Health system sues thousands of patients, seizes pay and puts liens on homes - <AUTHOR> https://www.msn.com/en-us/news/us/uva-has-ruined-us-health-system-sues-thousands-of-patients-seizing-paychecks-and-putting-liens-on-homes/ar-AAH27ni <comment><USER3> The out-of-network stuff is the most insane part of the American health system. No question, it's deliberately set up to trip up those who need urgent care. There are plenty of stories of people who go out of their way to find an in-network hospital to have surgery with an in-network surgeon, only to be billed for the anaesthesiologist who is out of network - something they cannot object to because they're being put under. Even if they could ask, what choice do they have - take the surgery while awake? So beautifully set up to screw over the patient.

It's often said that health is a highly profitable business in America. And yet it is astonishing how feverishly the average Joe will fight against free healthcare because those who make the profits have convinced them it's bad for them. Look at any country with nationalised healthcare; none of us in the UK have a bad word to say about paying for the NHS through National Insurance if it means we can walk into any GP's surgery or hospital and never need to worry about money or insurance.

In the best possible way I hope the system breaks completely and it has to be rebuilt from the ground up. Maybe then some semblance of fairness can creep in.

<comment><USER4> In America, it is virtually impossible to safely retire early knowing that you will have enough money to cover unexpected medical expenses for you and your loved ones. Without insurance, you may be on the hook for millions of dollar of liabilities.

<comment><USER5> Your 401(k) is bankruptcy-exempt nationwide, IRA balances are exempt up to state statutory limits (some states are unlimited here), Social Security payments are fully bankruptcy-exempt, and some states will even exempt your primary residence (eg, Texas).

Insurance is only really necessary to avoid large up-front cash payments - <USER2> healthcare provider will treat you with the expectation that they'll negotiate some amount of payment from your insurance provider. Past that, it's fully legal and completely possible to set up your retirement finances so that healthcare providers have to make you pay in advance to get any money out of you whatsoever.

For example: move to Texas to get your IRA 100% exempt. Buy a duplex that's also 100% exempt, live in half, and rent out the other half for cash or physical checks. Whenever you get money from your tenant, immediately convert it to cash and use the money to pay off credit card bills - if you're spending via debt, they can't seize the cash accounts you're using to make purchases.

More generally, there are plenty of ways to acquire bankruptcy-exempt assets with your non-exempt retirement savings. Delaying social security is the easiest of these.

<comment> munk-a It is depressing that our system is so broken that this kind of strategic planning is needed to avoid destitution in your elder years. For everyone who isn't familiar with bankruptcy law or hasn't been casually informed - how do they survive retirement. If you've shifted your 401(k) money into private investments for a better return or already burned through your IRA - if you're retired in a state that isn't protective of your primary residence (and lots of people have retired to places that aren't Texas) then what? Is it just "sucks to be you, you didn't understand all these complicated rules well enough?" and what if your mind is deteriorating, then it's on your inattentive descendants to make sure all of this is running as it should be? Or are you constantly losing money paying a firm to manage your affairs - essentially the "please don't let health insurance bankrupt me" tax.

<comment><USER5> >For everyone who isn't familiar with bankruptcy law or hasn't been casually informed - how do they survive retirement

That's a big thing that breaks my heart to see happen. People have a giant pile of medical bills, and a large 401(k), and decide to raid their retirement funds to pay off the bills when there's neither a legal nor moral obligation to do so.

>if you're retired in a state that isn't protective of your primary residence (and lots of people have retired to places that aren't Texas) then what?

My standard advice is to limit your home equity via a mortgage or line-of- credit. Losing a $300k house to creditors sucks, losing the $60k in home equity on a $300k house sucks a lot less.

>and what if your mind is deteriorating, then it's on your inattentive descendants to make sure all of this is running as it should be?

You should have a well-documented financial plan anyhow, especially if you want to make it easy for your heirs to deal with your financial assets.

</comment></comment></comment></comment></comment><comment><USER6> This has been par for the course for UVA for some time. When I was a student at UVA ~2 decades ago, I came down with an especially severe case of food poisoning after having dinner at one of the dining halls. One of my friends found me in a very bad state and took me to the ER. They refused to accept my insurance afterwards and when I attempted to dispute the bill, threatened me with an honor code violation (read: expulsion). They seized my tax refund nearly a decade later after "realizing they undercharged" me.

<comment><USER7> I ran into the something similar with Cigna and Kaiser (albiet for a much smaller dollar amount), I called both entities prior to going to urgent care and described the care I needed (xray, splint) and was told that the copay would cover it. Lo and behold, I got stuck with the majority of the $500 bill, wish I had not gone in retrospect.

<comment><USER8> that's the evil part. They can charge whatever they feel like and there is pretty much nothing you can do besides maybe having a lawyer on retainer.

</comment></comment></comment><comment><USER9> We had this problem in Australia.

Hospital treatement was the #1 cause of bankruptcy.

Then, 30 years ago, our universal healthcare system was introduced.

Problem solved. There is a levy on our taxes each year to pay for it, a bit like a private health insurance premium. But its worth it. It also covers people who can't pay, like the unemployed/disabled.

<comment><USER10> _It also covers people who can 't pay_

We have a similar levy in the USA, except it's mostly paid by people that _can_ pay for healthcare, so an aspirin costs $100 when administered by a hospital.

And since insurance companies are smart, they negotiate down those exorbitant rates to something more reasonable, so much of the burden lies on those stuck in the middle -- they don't have enough income to pay for health insurance, but have enough assets to pay for healthcare so they end up paying the exhorbitant rates because most people don't have time to rationally evaluate and price out their healthcare and choose the most cost effective provider, and even if they do have the time, the hospital can't tell you how much it's going to cost until the work is done and they bill you.

Even when you _are_ insured and have a procedure done by a doctor that's covered by your healthcare plan, sometimes another provider (like an anesthesiologist) will do part of the procedure and you end up paying $10,000 or more out of pocket for his services.

Our system is broken in so many ways.

<comment><USER11> This is the effect of lobbying (call it legalized corruption). Insurance shouldn't be that expensive that even middle class can't pay for it and a hospital shouldn't be allowed to charge arbitrary sums for this. It's clearly possible since many countries successfully pull this off.

But in countries that are "for corporations, by corporations" regular people can't lobby their way into getting what they want or need. Only the wants and needs of a certain few that pay for their laws are considered.

</comment></comment></comment><comment><USER10> _The $164,000 billed to Waldron for intestinal surgery was more than twice what a commercial insurer would have paid for her care_

This is one of the worst parts of USA healthcare -- why are uninsured patients charged _more_ than insured patients? (sometimes _much_ more, like 10 times more [1])

[1] [https://www.washingtonpost.com/national/health- science/why-s...](https://www.washingtonpost.com/national/health-science/why- some-hospitals-can-get-away-with-price-gouging-patients-study- finds/2015/06/08/b7f5118c-0aeb-11e5-9e39-0db921c47b93_story.html)

<comment><USER12> It's not insane to think that a service provider would give a discounted rate to a firm they have continuously done business with over time, who spend a large amount of money, and consistently pay their bills in any other area of business, so at the face of it, it seems sensible. The orders of magnitude are terrifying however

<comment><USER13> It still feels completely alien to me. It's not like there is a different medical procedure is it?

<comment><USER14> If you provided something that cost $100 to produce and there are two easily and legally segregable types of customers, one who will pay the bills in 99.9% of cases and whom you charge $110 and one who pays the bills in 30% of cases, how much would you charge the second type of customer?

(Having said that, I don't think the pathological cost divergences in US healthcare are mostly explained by this)

<comment><USER10> But they are charging that other customer $500 for that $100 procedure. If they charged him $110, it's much more likely that he could pay. And it's not like insurance companies are easy to deal with, optimizing payouts means hospitals hire entire coding departments and they still sometimes see long delays untill payment for complicated procedures.

And unlike, say, choosing between buying a $250k Lamborghini vs a $20k Toyota, the patient has to choose the $250k bypass surgery or he'll die. Which is why this can't fairly be judged purely in business terms, customers have little choice in whether or not they purchase healthcare services.

<comment><USER12> I don't think anyone in this tree disagrees with you here - the question the parent asked was how much should they charge? If the dollar cost of the procedure is $90, and insurance companies pay $100 and pay every time, how much should someone who has a 30% chance of paying pay for the procedure?

<comment><USER15> Please stop repeating this. Insurance companies do _not_ "pay every time". Hospitals have to employ entire departments of RNs to argue with insurance firms that this procedure was justified and that test was necessary. Cash patients don't get to make that argument!

<comment><USER16> And not only do they not pay every time, even when they agree to pay they frequently don't pay on time!

