Medical Billing Travesty.

Posted in Opinion on January 28th, 2014 by byronkho

Women in California can be charged between $3,296 and $37,227 for a vaginal delivery, and between $8,312 and $70,908 for a caesarean, depending on what hospital they are admitted into (adjusted for patient clinical and demographic issues). They’re comparing the SAME procedure with the SAME materials and manpower requirements, yet there can be 800-1000% inflation in prices depending on market?

“These results indicate that charges and discounted prices… vary widely between hospitals and are not well explained by observable patient or hospital characteristics.” I can explain it. If wages, low-income “pro bono” load and casemixes can only explain 1/3 of the variance… then the rest is due to Highway Robbery.

It’s a nightmare for patients, who are usually unable to get a good idea of overall cost upfront from hospitals and practitioners. (One cannot even assume reasonable prices: I’ve seen bills for five minutes of work, basic equipment and no brand name medications at an ER that are upwards of $2,000. Unreasonable.) And it sure must be Hell on Earth for government economists trying to wrangle the system so that it actually helps the American people instead of screwing it again and again.

Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study

Helltown.

Posted in History and Politics on January 21st, 2014 by byronkho

The other day I was walking by Elfreth’s Alley and I wondered a bit about what the neighborhood was like way back when…

During the latter 18th century, the area (which contains Elfreth’s Alley) bounded by Race and Market Sts., from north to south, and 2nd St. and the Delaware River, from west to east, was known as Helltown. This section of Philadelphia served as the watering hole for the city’s itinerant and unsavory, attracting gamblers, “drunken tinkers” (groups of wandering alcoholics… also, duh), “fustilugs” (dirty slatterns), “game pullets” (whores), the insane, the downtrodden poor, on-leave or AWOL soldiers and sailors, supposedly sober and hardworking servants that sought a release from their overly moral daytime servitude, and plenty of escaped slaves looking to blend in with the hordes of poor miserable wretches within Helltown.

Its centerpiece was a hard dive called the Three Jolly Irishmen, located at the corner of Race and Water Sts (whose sole attraction these days is the new FringeArts building). Within its walls, one could gamble on cockfights, watch trained pigs caper, get thoroughly soused on watered-down “gin”, obtain “spanish flies” (an aphrodisiac made from beetles, which induces over-sensitivity in women and long-lasting erections in men and had its first celebrity overdose when it supposedly made Roman poet Titus Lucretius Carus insane and pushed him to commit suicide in 55 BC), find a Molly Malone or “backgammon player” willing to part with their charms for a dollar or two (then the actual going rate), or whatever other base entertainments one would be looking for on the wrong side of town. It must have been a fun place, as George Washington had to put two of his own servants into the workhouse as punishment for carousing once too often in Helltown.

John Roberts, otherwise known as Cock Robin, was a great example of the sleazy denizens of the neighborhood. With his “wives,” he leased a house just south of the Irishmen (sadly torn down at some point and now underneath the Delaware Expressway) and ran an almshouse where, its clerk scoffingly admitted, “the Paupers… [were] Debauched in every way.” After receiving entry, the inmates of Cock Robin’s lodgment were forced to sell everything they owned… and then encouraged to sell their only remaining item of value over and over again. Like many other bawdy houses in this neighborhood, Cock Robin’s establishment allowed freedom for those that wanted to speak their mind, or dress in scandalous clothing, or make love across class and race lines, or generally act unimpeded by colonial social rules. However, that also meant the freedom to get robbed by the pimps, cutpurses, untrustworthy faro dealers and back street hustlers that salivated at the sight of the Roberts’ customers, those hapless marks known as “cock robins”, the “easy fellows” that gave Roberts such pleasure at his own nickname.

Some of the military men on drunken binges in Helltown would get married to some unfortunate female via the “military marriage,” an ancient military tradition where a serjeant would conduct the ceremony and end it formally with the words “leap rogue, and jump whore, and then you are married forevermore!” Reminds me of the haphazard “Fleet marriages” that used to be conducted in the areas around the Fleet prison in London, prior to 1754, when the Marriage Act was passed. Since prisons were considered outside of Church of England jurisdiction, debtors could stay in the areas surrounding them without fear of arrest and those who wished to marry quickly without any canonical nonsense could do so (a truly civil marriage, in a time when civil marriage meant church marriage). Drunken, disgraced priests often conducted the ceremonies in the middle of dirty and unromantic public houses, with absolute creative freedom as to how the ceremony should go. Unsurprisingly, many examples from the time were completely vulgar. Also unsurprising were the scams: a common Fleet marriage crime was the “kidnapping” of some woman, making her insensibly drunk at some lowly gin joint, marrying her comatose body, and then blackmailing her family for her marriage dowry later.

