If you get an email containing a link to a Google Doc, don’t click. Check with the person who sent it before opening. There’s a phishing scam going around that seems to be widespread.
Otherwise, open thread!
This post is in: Open Threads, Cybersecurity
If you get an email containing a link to a Google Doc, don’t click. Check with the person who sent it before opening. There’s a phishing scam going around that seems to be widespread.
Otherwise, open thread!
by DougJ| 254 Comments
This post is in: Clown Shoes
All that hard work wooing “moderate Republicans” went swimmingly:
Some members of the Tuesday Group of House Republican moderates are plotting to oust Co-Chairman Tom MacArthur (R-N.J.) from his post amid frustration that he negotiated a deal on the ObamaCare replacement bill with the conservative Freedom Caucus, two Tuesday Group members told The Hill on Wednesday.
The matter could come up at a Tuesday Group meeting Wednesday afternoon, sources said.
“There is dissension in the ranks,” said one Tuesday Group member who backs MacArthur’s ouster. “The Tuesday Group, to me, is a group of concerned, like-minded representatives who discuss issues, not negotiate positions on behalf of the group, but have meetings on Tuesday and have lunch and discuss the pending issues of the day.”
I’m still hoping they have a vote tomorrow, that lots of Republicans from swing districts walk the plan and vote for the piece of shit, and then the smarter ones come in a neas and defeat it.
I don’t think that I can take it ’cause it took so long to bake itPost + Comments (254)
This post is in: C.R.E.A.M., Dolt 45, Open Threads, Republican Stupidity, Republican Venality, Assholes, Ever Get The Feeling You've Been Cheated?
oh my god the Mulvaney conference call, via @maddow pic.twitter.com/YPZr1tZfRo
— Bradd Jaffy (@BraddJaffy) May 3, 2017
As my old man used to say: ‘He couldn’t find his way out of a phone booth with the help of a map and a seeing-eye dog’…
Budget Dir Mulvaney says Dems tried "to make this President look like he couldn't govern..he beat them on that at the very highest level"
— Chad Pergram (@ChadPergram) May 2, 2017
Mulvaney: "The bottom line is this…They didn't get what many of them, including many in their base wanted. They wanted a shutdown."
— Francesca Chambers (@fran_chambers) May 2, 2017
this is such bad spin its hilarious. dems wanted no wall, pp/ocare funding and got it. trump/ryan got punked. https://t.co/k1bMQLVIHM
— Oliver Willis (@owillis) May 2, 2017
@owillis We also got $2 billion in funding for NIH, National Parks, (D) Reps are boasting on twitter about funding for state/local projects.
— Keith White (@keethers) May 2, 2017
Democrats also won a budget rider forbidding AG Jeff Sessions from messing with state marijuana reforms. That's pretty huge. https://t.co/OGhCmwbMq3
— Al Giordano (@AlGiordano) May 2, 2017
@owillis @NancyPelosi just straight up kicked their ass in the negotiations. As always.
— Brian Dress (@TradeUndrDaRadr) May 2, 2017
Gonna have to change the name from ‘Kinsey gaffe’ to ‘Trumpkin gaffe’…
QOTD: "This is going to be a disaster" —Mick Mulvaney on conference call with reporters where lines were unmuted/playing hold music
— Zeke Miller (@ZekeJMiller) May 2, 2017
Mulvaney: “We are competent, and we know what we’re doing, and the country is safe in our hands”
— Zeke Miller (@ZekeJMiller) May 2, 2017
“I’m smart! Not like everybody says… like dumb… I'm smart and I want respect!”—Fredo Trumpadministratione https://t.co/z5vG7xiutY
— Dana Houle (@DanaHoule) May 2, 2017
Open Thread: Never Trust A Guy Who Calls Himself ‘Mick’Post + Comments (238)
by Betty Cracker| 172 Comments
This post is in: Open Threads, Trump Crime Cartel, General Stupidity, Not Normal
Comey owes us an explanation. Will we get it? Probably not! But here’s a preview of some of the questions the senators plan to ask, via CNN:
Senator Blumenthal: “The American people really deserve answers about why he did release his comments and letter, and I think he may want to be more forthcoming and he may want to use this forum as an opportunity to tell the American people his side of the story.”