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER17> This utterly sickens me - it also gave me a thought - If the uninsured could pay medicare or medicaid pricing for services, they may not need insurance to cover their care.

The uninsured should always get the lowest price the hospital is willing to charge anyone for that service, period.

</comment><comment><USER18> Reading this article just down right sickens me... Corruption is everywhere, people who do the right thing get screwed over in the end. Why can't we just adopt the European model or Canadian model. This is the very reason why I just want to leave the US.

<comment><USER19> It's getting harder and harder to envision what retirement will look like for millennials, between this and student loans.

An incredible number of boomers are going bankrupt due to medical expenses and have nothing for retirement.

I like to think we'll have together in 30 years, but if the last 30 years is any indication, we're in big trouble.

<comment><USER20> It's hard to envision any good outcome with the current system. But if we pass a universal healthcare like Medicare for all, and forgive student loans, and a number of other measures like girding against climate change, then for the first time in long time I could a positive trend for the majority US residents.

<comment><USER21> The "majority of US residents" have private healthcare and don't have student loans. That majority will pay more taxes to make life better for the minority of people who don't have those things.

I'm in favor of universal healthcare, but billing it as something that will help the majority is disingenuous. This is the most likely outcome. Costs stay the same or go down a little bit, but nowhere near what it would take to make costs competitive, even as a percentage of GDP, with Europe. That means taxes will have to go up, and by a lot because our public sector is so inefficient compared to Europe. (It costs is 7 times more to build a mile of subway than France, why on earth would you expect building a hospital to be any different?) These taxes will have to be paid by the middle class—because that's how it's done in Europe. It'll be totally unfeasible to have much higher capital gains or corporate taxes than France. (Which has low business taxes and pays for universal healthcare through regressive taxes.) At the end of the day, the middle class household making $80k/year will pay a lot more taxes, and their out-of-pocket healthcare spending won't go down by much, because they had employer-paid healthcare to begin with.

But the hourly workers and those folks will be able to see doctors! And that will be a good thing. But it will also be quite unpleasant for the majority of people who we're doing okay under the current system.

<comment><USER22> A friend of mine studied healthcare management for his thesis. One of the hidden costs in US Healthcare is the waste and duplication that comes from competition. His example was a town with enough population to support a single CT machine. They are expensive to maintain, but there was enough use to justify it.

One hospital bought a CT machine. Doctors who are the most important customers for any commercial hospital, began to sign contracts with that hospital because it made access to the CT machine for their patients easier. The other two local hospitals had to compete and bought their own. Now there were three machines and only enough patients to support one of them. That didn't reduce the maintenance costs. The cost inevitably is passed on to all patients. This is only one example from hundreds where competition led to unnecessary cost from duplication. Add to that the overhead for people who specialize in insurance billing because the competing companies are different and very complex, add to that the profit for the investors in the hospitals, the profit for the investors in the insurance companies and that's not even touching the similar stack for pharmaceuticals and supplies. That's not even adding in the cost of delayed and emergency treatment due to lack of preventative medicine for the uninsured and the under insured. All of that adds up to the $99 bag of $0.99 saline that comes out of your pocket one way or the other.

It would be difficult to create a more wasteful or expensive system if you set out to do it on purpose.

<comment><USER23> CT scanners and all the shit you need to run them don't cost that much.

The insurance I used to have negotiated with the hospital to charge ~$2000 for a five minute CT. The radiologist charged like $30 to interpret it. You can a buy a brand new machine every year with 5 or 6 patients a day.

The anecdote may have been true in 1982 or something.

Meanwhile, no one else can buy a CT because the state regulates who gets to own one.

<comment><USER24> Actually the maintenance costs less than $60 per patient and most of it is in autoinjector, some in coolant and checks. You're being gouged. Source: in Poland, checked the costs.

The cost of a new full size CT machine with surrounding equipment is quarter of a million USD though. Some are more expensive than others, but you can get a new good one for this much.

USG costs few tens of thousands, and maintenance is super cheap, mostly consumable gel, some $8 per patient.

MRI machines are more expensive at half million USD and $120 per patient. (cooling costs)

This includes salaries.

Hospital bed is like $12 per night, staff included.

Germany and Sweden have even better healthcare, mostly due to larger number of doctors and nurses. Not that much more expensive too. Our education and salaries don't keep up.

<comment><USER25> Even in russia you can get MRI for $50 (depending on body part and resolution it might go as far as $300).

Possible solution to duplication: decouple tech (test labs) from doctors (hospital)

<comment><USER26> Oddly enough, it seems like tech is closer to doctors in Germany than in the US. Just about every Hausarzt (general practitioner) and every internist and ob/gyn has an ultrasound machine in their practice and uses it themselves. When I've been in the emergency room, the doctor does the ultrasound, not a technician, though nurses set up and run EKGs.

And it's all amazingly cheap compared to the US, even as a private pay patient. An overnight hospital stay is about 200 EUR, including the attending doctor's fee.

<comment><USER27> That's interesting. In the US, these things go for $10K or so. Maybe they lease them? At $500/mo if it got used every day, that's be under $20 per use.

<comment><USER26> No idea, but there's a lively enough market that I've seen older ultrasound machines at veterinarians' offices.

Vet services, by the way, do cost approximately as much as they do in the US, at least for birds.

</comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER28> The moral of the history is: Not everything should be run by businessmen.

<comment><USER29> That's the wrong moral, this hospital is state run.

</comment></comment><comment><USER8> Stuff like this simply shouldn't happen in a developed country. It's insane that this can't get solved.

<comment><USER30> Too many people with connections profit off of the current situation, the poorest people pay the price.

This is why there is no demand for real change and why all previous efforts got essentially stonewalled.

<comment><USER31> It's actually the middle class that pays the price, through insurance premiums, out-of-pocket co-pays, and high deductibles. Poor people have Medicaid.

Medicaid, which even happens to pay reasonable amounts for procedures performed. The entire system would re-adjust into a sustainable steady-state, if all prices were equivalent to Medicaid reimbursements. But I suppose that under such a model, the average middle-aged surgeon wouldn't be able to afford their third summer home...

<comment> munk-a Medicaid is probably the second best place to be in the US system after Medicare - but it suffers from extreme politicization of care (good luck trying to get HRT or an abortion on Medicaid), rationing, shortage of supply (not all providers are required to or will service Medicaid patients) and stringent requirements to ensure continued availability (these in particular are getting much worse under pushes to get rid of "welfare queens" _sigh_).

That said, the only way to win is to not play - never get sick and emigrate before you have any serious health issues.

<comment><USER31> All of these problems come from Medicaid and Medicare paying a lot less for procedure performed (In line with what Canada, and Europe pays) than the public market. It's a drain on most hospital budgets.

If all procedures performed were done at Medicaid-like prices, hospitals and physicians, and pharma firms, and, by proxy, insurers and medical schools would have to tighten their belts, and figure out how to cut costs. That's the entire point of such an exercise. We can't let health costs grow in an unbounded manner.

<comment><USER32> 100% agree with the drain on hospital budgets, at least so far as I know.

Dunno how 'Medicare for all' will work out if you simply start paying providers what Medicare currently pays. Dictating a price might work in the long run but would be plenty hairy in the short.

<comment> munk-a A lot of people that get paid a lot of money for doing absolutely nothing will lose their job - tough luck for them.

I can sympathize with the on-the-ground employees but the businesses they're keeping the lights on in are leeches on the healthcare market - I posted separately on this article going into the specific functions of PBMs, Pharmaceutical Manufacturers, Providers and Insurers if you're curious about the details, but there is a ton of inefficiency here.

<comment><USER32> I'm thinking partly in terms of paying US health professionals what they make in places like France. A certain amount of hilarity would ensue.

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER33> Ok so dumb question I always wanted to ask, about the arbitrary prices. Let's say I have no insurance and I collapse on the street, get rushed to the hospital and revived, after which they send me a bill for $10k. I didn't agree to any treatment; I didn't sign anything. What prevents me from saying that I won't pay it - not in "you can send it to collections" way, but in a "this is a fraudulent bill" way, like I don't owe anything at all? If the hospital can claim by fiat the price was $10k after the fact, how come I cannot claim by fiat the price was $100, or send the hospital a counter-bill for $9900 for having had the privilege of touching my chest? I mean, a car dealership cannot send me a bill after the fact for an extra $10k for driving off the lot? (Semi-)serious question, actually. What would they do? There's no contract.

Even if I did sign something in an emergency, I may be able to claim to not have been capable enough to reason about it, due to shock/mental issues given the emergency.

<comment><USER34> > Ok so dumb question I always wanted to ask, about the arbitrary prices. > Let's say I have no insurance and I collapse on the street, get rushed to > the hospital and revived, after which they send me a bill for $10k. I didn't > agree to any treatment; I didn't sign anything. What prevents me from saying > that I won't pay it - not in "you can send it to collections" way, but in a > "this is a fraudulent bill" way, like I don't owe anything at all?