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A few words on the worsening California drought.

Posted in Opinion on January 16th, 2014 by byronkho

To the jerkwads who posted “it’s so nice in Cali” bikini and shorts videos during the Polar Vortex… Also, global warming.

“And in California, strict water rationing is next… The Central Valley agricultural industry is already getting 95% less water than it would in good years. And in Northern California, rationing means that marijuana farmers will be struggling.”

NO.

Oh wait, here’s the actual important part: “The ongoing drought—described by climate scientists as a “megadrought”—is already 13 years old in the American West. ” Wow.

As California Burns, Hot Dry Weather Predicted For Entirety of “Winter”

Vodka in Russia from the 1850s to the Bolshevik era: surprisingly important!

Posted in History and Politics on January 8th, 2014 by byronkho

On the eve of World War I, the Tsar of all the Russias decided to institute a ban on alcohol. The stereotypical Russian love of alcohol wasn’t comparatively bad; in fact, it was a mere 1/3 of the per capita alcohol consumption of the turn of the 21st century Russian citizen. However, it still had an enormously deleterious effect on discipline and efficiency in all sectors.

In the military, rampant alcoholism caused a plethora of issues. Throughout the 19th century, military officials believed that vodka rations were invaluable in keeping morale up, and moreover, they believed vodka provided health benefits to soldiers. Despite learning that many of the ailments and deaths in the military were somehow related to alcohol overconsumption, they continued to provide and encourage vodka rationing and turned a blind eye to the 50% of their soldiers that drank considerably more than their weekly rations.

It wasn’t until the enormous debacle of the 1904-5 Russo-Japanese War that commanders realized the depth of their mistake. Contemporary records state that during the war, an average of 25 pounds of vodka was provided per soldier, for a grand total of 19 million pounds. The amount of happiness this provided was related by thousands of chroniclers, who left accounts of drunken Russian soldiers who were haplessly bayoneted by the Japanese without even the semblance of fighting back. The ones that weren’t bayoneted could barely operate their weapons (…if they had any. In 1914, there was one machine gun per 1000 men). And even if there were weapons, many of them would be destroyed due to incompetence (…a problem that still extends to the modern Russian army, as of internal military review from the 90s). And if those men eventually made it back to the canteen, the quartermaster would provide them with even more vodka; perhaps their dead comrades were happily giving up their shares of the dole to their old friends. One wonders what would have happened had the vodka supply chain been disrupted.

It wasn’t just the soldiers who lived vodka as a way of life – it was everywhere. Indeed, the government had directed national efforts to increasing vodka production for more than 100 years. In the 19th century, a tax-farm system existed in which the nobles managed vodka production and were forced to sell 100% of their product to the government at a fixed price. The government, in turn, sold for massive profit to regional vodka monopolies who were granted short-term licenses and had to continually bid for further licenses. Thus the government won at all turns: they kept the nobility in check, brought itself massive revenues due to taxes and “commissions,” and induced bribery from both sides providing the monopolies and turning a blind eye to attempts to circumvent some of the more onerous tax regulations. Interestingly enough, the government started offering detailed census reports (including numbers on vodka drinkers and amount drank per head) of all areas of the country to encourage bidding on the monopolies from interested tax farmers. Undoubtedly, number-crunching for the purpose of organizing social services for these areas were lower priorities for the Census-takers.

Much of the governmental insistence on vodka was not only economic but political. It was much easier to control a populace that could be held insensible with free public giveaways of hooch: if there was unrest, declare it a public holiday and have a free orgy in the public square. The church helped out by declaring that every drink was honoring God; thus, spending 1/3 of the calendar on feast days meant that people were at least honoring God for 1/3 of the year. The appeal of vodka increased to such a point that it was of considerable appeal in the form of peer pressure to accept wages (for regular folk) or bonuses (for army folk) in vodka rather than cash.