Yes, let’s get to the bottom of that, Senator Blumenthal!
Senator Coons: “The most important investigation the FBI is currently conducting is into Russia’s interference in our last presidential election. This isn’t just about understanding Russian interference and potential coordination of some kind with the Trump campaign. This is about defending our next election as well.”
Thank you for keeping future elections in mind, Senator Coons! It’s important to note that the Republicans who are obstructing this investigation haven’t just sold out to Putin as a one-off for the demented Circus Peanut; they are imperiling future elections too. Maybe someone will remember to mention the Russian interference in House races in 2016. Eh, probably too much to hope for…
Senator Graham: “I just want an answer. I just want to know what is going on here. You had (former Director of National Intelligence James) Clapper say there was no surveillance of the Trump campaign or Trump Tower. You’ve got press reports a FISA warrant was issued for Carter Page because of his ties to Russia. I just want to know what happened. And if we can’t do it in an open session, let’s do it in a closed session.”
This signals that Huckleberry Hound is on the Trump Train. He’s giving cover for Twitler’s ridiculous Twitter accusations and worrying about surveillance instead of addressing the possibility that Putin keeps Trump’s balls in a tiny specimen jar on his mantel at the Kremlin. Worthless sack of shit.
And speaking of worthless sacks of shit…
Comey Hearing Livestream — with Bonus Questions!Post + Comments (172)
by David Anderson| 37 Comments
This post is in: Anderson On Health Insurance, Clown car
The Upton Amendment is out. It is $8 billion dollars to pay for the late enrollment penalty of people in states who elect to waive non-underwritten guarantee issue so that these people don’t get dropped into the high cost risk pool.
Wait.
Wait.
The Upton amendment effectively builds a fund to support free-riding? https://t.co/vUoo1OiK61 pic.twitter.com/4rw0AoeWr7
— Adrianna McIntyre (@onceuponA) May 3, 2017
The AHCA has a 30% penalty for up to one year if a person applies for coverage on the individual market after having a 63 day gap in qualified coverage. The theory is that this aligns the individual market with the employer sponsored market and it will act as a pool participation mechanism. The CBO disagreed as it projected the penalty would enhance the value of staying out of the market for the healthy far more than it would keep low cost people in the market.
This amendment makes the CBO position a highly probable underestimate. It does not change the incentive for the healthy to avoid the market until they have to get in. However, it weakens the incentive for the modestly sick to stay in if they have reason to believe that they are going to have a low cost year, they can drop coverage and then get back in at the next open enrollment.
The AHCA has thrown other key elements of conservative health policy goals overboard. The HSA life cycle model of savings in youth and health to self-fund expenses in age and infirmity was thrown overboard early in the process.
In the original version of the AHCA, the subsidies were set up so that they could be split. If a person found a policy that cost less than the subsidy, the remaining portion of the subsidy would be deposited into an HSA. This makes a decent amount of mechanical sense. The young and healthy people would buy dirt cheap policies and deposit a significant amount of the subsidy into an HSA. Over time, the HSA would grow until the cohort of people who were once young, healthy and cheap to cover are no longer young, no longer healthy and no longer cheap to cover. At that point, the savings they had accumulated in their HSA would be available to pay for either care or premiums…..
The Monday Manager’s amendment took away the ability of a subsidy to be split between a premium and the HSA…. The second is that it completely destroys the mechanical theory of change for an HSA system. People can’t use [the subsidy] to pay part of their first dollar expenses in the current year. And more importantly, the young can not partially prefund their health care expenses when they become old as they can’t rollover a partial subsidy into their HSA.
Upton makes a complete hash of any personal responsibility and anti-free rider logic ever advanced in the bill. This is a mess.
Upton and more policy incoherence in the AHCAPost + Comments (37)
This post is in: Anderson On Health Insurance
I am noodling around on some risk adjustment thoughts. These are not fully formed and I am putting them out here just to get some clarity imposed in the process of writing.
Risk adjustment is needed in guarantee issue, community rated plans. It can minimize the pay-off for cherry picking and risk dodging strategies. Without risk adjustment or some other mean of funding high cost care for sick individuals, no carrier will even think about looking to cover sick people. Instead they will devote incredible amounts of effort to avoid potentially sick people and only cover people who will never file a claim.