Not a dumb question. If you don't have insurance, you can make such claim, and very likely you'll never have to pay. If you do have insurance, it's very likely that your insurance has pre-existing contracts with the hospital. Even though the hospital can't force you to do anything, it's likely that they can force the insurance to pay.

</comment></comment><comment><USER35> >...is taxpayer supported and state-funded, not a company with profit motives and shareholder demands. Like other nonprofit hospitals, it pays no federal, state or local taxes on the presumption it offers charity care and other community benefits valued at least as much as those breaks. Gov. Ralph Northam (D), a pediatric neurologist, oversees its board.

</comment><comment><USER36> We could have solved this in the 1970s or 1980s, but didn't, wonder why not. Vote next time.

</comment><comment><USER37> most people here can't seem to view the apple and the trees.

The US is the only country in the world where you get healthcare through your employer. This did not happen naturally. It was mandated by government after WW.

Second, all treatment here is expensive: \- there is a lack of supply (hospitals require approval from nearby hospitals before opening. Imagine... McD's needing approval from Burger King be4 opening across the street!) \- there is no legal a-la carte offering. (no such thing as catastrophic insurance can be sold. So you must buy everything... or nothing) \- there is a floor on pricing (medicare, medicaid) \- there are no legal substitutes (doctors all must be ferraris, you cannot have Toyota nurses or unlicensed doctors doing treatment) \- there is a huge barrier to entry (doctor must undergo many years of training and expensive education)

I could go on, but every single distortion we have today in healthcare can be directly traced to some kind of government action. So now we have a corrupt system which was carved out by government.. for corporations.

Should the current system die ? Absolutely.

For single payer ?? The government is what got us to where we are today. What confidence you have in that they will do better on the evidence presented above ??

</comment><comment><USER38> I really wish one of the big corps not currently in the healthcare scheme would lobby to change or disrupt the healthcare industry. I recall Amazon, Chase, and Berkshire Hathaway were trying to do this for there employees, but I havent heard the result of that for a while. The current players are too entrenched for any one entity without a lot of capital to disrupt.

</comment><comment><USER24> Yes, the main goal of US healthcare system is profit, not health. Totally wrong priorities.

</comment><comment><USER39> The USA is a pure capitalistic country and appears to have little or no sympathy for the poor and disenfranchised.

<comment><USER40> Yup, which makes you wonder why poor people go to the USA compared to say the Netherlands or some European country. If you are poor in the USA, you will be exploited.

<comment><USER41> It baffles me as well. Especially considering that the "American Dream" (technically defined as Social Mobility [1]) is more achievable in Europe. Especially in Scandinavian countries which are also the "happiest" countries on the planet.

[1] [https://en.wikipedia.org/wiki/Social_mobility](https://en.wikipedia.org/wiki/Social_mobility)

</comment></comment></comment><comment><USER42> The way we pay for medical care in the US is screwed up.

That said...

I've always thought it weird that people feel entitled to free (or massively discounted) medical care.

Consider the case where some business could sell you a product or service that might add years to your life. How much is that worth? Why is it somehow unfair or immoral if someone buys such a product or service, without considering their ability to pay, and bankrupts themself?

Yes the issues are more complex here in the US due to the opacity and arbitrariness of medical billing, but if we set that aside, how much is your health worth to you?

<comment><USER43> I've seen this type of argument by a few people who are against state medical care (not saying you're one of those in particular).

The product or service that extends your life is essentially not critical to survival or even just your status quo health-wise. From an economic perspective, this is a price elastic situation so charge as you like (i.e. basically according to supply/demand).

The situation that is actually the problem (and way more common, of course) is that if I'm in a life threatening situation I don't have the option to chose a particular product or service, that's price inelastic and not beholden to supply/demand. So you're comparing apples to oranges from an economic viewpoint, especially when we're talking about something as critical as healthcare.

<comment><USER44> For what it's worth, there are _some_ UK parties, where if they got into power I suspect they would nationalise such a product/service for the betterment of everybody.

</comment></comment></comment><comment><USER45> This violates our long-held arrangement-- that they can keep charging these ridiculous prices because we have no intention of paying them.

<comment><USER46> Turns out the entity with the money and lawyers can change the agreement at any time - who knew?

</comment></comment><comment><USER47> I mean, I don't blame them for trying to get paid for treatment they provided. The problem is generally that these patients aren't covered by private or public insurance at the time of treatment, correct?

I mean, someone has to pay for the treatment somehow, right?

I'm not sure what is interesting exactly about this article.

People being uninsured and unable to afford health insurance is a huge problem. Medical providers attempting to get paid for services they provide seems like what they should do.

<comment><USER48> It's an example of how incredibly dystopian the system as a whole has become. The individual mechanisms aren't egregiously wrong in isolation; it's the big picture that's clearly broken.

</comment></comment><comment><USER49> A criminal racket. Where is the outrage?!

</comment><comment><USER50> Use the right tool for the job. Consider that possibly free-market capitalism is not the right tool to solve health care

</comment><comment><USER51> Hippocratic oath meet capitalism

</comment><comment><USER52> A two word solution: Socialised medicine. The civilised world does it, about time the USA caught up. Socialised medicine is not perfect, but the USA spends the most for the worst results. How American!

<comment><USER53> Socialized Medicine might solve the payment problem for people that can't afford it but I lived under the Canadian System of Health Care (OHIP) and much prefer the Health Care I have in the USA (TX). The service/quality of care I receive in the USA is far superior in my opinion.

Here is a breakdown of Ontario, Canada's debt.

[https://en.wikipedia.org/wiki/Ontario_government_debt](https://en.wikipedia.org/wiki/Ontario_government_debt)

>Health and education together account for more than 50% of Ontario's spending ($61.3B and $29.1B, respectively)

If you don't mind paying incredibly high taxes for health care or having other people subsidize it for you, then you will probably enjoy socialized medical care.

<comment><USER54> > If you don't mind paying incredibly high taxes for health care or having > other people subsidize it for you, then you will probably enjoy socialized > medical care.

I have no problem with my bracket (32%) going up to 50-60% or so if it means I don't have to worry about my parents getting the kind of care they're getting now under the American system.

<comment><USER55> The best part is that it isn't that high and the parent you're responding to is speaking relatively nonsense.

I'm in one of the higher tax brackets in Canada and my _net_ tax rate for 2018 was 28.74%—and that is both _federal_ and _provincial_ taxes.

Per Revenue Canada documentation, the 2019 rates will be: * 15% on the first $47,630 of taxable income, plus * 20.5% on the next $47,629 of taxable income (on the portion of taxable income over 47,630 up to $95,259), plus * 26% on the next $52,408 of taxable income (on the portion of taxable income over $95,259 up to $147,667), plus * 29% on the next $62,704 of taxable income (on the portion of taxable income over 147,667 up to $210,371), plus * 33% of taxable income over $210,371

Ontario adds on to that:

* 5.05% on the first $43,906 of taxable income, + * 9.15% on the next $43,907, + * 11.16% on the next $62,187, + * 12.16% on the next $70,000, + * 13.16 % on the amount over $220,000

[https://www.canada.ca/en/revenue- agency/services/tax/individ...](https://www.canada.ca/en/revenue- agency/services/tax/individuals/frequently-asked-questions- individuals/canadian-income-tax-rates-individuals-current-previous-years.html)

I'm in the third tax bracket. My wife and I together would be in the fourth (but income taxes are not blended that way).

So…no, Canadian taxes are not, and have never been as bad as people say. (Before I émigrated, my wife and I made the same amount of money one year—and I paid more in state and US federal taxes than she did, in the 90s.)

And I get healthcare and a healthy society out of it.

</comment></comment></comment></comment><comment><USER56> Seems unremarkable. Most businesses will do this if you owe them money and don't pay.

</comment><comment><USER57> The capitalist solution is......

GROUPON

This speaks to the opacity of pricing in the healthcare industry. There should be a price list at the door of the hospital for common services.

<comment><USER58> I would love to know how I could price discriminate when I was in crippling kidney stone pain.

Price transparency is only a minor issue.

</comment></comment><comment><USER59> "for-profit hospital" industry. It's not your pal. It's there for your money.

<comment><USER29> Quite an ironic statement. This hospital is entirely state run and non-profit.

</comment></comment><comment><USER60> How is our health system legally mandatory? Why do we HAVE to pay into medicaid etc. if the system is not run efficiently? Why is there not an alternative?

<comment> munk-a Because the market has been fully captured by current players and new entrants either play along or are forced out of business - but generally don't even try to join because of the prohibitive barriers to entry.