The cost system itself for vodka was rather nonsensical and completely open to corruption. To purchase booze from the government, a vodka tax farmer would have to buy the 40% strength vodka from the government at 2.41 rubles a bucket from the government and then pay another 2 rubles in taxes. Following that, they sold a) 50 to 80% of their stock of the 40% strength vodka at the government-mandated loss-incurring 3 rubles per bucket price (AKA “no profit,” though this was more like giving it away) and b) the remainder as is, or via improvements (aka sand filtering, honey additions, double distillation). Naturally, when they could, the 40% strength vodka was sold at 7 rubles or more – economically, they really couldn’t do otherwise.

If the official sale price was 3 rubles and the real sale price was 7 rubles, one could safely assume that at any given point at least 50% of vodka revenue was generated illegally. Indeed, since the official vodka tax revenues from the mid-19th century to the beginning of WWI roughly came out to 500 million rubles a year, that meant that another 500 million rubles, at minimum, were lying around every year. A good portion of this loot went to use as direct bribery of governmental officials, who had to be persuaded to not institute onerous and random fines, provide them with insider information or steer licensing auctions their way, and to protect their shipments and farms from interference from other governmental officials. When the rate for bribery was 4-5x the annual salary of any official, up and down the line, it would be hard to find someone who hadn’t taken the money. Indeed, in 1856, the first Russian governmental inquiry into official corruption concluded that “bribes under 500 rubles should not be counted as bribes at all.”

Because of the overwhelming nature of the bribery, the government was increasingly getting itself stuck under the thumb of the mafioso tax farmers. Any centralized decisions ended up being paralyzed at the local levels due to the interference of tax farmers, who argued that they should lower their own production if certain policies went through. The government could not stomach the loss of that kind of tax revenue, so in almost all cases, the imperial mandates were rescinded. A rather poignant set of statistics: in 1859, vodka accounted for 20% of all internal trade, and taxes on vodka sales accounted for 40% of national revenues. In 1861, the government had been pushed around enough. The tax-farm system was abolished and price controls for sales of alcohol to the government were loosened. This, however, didn’t stop up the illegal revenues being generated; it just stopped the necessity of enormous bribes to officials. Instead, the extra money went to entrepreneurial ventures that made some of these former tax farmers into railroad, mining and banking magnates. On a macro level, the decision was better for the Russian economy in that it rerouted money from unproductive investments into productive areas that helped build national infrastructure. Unfortunately, many of the control issues would still remain.

Fast forward 50 years. In 1913, the Russian annual expenditure was 3.094 billion rubles; in 1914, the taxes on vodka sales netted 1 billion rubles. So many decades later, and still vodka was paying for a third of the governmental budget – and this in a year in which military expenditures were increasing exponentially to mobilize for World War I. Taken over the previous 60 years, vodka was paying for at least 25% of the annual budget and so constituted a spectacular loss of revenue if it were to be removed – which is just what happened. After Nicholas II’s ban on alcohol, the state saved peasants upwards of 1 billion rubles per year, while at the same time markedly decreasing its own revenue intake and greatly destabilizing the grain market. Wheat producers began illegally making vodka, depriving the market of a large amount of grain that would have gone to the army or on sale to the populace. To make up for the shortfall, the government was obliged to provide some free food to the public but was unable to afford doing so; they had to also feed the army and provide the soldiers with weapons, the latter of which was a spectacular failure and a major reason (aside from incompetence and drunkenness) the death toll in WWI was so high. The great budgetary deficits that resulted forced the Russian treasury to obtain foreign loans, and the repayment of these loans encouraged large inflation. This hit the populace in force by the end of the war, when a double whammy of inflated prices and low grain availability made starvation a palpable event for returning soldiers. Those that were out of work and starving began to protest: the first riots of the Revolution were sparked by women complaining about the non-affordable price of flour.

Under Lenin, the Bolsheviks were aware of the role that vodka played and had to slowly phase out the prohibition. With so much grain tied up in bootleg distilleries, the Bolsheviks needed to find a way to return that grain to better uses, like feeding people. They also needed to regain the revenues that alcohol provided. If it was going to be made regardless of legality, why not profit off of it? So rather than choose economic enslavement to Western countries, the Bolsheviks turned to a hypocritical, tsarist throwback: the vodka monopoly. In 1919, the legal distilleries got back to work, and the great experiments in socialist farming began. In 1925, Stalin remarked that “one cannot build socialism in white gloves.”

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