)
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Re: There must be a pony in here somewhere.

Post by Sandy » 26 Jul 2017, 16:44

Jennifer wrote:
26 Jul 2017, 16:06
JasonL wrote:
26 Jul 2017, 15:35
If you perceive that the total cost of american healthcare is too high and you note that rates paid to providers are stunningly large compared to rates paid anywhere else in the world and you observe that the largest reason insurance has been unable to contain payments is the efforts of providers in both the political space and the scaring grandma space, I think it is entirely reasonable to ask questions when providers directly refute accountability for costs with "we shouldn't have to care about costs".
But a lot of defenders of the current American medical status quo will counter by arguing "Americans might pay more for medical procedures than anyone else in the world, but America is also the leader in developing new medical technologies -- without it, people will stop making new discoveries, and medical progress will stagnate." (Granted, the hospitals and/or doctors and/or middlemen like EmCare generally are not the ones making these new discoveries and producing these new inventions -- but defenders of the status quo tend not to make such distinctions. IIRC, that wretch of a Martin Shkreli tried using a similar argument to justify his buying the patent on that one lifesaving drug and then jacking up the price several thousand percent.)
FWIW, I've only seen that seriously said about drug costs or experimental procedures, not routine care.
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Re: There must be a pony in here somewhere.

Post by Dangerman » 26 Jul 2017, 16:52

IIRC Shkreli's argument was that no person would ever pay the exaggerated price, that's just what they billed the insurance companies. I believe he even laid a challenge to produce one person who needed the drug but couldn't afford it.

But Shkreli is just a boogeyman cutout to burn in this thread, so I don't really care.
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Re: There must be a pony in here somewhere.

Post by fyodor » 26 Jul 2017, 17:08

JasonL wrote:
26 Jul 2017, 15:35
If you perceive that the total cost of american healthcare is too high and you note that rates paid to providers are stunningly large compared to rates paid anywhere else in the world and you observe that the largest reason insurance has been unable to contain payments is the efforts of providers in both the political space and the scaring grandma space, I think it is entirely reasonable to ask questions when providers directly refute accountability for costs with "we shouldn't have to care about costs".
Absolutely ask questions. Just color me skeptical if one claims that the answer is that American providers are greedier, er, more inclined to scare grandma, than providers elsewhere.
Your optimism just confuses and enrages me. - Timothy

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