Medicaid is one of the less broken parts of the system actually.

</comment></comment><comment><USER21> There are good arguments against our existing healthcare system, but this is not one of them. Collections is an issue whether or not you have universal healthcare, it just happens one step removed. What exactly do you think happens when you don't pay your taxes? The government takes pity on you and lets you off the hook? In my county, the government auctions off a lien on your house when you fall behind on your property taxes.

<comment><USER46> No, this is an excellent case of universal healthcare. In countries with it, this situation - an emergency illness leading to a pile of debt, doesn't happen. There's a huge difference between "you didn't pay your taxes" and "you got stick and are now stuck with a bill you can never hope to pay off".

<comment><USER61> It's pretty sad to think someone could be in a situation where they are sick and simply won't go to the doctor to get help -- because they can't afford it. The last thing someone should have to worry about when trying to recover from cancer or some other illness/injury is how is this bill going to get paid. I'm in law enforcement, imagine how many less calls there would be if the person calling the police had to pay for the service (directly, full cost). Healthcare should be in the same bucket as other public services, regardless of the income generated by that person.

</comment></comment></comment><comment><USER32> Am I missing something here?

. Hospital system is a bastard to people who owe them $$$$.

. This is an argument for government-run healthcare.

. Hospital system is run by the government.

I'm certainly not against copying someone else's system (Switzerland? Singapore? it isn't like they're the same) but just assume nothing good will happen. There's too many iron rice bowls, including actual providers, plus you have to fix the plane while it's flying.

Best to deal with the world as it is and keep your head down. That memory care center in Thailand is starting to look pretty good.</comment>


Nokia on the skids, analysts eye Microsoft takeover - <AUTHOR> http://www.guardian.co.uk/technology/2012/jun/14/nokia-survival-question-10000-jobs-cut?newsfeed=true

<comment><USER2> Typo in the title. Nice.</comment>


Building the World's Smallest Atomic Clock: A Nitrogen Atom in a Carbon Cage - <AUTHOR> https://spectrum.ieee.org/semiconductors/materials/to-build-the-worlds-smallest-atomic-clock-trap-a-nitrogen-atom-in-a-carbon-cage <comment><USER2> They're shockingly ugly (and expensive) beasts, but you can now get atomic wristwatches. (Actual atomic watches, not the "atomic" kind that simply receives the radio time signal.)

[https://www.hoptroff.com/collections/atomic- timepieces](https://www.hoptroff.com/collections/atomic-timepieces)

<comment><USER3> Could atomic clocks provide more accurate GPS positioning for GPS receivers? It's my understanding that GPS works by measuring tiny differences in the time it takes equivalent signals to reach the receiver from different satellites. It may be the case that other factors (like noise and refraction) dwarf any inaccuracies in the quartz clocks in our everyday GPS receivers.

<comment><USER4> We don't need super accurate clocks in the GPS receivers; instead, the GPS satellites carry atomic clocks with them, and include timestamps in their broadcasts. So you get two signals at the same time, compare the time the satellite said it sent each signal, and you've got the difference in travel time.

<comment><USER3> Oh, interesting. What's the time granularity transmitted by the satellites? I assumed that the satellites broadcasted a course stream of times and the receiver had to finely measure its local time difference between receiving the same time from multiple satellites.

<comment><USER4> So did some poking around; apparently, there are two timestamps in GPS messages, and the more precise one is packaged in a custom hash function and called the "ranging code". The timestep (called a "chip") is a bit under a microsecond.

But yes, the receiver does have to measure small time _differences_ between received signals; but that just requires a local clock with high resolution, not one with low drift or low absolute error.

For example, if your local clock is a second off, but still measures time intervals to pretty high precision (say, 0.01% - losing a second every three years) that's probably not going to mess up your location fix very much. Especially when the problem is overconstrained as it usually is intentionally. Compare the theoretical minimum requirement of three visible satellites to make a measurement with the 4-12 satellites that the system guarantees will be in sight at any time.

</comment></comment></comment></comment></comment><comment><USER5> Hm; tried to revive some primary school-level physics/chemistry knowledge to calculate price-per-molecule or #-of-molecules-per-£. Is my calculation correct, or have I botched it? :)

Given atomic mass of C is 12.011, of N is 14.007, the molar mass [1] of the fullerene should be:

_M_ (N@C60) = 14.007 + 60×12.011 [g/mol] = ~734.667 [g/mol]

Then, given:

N_A = 6.022140857e23 [1/mol] — [https://en.wikipedia.org/wiki/Avogadro_constant](https://en.wikipedia.org/wiki/Avogadro_constant) (number of molecules in 1 mol)

p_g = 200e6 [£/g] — price per gram given in article

n = ? [1/£] — number of molecules one would get for £1

I devised:

n = N_A / (p_g × _M_ (N@C60)) = [1/mol] / ([£/g] × [g/mol]) = [1/mol] / [£/mol] = [1/£] = 6.022140857e23 / (200e6 × 734.667) [1/£] = ~ 4e12 [1/£] ?

In other words, it seems you could buy ~4'000'000'000'000 molecules for £1 ?

—

[1] [https://en.wikipedia.org/wiki/Molar_mass](https://en.wikipedia.org/wiki/Molar_mass)

</comment><comment><USER6> The description of their "high-pressure liquid chromatography" technique sounds an awful lot like how one would enrich uranium (you know, as one does.) Did they accidentally invent a better uranium enrichment process (or independently reinvent a classified one?) Or is there some difference between {C60, N@C60} and {U235, U238} that makes using HPLC to enrich it impossible?

<comment><USER7> HPLC separates molecules based on some chemical property. In this case, the N@C60 fullerenes are probably very slightly larger, distorted from pure icosahedral symmetry, or have different electronic structure to the plain C60. Chemically speaking, U235 is probably very much like U238 and the chemical compounds of the isotopes are probably chemically almost identical (since isotopic chemical reactivity depends basically on the so-called kinetic isotope effect, which is larger if there is a large difference in mass between isotopes). HPLC is basically a standard synthetic laboratory procedure and has no relevance (that I know of) to uranium separation aside from purifying bulk chemicals.

<comment><USER6> My understanding was that HPLC was just a way to do gaseous-diffusion enrichment (i.e. "standard chromatography") without the really long tubes. From the article:

> In standard chromatography, substances having different chemical > characteristics are separated by making them run a kind of gauntlet—an > obstacle course that blocks the passage of one thing more than the other. > HPLC works by using a pumped solvent (hence the term "high pressure") to > strip off the laid-down film of carbon fullerenes in such a way that the > desired molecules—the fullerenes encasing nitrogen—are carried away > preferentially.

My interpretation of that statement is that HPLC uses a solvent that manages to detach the slightly _lighter_ (and/or less electrostatically-attracted-to- the-film) molecule first, giving it a head start down the diffusion tube, letting the tubes be really short, and thus giving you a tabletop device instead of capital equipment in a dedicated facility.

Maybe HPLC of N@C60 really leans on that differential-electrostatic-attraction property, but it seems like the process would still _work_ to separate isotopes that differ only by molecular weight.

I'm not a chemist of any sort, though, so I'd be glad to "get schooled" here.

</comment></comment></comment><comment><USER8> So how precise would this make our location?

Could I replace my 3D-mouse by a cellphone using this technique?

<comment><USER9> I'm not sure that is the goal. Having cheap and small atomic clocks simplifies time sensitive applications that can't always rely on satellites or ntp. Clock synchronization is currently not a solved problem for the masses.</comment></comment>


Simple System Could Transform American Medicine - <AUTHOR> http://www.wired.com/2014/10/number-needed-to-treat/?mbid=social_fb <comment><USER2> I teach medical students and residents this method, and use it in my practice. There are some important caveats that make it more complicated than it looks at first glance. The primary one is that the NNT is tied to a very specific outcome; for example: How many patients do I need to treat with a statin to lower cholesterol? That's a lower number than the number I need to treat go get the outcome I actually care about: How many patients do I need to treat with a statin to prevent one heart attack or stroke? And even then, the answer I actually get is: How many patients do I need to treat with a statin to prevent a heart attack or stroke in a one year period?

So, I would respectfully submit that it's not so simple as the article makes it sound, but it adds much-needed empiricism to prior standards for clinical decision-making.

<comment><USER3> I also wonder if the situation isn't further complicated when you consider accuracy of diagnoses. A snippet from wikipedia: "It is estimated that between 10-15 percent of physician diagnoses are erroneous" [1], which is apparently attributed to overconfidence.

This would probably have a larger effect in conjunction with treatments having a higher NNH (number needed to harm).

In any case, I suspect that the push for (a more) evidence-based medical science will only have positive effects, and thanks for your information!

[1] Berner, E.S., and M.L. Graber. "Overconfidence as a cause of diagnostic error in medicine." American Journal of Medicine 121 (2008): S2-S23.