I want to play with two different risk adjustment models and shake through some incentive structures. The first is a revenue neutral model where carriers with proportionally lower coded as sick people transfer funds to insurers that have proportionally higher number of people coded as sick. A dollar that Insurer A gains means Insurer B loses a dollar. What are the incentives for the following two states: single carrier in a risk transfer region and multiple carriers in a risk transfer region?
In a revenue neutral system, a single carrier in a risk adjustment region has no incentive to care much about the coding practices of their providers. There is no other carrier that can give the sole carrier revenue or take revenue away. The solo carrier has already priced in the full risk of the population into their premiums. The only incentive for an insurer in this scenario to care about coding is if the coding is so bad it is missing clinically relevant information that could have saved money and improved patient outcomes. This is a weak constraint.
Now if there are multiple carriers in the rating region, the incentive changes. The carriers are locked in a zero sum competition. They are red queen racing. As soon as one carrier engages in aggressive coding maximization, every carrier has a strong incentive to engage in aggressive coding maximization. This behavior can be legal and legitimate. An individual with diabetes and nerve pain in the feet should be coded as diabetic with peripheral neuropathy which is a higher level of risk than just diabetes without complications. An individual with a left arm amputation should have that information in their chart every year. If there is no limit on the amount of revenue that changes hands, the incentive to maximize coded risk score is very strong. If there is a limited amount of premium that can move for risk adjustment, there is a limited incremental gain for risk adjustment optimization.
The other funding model is an externally funded widget payment model. There are two variants. The first is open ended like Medicare Advantage and the other is a fixed sum proportional system. Medicare advantage pays a fixed sum for each diagnosis category found on claims or retrospective chart review. Insurers are not competing for a fixed pot of money. As long as an incremental coder can bring in more incremental revenue than their costs, it makes sense to chase diagnoses very aggressively. Feed back is often given to doctors on how to maximize the coding revenue from a menu of medically similar coding choices. Doctors frequently receive incentives to code aggressively in a risk adjustment revenue optimization direction. There is a difference between aggresssive coding and fraudulent coding but the money and more importantly the direct attribution of money to a particular code does provide an incentive to cross the line between aggressive but medically defensible coding to fraud. Medicare Advantage upcoding drives billions of dollars in incremental costs. Every carrier has a strong incentive to push upcoding as it is free money.
The same logic of revenue neutral multi-insurer behavior applies if there is a capped pool of external money. Every new diagnosis brought in increases the relative risk score of a carrier which means more money for that carrier. This is where red queen racing works in society’s favor as aggressive coding practices will cancel each other out.
One of the side notes that I am fussing with is the impact of Medical Loss Ratio regulations. Current regulation requires Medicare Advantage plans to have an MLR of 85%. The MLR is claims expense plus quality improvement expenses divided by the sum of premium revenue and net risk adjustment revenue. Coding does not drive claims expense. Adding a Z-code to a claim does not increase the reimbursement value of a claim. Adding a Z-code to a claim will increase the risk adjustment revenue. The numerator stays constant while the denominator gets bigger which means the MLR incrementally gets smaller. The 85% MLR places a limit on the value of chasing additional diagnoses. Are we seeing any impact of MLR on risk adjustment revenue optimization behaviors?
by David Anderson| 61 Comments
This post is in: Anderson On Health Insurance, Election 2018, Organizing & Resistance
Mark Sanford not optimistic on OCare repeal, tells me that "full repeal was, in essence, a pipe dream from the very start."
— Alexandra Jaffe (@ajjaffe) May 2, 2017
I want to get back to this comment at a future date, but first we need to bury the pipe dream and then pack the hole full of M-80s, det cord and a lit match before we run for cover (why yes, I had an interesting childhood).
Time to call Congress. We need to thank Democrats for staying firm, welcome the No vote’s, strengthen the undecided and waverers and scare the Yes votes. There is a strong rumor that a new round of amendments will be coming through sometime soon that will throw more money into the high cost risk pool but who knows.
Demand a CBO score for this complex bill that touches 17% of the economy. That is the easiest ask. No CBO, No Vote.