</comment></comment><comment><USER4> Several close relatives of mine died in similar circumstances, so I especially appreciated the humane treatment of the elderly stomach cancer patient. Everyone in medicine should be looking for _anything_ that can reduce abuse via "heroic measures".

</comment><comment><USER5> > In this case, though, the general consensus "among people who care about > this kind of stuff," Newman says, is that the antibiotics are unnecessary > for a simple abscess like this one, even in the age of nasty antibiotic- > resistant staph infections. Just getting all the junk out and keeping the > wound clean is usually enough. But Newman isn't going to pick that fight > today. He doesn't want to get in the way of doctors' plans for their > patients. If he respects their decisions, they'll be more likely to respect > his, after all.

This is something everyone should learn from.

</comment><comment><USER6> This statistic seems like a useful tool for doctors and others prescribing medicine.

However, I don't at all like the insinuations this article repeatedly makes that doctors are keeping information away from patients that could save their lives. Doctors go to med school for years so that they can make medical decisions for the rest of us. It's almost insulting to do armchair pharmacology and assume you know better than the doctor who's trained for years. This is the same kind of thinking that brought us vaccine autism scares and the chronic issue of people not finishing their antibiotic courses.

<comment><USER7> > It's almost insulting to do armchair pharmacology and assume you know better > than the doctor who's trained for years.

Yeah but doctors in the U.S. basically get fake medical training, which is (partly) the point of this article.

<comment><USER2> What are you talking about? Medical training is more rigorous than ever, and requires constant testing, continuing education, and renewal of board certification. All while competing groups have sought independent prescribing privileges with none of these assurances.

<comment><USER7> > Medical training is more rigorous than ever, and requires constant testing, > continuing education, and renewal of board certification.

\- Much of the med school curriculum isn't based on science at all. This article gives several examples of that.

\- Of the part that is based on science, much of the science is completely wrong for various reasons.

\- Medical education mostly consists of sponsored content that's paid for by pharma companies rather than students/doctors, at least for continuing education.

<comment><USER8> You're making extraordinary claims, with zero evidence to support what you're claiming.

For example: "much of the med school curriculum isn't based on science at all"

Ok, now show me the proof to back up that statement so I can verify for myself that you're not just opining.

"Of the part that is based on science, much of the science is completely wrong for various reasons"

Ok, which parts, and prove that it's wrong. At least support your extreme claims.

"Medical education mostly consists of sponsored content that's paid for by pharma companies rather than students/doctors, at least for continuing education."

More truly massive claims. "Mostly" typically implies majority. You've got a lot of proving to do.

<comment><USER7> So basically it's not your job to read books and become well educated, it's my job to do your homework for you. Good luck with that.

</comment></comment></comment></comment></comment></comment><comment><USER9> The site appears down; TheNNT.com just returns a vanilla wordpress site.

<comment><USER10> Yeah, i get barely-formatted content. Something is definitely going wrong

</comment></comment><comment><USER8> I was pretty sad to see this on TheNNT.com at the moment:

"Welcome, Wired Readers! We're glad to have you but you've crashed our tiny, bare bones website created by hand from a bunch of passionate physicians in our spare time! Please bear with us while we get back up and running!"

</comment><comment><USER11> maybe other people have different experiences, but i find this article complete BS.

first off, its nearly impossible to get prescribed antibiotics for something like bronchitis. Only after 3 doctors visits and a raging fever and cough that was going on for 3 weeks did they prescribe me antibiotics. of course by that time I already had pneumonia.

more recently this may, i had a bad cough, fever, and raging sore throat. i could tell from how my body felt that everything was emanating from a single spot in the back of my throat, but of course when telling a doctor this they look at you like you have a 3rd eye, and then send you home (telling you to drink plenty of fluids and rest) after crawling there and paying a 50$ copay. its inconceivable to them that we might actually understand our bodies, but i digress. Even though I had puss nodules on the very spot (my left tonsil) I felt everything was coming from, I was not prescribed antibiotics because the strep test came back negative.

note, these are two severe cases where I was REALLY sick and not getting better. not only did doctors not prescribe antibiotics for these, but for all general colds and flues that i have ever had - I have never received that as a prescription. they simply will not do it.

lucky for me, I had a plane jane penicillin script that was never taken. within an hour of taking it, the sore throat abated as did the fever. by the next morning, I was nearly better. maybe coincidence, but i seriously doubt it.

they love to fear monger about over prescribing antibiotics, about creating super bugs, etc. but the truth is, they do help. even with viruses, because quite often these diseases wreck your immune system allowing many other things to take hold. for instance, bacterial ear infections are quite common enough with these types of infections and antibiotics totally prevents them - and the good possibility of hearing loss.

however, evidenced based medicine is often set up to prove whatever agenda they want to pass. a few people with reduced hearing is inconsequential to their idea of a greater good. especially in the agenda to reduce people receiving antibiotics - even when evidence has shown that the amount of antibiotics farm animals are given probably over shadows any lack of antibiotics given to sick humans trying to get better.

<comment><USER12> It of course depends on the doctor. My experience is that if I go to the local Sansum Urgent Care with the symptoms you describe (which I have done often) it is impossible to not leave with a prescription for antibiotics, even if the doctor and I both agree I probably have something that will get better on its own and will not likely be helped by antibiotics :/.

A couple weeks ago, I walked into a tree and got a tiny scrape on my forehead, and just wanted to know if there was anything special I should do to minimize scarring: the doctor largely ignored my questions (giving me really useless answers) and instead did a swab to check for staph and then wrote me a script for an antibiotic that I should take if I saw any changes... and the stuff she listed was stuff I'm certain many people would just panic and assume were happening :/.

Hell: I'll up the ante here, and say that if I get this one guy when I go, a doctor I like to call "Dr. Happy Pills", not only will he try to get me to start taking antibiotics, he will also try to get me to start taking steroids (whether oral prednisone or an inhalable version), and will refuse to let me leave until he's found enough free samples of some random form of steroid in the office to feel like he's "helped" me :/.</comment></comment>


A Front End Does Not Have to Be Rich - <AUTHOR> https://www.apress.com/us/blog/all-blog-posts/your-front-end-does-not-have-to-be-rich/16537718 <comment> duncan-donuts I agree with what is being said, but I don't really see any new thoughts here. This is such a tired conversation. I used to have opinions about this, but I've grown to have a position of, "ship over anything else". Do whatever you can to ship faster. If that is nextjs, great. If that just a bunch of PHP files on an apache server? great. None of it is one-sized fits-all. /shrug

<comment><USER2> In my experience going SPA seems to double the amount of code needed (at least).

<comment><USER3> Yay, the world is waking up, google search is not spa, Ebay is not spa, Wkipedia is not spa, Youtube is not spa, Stack exchange is not spa, Duck Duck Go is not spa, HomeIdea3D.com is spa though

<comment><USER4> YouTube is indeed a SPA.

<comment><USER5> YouTube is not really a SPA as in React or Vue. It looks like they use something similar to TurboLinks or Intercooler: [https://youtube.github.io/spfjs/](https://youtube.github.io/spfjs/)

Edit for downvoters: Ok, technically, YouTube is a SPA. What I meant, in the context of this discussion, is that YouTube uses a technique similar to what GitHub does, where the server returns fragments of HTML.

</comment></comment></comment></comment></comment><comment><USER6> I feel odd dissing this article, because there's nothing wrong with it: Saying that you should consider your audience, focus on your content, and use "rich" (oh man, I remember when RIA was the buzz-de-jour) websites when, and only when, appropriate, is not controversial.

That said, I don't feel like there's much actually said. Just restating what is commonly advised (if not practiced) best practices, and not really doing anything to address WHY it isn't practiced. It also failed to mention the differences when you have an application that DOES benefit from being "rich", how progressive enhancement is still a good theory (I'll be honest, none of my workplaces have DONE it).

I've seen plenty of dismissive "web coders are trash" and "lol, Js, learn to code" comments (paraphrasing) in various discussions, as well as more informed discussions as to what is and is not a real cost/benefit of various approaches, but I've not seen much in-depth discussion about why the best practices really are rare, and how to fix that. I wish the author had gone beyond the basics and addressed that.

<comment><USER7> Yep. There's a proliferation of reductive posts that essentially repeat the same truisms we've all heard: You don't need a SPA; NPM is a ghetto; Front end web development has too much churn.

Who cares? If you don't like the state of web dev, leave or learn to make it better. If someone were to write yet another NPM sucks article, BUT include in it a description of a PR they opened to improve the process, I'd happily upvote them. But instead people seem to be satisfied with complaining with little action.

<comment><AUTHOR> I'm not sure how you drew the last 2 conclusions from this article. The point is to make sure people think twice before they default to an SPA to make sure it's the right decision - in my experience a lot of people are jumping to the SPA pattern without considering the alternatives. Do you not think an article like this, which aims to increase awareness of non-SPA architectures, is helping to make it better? What else would you like to have seen this article cover?

<comment><USER7> The last two points are not specific to the article but to the category of vaguely contrarian points about modern web development in which the article resides. And I'm a little skeptical of the premise, which is that we need to increase awareness of non-SPA architectures. Even though there is a lot of hype around SPA's and fancy front end driven architectures, I'd bet that the vast majority of code written and new developers minted are primarily focused on server side web applications. It's just nobody ever says "yknow what's new and hot and the thing everybody should use? Java servers!"

</comment></comment></comment></comment><comment><USER8> Agree 100% with the need to consider the project in question. I don't know the context of you guys, but at least in mine, I don't see such kind of planning very often.

I'm currently involved with two projects. One is a youtube-like app and the other one, a business management application. In the former I'm using SPA and rich front-ends as if there is no tomorrow; in the last I'm coding as if it were 2000's, with form submits, page reloads and client javascript only to the minimum level needed to ensure a reasonable responsiveness.

However most projects I'm aware of are using Angular or even React + Material Components to build business apps with lots of data tables and input forms. In my opinion this is a serious drawback, since it increases the project complexity and adds basically zero value to end users, who get a good-looking application which, at best, does the same thing but it's more expensive to write and maintain.

P.S. those are my impressions about my local market (Brazil), your mileage may wildly vary.

<comment><USER9> >However most projects I'm aware of are using Angular or even React + Material Components to build business apps with lots of data tables and input forms. In my opinion this is a serious drawback, since it increases the project complexity and adds basically zero value to end users, who get a good-looking application which, at best, does the same thing but it's more expensive to write and maintain.

So what (if any) framework do you use for the business-like apps that don't need a rich frontend? I agree that using something like Angular can be bloated, but it does offer some nice "shortcuts" for even the blandest of UIs. Specifically model binding.

<comment><USER8> It depends.

I have routines using vanilla javascript, believe it or not.

Model binding is a requirement only if you are going to deal with your model in javascript. Maybe to perform an ajax call or something alike. But I often simply do a form submit like in the old days.

In more complex routines I may use Angular.js (not Angular). But not as a single page application, bundling code, minifying it etc. I often get away with an angular.js application locally to the page which is going to use that script.

I won't lie, the codebase is ugly, inconsistent and unpredictable as hell and new developers, when arrive to the team, get immediately convinced that the architecture was planned by some amateur who don't know what he is doing.

They are probably right, but get familiar with the project really quickly and understand that there is order under that apparent surface of chaos.

I'm pretty sure this leads to more code having to be written, but it's code easier on the brain, easier to split in tasks to different developers and so on. We are not typists after all, experience shows that it's best to spend more fingers and less brains.

This is the best I could do so far to make a fairly inexperienced team deliver at a reasonable pace while dealing with users changing their minds at relativistic speeds.

</comment></comment></comment><comment><USER10> I think there's a conflation of client-side-SPA === rich/complex here. For all practical purposes, this may be true as SPAs have gotten reliant on _complex_ frameworks like React, Vue, ..

In 2019, with ES6, I believe frameworks to be an overkill. When React was introduced, it did goad people into thinking in components, etc. However, classes and higher-order-functions in ES6 allow one to think modularly without a framework. And the Virtual-DOM's value proposition is questionable when DOM updates are properly batched ( like when using [https://github.com/wilsonpage/fastdom](https://github.com/wilsonpage/fastdom) ).

Complexity is bound to increase with features, either in the back-end or front. But SPAs (with PWAs) offer advantages of being fully functional when offline, or with spotty connectivity, which is a significant value proposition. Not to mention lower server-side costs (in use-cases where server costs are prohibitive, SPA-PWAs is the only economically viable option).

My takeaway is to evaluate not just the reliance on SPA/PWAs but also on complex frameworks with diminishing returns.

<comment><USER11> I actually tried to implement a SPA using just ES6 (in Typescript) some years back and ran into quite a few problems with data flow, which frameworks like Vue.js readily solve.

I think that (for example) Vue by itself is quite light (mu Vue apps were never slow, even on a computer that choked on most other webpages). The problem is that many web developers don't care about performance and will hapilly fire tens of HTTP requests while loading the page, which happens to be over 1M because of all the unnecrssary JS and CSS libraries (looking at you, Bootstrap!).

</comment></comment><comment><USER12> Equally it's acceptable to go down the single-page-application route and just make sure you prioritise performance. A lot of SPAs/"rich" web applications are not slow because of inherent performance disadvantage to that model, they're slow because they're poorly written.

Perhaps just because I've dedicated a lot of time to it but I think something like React makes it a lot easier for me to find where my performance bottlenecks are and eliminate them vs. mixed server-side dynamic HTML / progressive enhancement.

<comment><USER13> _> A lot of SPAs/"rich" web applications are not slow because of inherent performance disadvantage to that model, they're slow because they're poorly written._

I feel there is a wrinkle here, though. SPAs aren't _inherently_ slow, but they are built around models that will ineluctably _tend towards slowness_ unless the developer works hard to avoid that.

SPA frameworks are all about breaking your site down into small, self- contained interface elements that can then easily be composed into a larger whole. When each interface element is acting independently, though, you end up with lots of network requests getting fired as each one builds up its state independently of the others. Network requests are slowwwwww, and it only takes one of them stalling out to make the whole page feel sluggish or broken.

There are ways to architect around this problem, but they require understanding that it actually is a problem, and they take away some of the "shared nothing" developer independence that made the SPA approach so appealing in the first place. So it's not surprising that so many SPAs either don't take advantage of them or do so incompletely.

<comment><USER14> To build on this, I think it may be an issue with the REST model specifically as opposed to SPAs themselves (which you may have been alluding to). It inherently encourages several small network requests. I'm not a huge GraphQL fanboy and I haven't worked with it closely, but it's a lot more conducive to batching data fetches into only a few requests. You can get around this by violating some REST assumptions like making heavy endpoints that return all of the data you know you'll need at the initial loading of an application, but then you open yourself up to criticism from pedants.

</comment></comment></comment><comment><USER15> SPAs should just die out. As a user the experience virtually always means slow loading, large downloads, and more fragility.

Seeing a loading spinner makes me cringe.

<comment><USER16> It's funny, I have the opposite association.

Usually with any website which involves booking tickets, if I see it's a SPA I think there's a good chance that the company spent some effort on this and therefore care and it's likely to work OK.

If it's a server-rendered forms type application, I almost expect it to be poorly implemented, be frustrating to use or fail completely.

My suspicion is that, because these server-rendered forms type frameworks are very mature and much easier and faster to build something with, they are the go to option when budget is low, i.e. when quality is not a priority, and I think that may explain the correlation I've seen. Nothing to do with the underlying technology of course.

<comment><USER17> My experience matches yours for large organizations; fairly or not, if I'm booking a plane ticket through the airline, an SPA page makes me feel confident that there was some real work put into it, while a basic server-side forms + JS approach makes me worry it's a semi-abandoned afterthought.

That's reversed for websites & apps for small companies and startups. In those cases, SPAs tend to feel fragile, buggy, and full of weird defaults and unusual behavior, especially compared to the relative simplicity of a basic form with some JS sprinkles.

No idea why that is, or if the perception is even accurate.

<comment><USER18> please keep in mind server-side doesn't mean necessarily "basic" you can have a server-side app and still have the same user experience as a full-blown SPA app, as long as you know what you must do in the client for a great user experience.

</comment></comment></comment></comment><comment><USER19> I've been wondering over the last couple years what the state of the art is on server side rendering. There seems to be a lot of energy on the FE side with react and angular, but other than dockerization, I don't hear about the same class of big FAANG shiny backend rendering tools. Even the article is just pointing out that server side exists. I'm working on setting up a small website for my wife's business and am still thinking of running Flask/gUnicorn just like I did years ago. Maybe there is something with Elixer / Erlang, but that seems niche. What should I be looking at, if I want to skill up to the new shiny in server side rendering.

<comment><USER15> Server-side rendering doesn't really have "new shiny". It works, just as it has, and that is a feature, not a bug.

<comment><USER19> This is why the next generation of dev's is going to be FE heavy, I think. Because the big marketing of mindshare and talks is going to all the developments on FE, vs server side where it is steady and reliable.

</comment></comment></comment><comment><USER20> Another argument for keeping business logic server-side is, well, that your proprietary and presumably valuable code remains on the server instead of being widely disseminated.

<comment><USER21> This is my biggest issues with SPAs. Its not that it is that hard, its just so much easier to keep it secure if its being done server-side.

<comment><USER22> What's an example of something that would be proprietary, reasonably on the front-end, and stealable from minified source?

In my mind, anything complex would probably be server side anyway for performance reasons (though I admit there are many, many SPAs with seemingly little thought about performance.)

<comment><USER23> An inexperienced dev might do something like put API keys in frontend code. You can even do an advanced search of Github to find people's keys to steal to get access to paid APIs.

<comment><USER24> Inexperienced devs already leak keys into front end code before SPAs.

</comment></comment></comment></comment></comment><comment><USER25> Considering we have had an entirely new paradigm shift in front end development, I have yet to see anything that has blown my mind for usability or UI. Usually it's the same site and design except now it jiggles about as stuff loads asynchronously or repaints. I see way more degradations than I do improvements. I would love to see the creme of the crop, if anyone has any good applications using new tooling they think are a good example?

</comment><comment><USER26> > business logic being implemented in the client

I disagree, typically business logic is implemented in the API not in the client.

<comment> duncan-donuts Yeah, business logic in the client is not a great idea. What happens when you add a new client (mobile app?), and you get to relive all of the same bugs you fixed? Just don't do it.

<comment><USER26> exactly, that's one of the advantages or the modern way of web development - decoupling business logic and UI (HTML)

</comment></comment></comment><comment><USER27> Going back to the early 2000s with freemarker/twig/mustache is what he means I guess? Nextjs and Gatsby are what they are for very good reasons and backend apis can be written in whatever you please these days... Why would you consider using those dinosaurs again? When that is all you and your team is comfortable with?

</comment><comment><USER28> I'm a really late comer to web development. I got introduced to it through angular and react SPA. At this point I don't know how to do anything except these types of projects and not a lot of time to dedicate to learning a new (or old, depending on your view) way of doing things.

I need some type of remedial web dev training.

<comment><USER29> Just type "jquery" in front of every programming-related web search you do.

If you want something old-school but even more advanced... type "jquery plugin."

I know what you're thinking... I should write an ebook. But I'm too deep in mountains of jquery slop at work, I barely have time to write this comment.

<comment><USER30> No, we don't think you should write Yet Another E-Book. :(

</comment></comment></comment><comment><USER18> agreed:

everything that you must do client-side because of latency, offline and/or device capabilities: do it client side.

everything else should go to the server.

</comment><comment><USER31> Product designers and managers might disagree.</comment>


Google celebrates its 1000th Chrome experiment - <AUTHOR> http://designhooks.com/google-celebrates-its-1000th-chrome-experiment/

<comment><USER2> Impressive as many of them are they all turn my MBPr into a giant heatsource that could boil water.</comment>


Peer Review - <AUTHOR> https://rodneybrooks.com/peer-review/ <comment><USER2> I don't consider myself an expert in computer networks research but i still have 10 accepted (and ~20 rejected) papers with ~100 citations in journals, conferences and workshops within my 3 years working on R&D. Hence my comments below derive from my non-academical and more development-oriented background.

Peer review is completely broken nowadays for the following reasons:

-Reviewers might not have relevant expertise to judge whether a paper is good or not. I am not talking about top-notch conferences, mainly lower-tier ones and workshops. I have seen a lot of professors pushing paper reviews to their PhDs, or even students. I was also invited to review a paper as soon as i submitted my first one (and it was rejected btw)! In another workshop i was invited to review papers just because i was a colleague of one of the organisers.

-Old-school academia. This might not apply to all fields or all academia, but i have had good papers rejected because they didn't have a lot of math or simulations! My paper was examining an actual implementation of an SDN (software defined networking) protocol or a strategy with platforms and orchestrators which require weeks to setup and implement (Opendaylight, Openstack, OpenMANO, etc) with actual experiments on real users' video activity, yet to be rejected because i didn't provide any simulation. Jeez, novelty does not come only from theory, somebody has to implement and test these things in actual machines..

-Politics. I won't say much on this aspect, other than a colleague of mine had 1000 citations within the same time just because there was a "mafia" (not my words but his) of professors, lecturers, PhDs reviewing and accepting all the group's papers because they were overloading them with each other's references and co-inviting them to each other's conferences and workshops.

<comment><USER3> From the original piece: _I don't have a solution, but I hope my observations here might be interesting to some._

I have a partial solution: researchers "publish" papers to arXiv or similar, then "submit" them to the journal, which conducts peer review. The "journal" is a list of links to papers that it has accepted or verified.

That way, the paper is available to those who find it useful. If a researcher really thinks the peer reviewers are wrong, he/she can state why, and why they're leaving it up, despite the critiques. Peer-review reports can be kept anonymous but can also be appended to the paper, so that readers can decide for themselves whether the peer reviewers' comments are useful or accurate.

<comment><USER4> This is how many CS conferences already work (even with public anonymous peer review, go to openreview.net to see it in action). It does seem to be better, although the frustration level for researchers is not really less.

Edit: also, in CS there is a norm that reviewers will not go out of their way to figure out if a submitted paper has been previously posted on arXiv. I don't think it's possible to have perfect anonymity without forbidding researchers from publicly talking about work in progress, so this seems like a reasonable compromise.

</comment></comment></comment><comment><AUTHOR> Rodney Brooks subsumption architecture revolutionized robotics. Back in the 90s you could replicate his work with Attila and Genghis and recreate hexapod robots for under $1000 which was an pittance for a robot.

He was at MIT when he submitted those papers. The churlishness of those reviews is staggering. What if he had given up and gone on to something else?

<comment><USER5> _What if he had given up and gone on to something else?_

Maybe he would have accomplished even more?

<comment><AUTHOR> What would have happened if he had moved on to another field? Subsumption architecture would eventually have been discovered by someone else, standing on the shoulders of giants and eventuality of all discoveries etc.

Or it might have taken another 50-100 years. Fundamentally unknowable.

</comment></comment></comment><comment><USER6> Peer review is broken. More than once I've learned that papers get easier through peer review if you cite the paper of a reviewer (of course you don't know in advance who reviews it so it's basically luck). I often got comments about missing related work "from relevant authors".

<comment><USER7> I'm not sure that's exactly the reason it's broken. Usually an editor will give a paper to people who are specialists on your topic, and they will have thus likely written papers related to the topic as well.

One major issue is that, because of this, they will sometimes have a vested interest (conscious or not) in blocking the publication of your paper if it shows flaws in their own.

<comment><USER8> Many journals I'm familiar with allow you to suggest referees, as well as suggest which researchers should be avoided as referees. If I'm publishing something that is competing in some sense with the work of other people, I will usually suggest to the editor to leave them out from the peer review process.

<comment><USER7> This has only been occasionally available in my experience, and itself introduces perhaps worse problems. If I'm explicitly arguing against someone's theory, they are likely to be a relevant judge of the merits/demerits of the arguments.

Having a good editor who can discern the difference between a reviewer's relevant responses and 'turf warfare' is probably best one can wish for.

</comment></comment></comment></comment><comment><USER9> There are two types of peer review.

1\. _Pre-publication peer review_ Reviewers examine the work before it's presented to the rest of the people.

2\. _Post-publication peer review_ Paper on an online forum where others can read and comment and cite them. Papers can be accepted into journals and go trough peer-review later.

Post-publication peer review does not mean that authors can't use pre- publication peer review. Scientists can (and should be encouraged) to ask their colleagues to review papers before posting online to spot errors.

Some fields have long tradition to publishing and circulating working papers, manuscripts, drafts, posters etc. years before they submit the final paper for publication and pre-publication peer-review. That works as well.

</comment><comment><USER10> I think peer review is quite important.

Note the word "peer," though.

I would not peer review papers on robotics or AI, as those are not my forté. I could review papers on some generalizations of software engineering or the Swift programming language.

Editing is a different matter. My mother was a scientific editor, and absolutely _brutal_. She edited a book I wrote on writing software for a certain specialty of Web site, and it was quite humbling. She knew nothing at all about the technology, yet provided an immensely valuable service.

The book is long past it's "sell-by" date, yet stands as maybe the only "perfect" artifact of my life, thanks to her.

Then there's comment threads in venues like this one, which some might equate to "peer review."

There was an old Dilbert comic on Peer review. I don't think it can be found online, but was in _"Build a Better Life by Stealing Office Supplies."_

It was entitled "The Joy of Feedback," and probably applies to comment threads.

</comment><comment><USER11> Peer review is flawed, but I don't think it's _broken_. For context, I'm a late-year PhD student in machine learning theory, and I submit almost entirely to conferences, which is the norm in my field.

To me, the big problem is that there is little incentive for experts to review papers. I write a few papers every year, and I review 5x that number. Slightly more senior people -- postdocs and junior faculty -- may review more like 30-40 papers. Most papers I review are not good papers. This is especially true at the big machine learning conferences like NeurIPS, ICML, and ICLR, where a disconcertingly large fraction (1/3?) of submissions are outright bad. Most of them are at best "meh". So there's not much benefit to the reviewer beyond some notion of community service.

I think my ~colleagues (PhD students, postdocs, young faculty) have similar opinions. We've certainly discussed these issues in the past. One positive step NeurIPS has taken is giving "best reviewer" awards that come from with a free registration. That's a nice benefit, even if it won't on its own incentivize good reviews. Some people have suggested outright paying people for reviews at some quasi-competitive rate, maybe $100 per review (note that this is not great -- a good review takes at least several hours if the paper is not terrible). NeurIPS also added a requirement this year that all submitting authors must review, which is an interesting experiment.

My impractical wish is that we also have some kind of "worst reviewer" sticker for all the reviewers who just paraphrase the abstract, add some milquetoast feelings on novelty, and weak reject. Less facetiously, some kind of StackOverflow reputation system might be useful. As is there's so little external signal about being a good or bad reviewer that the incentives are pretty wrong. Some kind of points system might help.

But my overall point might be: reviewers by and large aren't malicious, jealous people who are only rejecting your work because they want to protect their own turf. They are more likely good faith actors who are trying to balance time spent on a pretty thankless but societally useful job (reviewing) with time spent on much more personally enjoyable and rewarding activities (research, family, hobbies, etc). There aren't really obvious solutions to tilt the balance toward better reviews that can still handle the volume of papers.

<comment><USER12> Dunno about paying. Remember Amazon Turk? Folks just spammed it with zero- effort submissions and 'closed' thousands of contracts with bots. Instantly gamed, so some jerk could walk off with thousands, $1 at a time.

The shaming idea, that could work.

<comment><USER13> Mechanical Turk is still useful, though. And there's a big difference between paying a bored rando $1 to identify pictures of frogs and asking an academic who is highly invested in the relevant ideas to review a (hopefully interesting) paper.

<comment><USER12> But is it different in the, nobody-will-scam-it way? Remember, we're talking starving academics. They don't have a great history of philanthropic behavior.

</comment></comment></comment></comment><comment><USER14> That's peer review from 3+ decades ago. Things have changed substantially. PIs dont have enough time to review all that stuff, lot of it is delegated to students, reviews can be hasty, with reviewers who may latch on to a specific detail and let the rest pass through. It's not even that they are not trying hard enough - Peer review is not doable in 2020. If you honestly want to scrutinize and improve every detail of a manuscript, you re better off posting it in reddit or twitter.

> clamor for double blind anonymous review

That's not even possible in most fields. you can easily tell which lab it comes from (you can even often guess who the reviewer is)

</comment><comment><USER15> Any ideas for how the system might work differently? Could peer review learn anything from the open source community?

<comment><USER16> Currently, peer review fulfils three distinct functions, to the detriment of all of them:

1\. Acting as a filter for what research is worth reading.

2\. Providing input to the author on how to improve their work.

3\. Influence the author's professional evaluation.

The first is the most blunt instrument: when something is not considered worth reading, it doesn't get published at all. This is problematic in the cases where the peer reviewers misjudge, or when an article is evaluated on more than its academic merit, e.g. whether it's "groundbreaking" enough for a particular journal.

The second is useful, but made less so due to the power imbalance - an author cannot judge for themselves whether the feedback makes sense in the context of their work. This is especially problematic when someone has to take their work to multiple journals and/or gets conflicting feedback.

And that power imbalance is the result of the third point: it can be more important to the author to get that stamp of approval by the reviewers than to meaningfully contribute to science, because that's the only way they can stay in academia.

Ideally we'd split them up, but that does require aligning the academic community - which is a hard problem, especially considering there are strong vested interests in the status quo.

(Disclosure: I do volunteer for a project ([https://plaudit.pub](https://plaudit.pub)) aimed at splitting evaluation from publication, because I think it's an important issue.)

<comment><USER17> Plaudit is nothing more than like an upvote, right? I don't think this is really helpful. We already have a very similar metric, which is citation count. Which is definitely a useful metric.

At first, I thought that Plaudit adds some post peer review platform, or discussion forum, for each paper. Similar to OpenReview but for any paper. I think this might actually be a great idea.

I think that [https://fermatslibrary.com/librarian](https://fermatslibrary.com/librarian) actually provides a similar functionality. But it has not seen much adoption.

<comment><USER16> It's not a metric, it's an endorsement. Think of it like being published in a journal: it's not about in how many journals an article gets published, but in which ones. Likewise, what's important here is _who_ has endorsed it. Instead of a journal name acting as a proxy for "someone I trust thinks this work is worth reading", you can directly see the name of that person.

(That said, a big challenge with citation counts is that they take a long time to accumulate.)

As I mentioned, I think the three functions should be separated. Although Plaudit by itself does not facilitate giving feedback, it does not prevent it either. Ideally, if someone comes across e.g. an error in an article, they provide that feedback to the author (e.g. through an email, of using Hypothes.is - a project that I think you might like). There's no need to only contribute to improving scientific literature through a formal journal- assisted peer review process.

And who knows: if the author incorporates that feedback, the giver of the feedback might decide to endorse that article using Plaudit :)

</comment></comment></comment></comment><comment><USER17> This topic comes up again and again. (Here some references from a quick search: [https://news.ycombinator.com/item?id=10531374](https://news.ycombinator.com/item?id=10531374) [https://news.ycombinator.com/item?id=18523847](https://news.ycombinator.com/item?id=18523847) [https://news.ycombinator.com/item?id=8731271](https://news.ycombinator.com/item?id=8731271) [https://news.ycombinator.com/item?id=18595074](https://news.ycombinator.com/item?id=18595074) [https://news.ycombinator.com/item?id=22251079](https://news.ycombinator.com/item?id=22251079))

But there are not many good solutions.

Most seem to agree that we should move over to a more open system, like OpenReview, and also that all publications should be open for everyone afterwards, and not behind some paywall. But these are only two aspects of the system, and this is less about the peer reviewing itself.

The community already has the trend to publish more and more directly on ArXiv. Just in addition to submitting it to a conference. If the conference peer review filters it out for some unlucky reason, it's still open for everyone to see. That might be already an improvement of what we had before. But probably it's not really the optimum yet. But what is the optimum?

<comment><USER3> There are good solutions, but existing publishers like Elsevier like the current situation because it makes them rich ([https://www.universityofcalifornia.edu/press-room/uc- termina...](https://www.universityofcalifornia.edu/press-room/uc-terminates- subscriptions-worlds-largest-scientific-publisher-push-open-access-publicly)). Any existing individual academic is strongly incentivized to work within the rotten system, even though most know its pathologies and want to defect—but one person defecting alone will screw up their own career while likely leaving the system intact. The equilibrium is bad even though the solutions aren't complicated. [https://news.ycombinator.com/item?id=23291869](https://news.ycombinator.com/item?id=23291869)

</comment></comment><comment><USER18> I love this topic of peer review. Feels like arguing about methodologies, software QA & test, learning organizations back in the 90s.

Peer review and the reproducibility crisis are the absolute bleeding edge of the human experience. Science, governance, transparency, accountability, progress, group decision making. All of it.

I encourage all the critics, thought leaders to also consider how to apply these lessons elsewhere.

Every thing said about peer review also applies to policy making, product development, news reporting, investigative journalism.

Peter Drucker, way back when, stated that management is a technology. Same applies to peer review and reproducibility.

For whatever reason, this post prompted me to think "sociology of scientific progress". I encourage critics to also factor in the collective human psychology. Covered by so many books, like the classics Structure of Scientific Revolutions and The Diffusion of Innovation. (Sorry, none of the more contemporary titles, a la Predictably Irrational, are jumping into my head at the moment.)

</comment><comment><AUTHOR> Brooks initial papers like "Intelligence without representation", "Elephants don't place Chess" and robots like Ghengis and Attila changed the robotics landscape. It was a leap akin to going from a Mainframes to an Apple II.

Brooks was extraordinarily well placed to lead this switch in Robotics. He was at MIT, a place with very talented engineers - mechanical, electrical - etc. who could work on the robots. MIT also had limitless funding and a culture for disruptive research with long payoffs. This might not have been possible at other places like CMU where robotics has more industrial applications. I remember watching the movies of Atilla and Genghis over and over again, downloaded over an FTP connection!

[https://www.youtube.com/watch?v=-6piNZBFdfY](https://www.youtube.com/watch?v=-6piNZBFdfY)

</comment><comment><USER19> How is it that peer review hasn't changed in 30 years? With the amount of people afflicted has nobody had the time and/or influence to improve the process?

There are no doubt lots of smart people concerned by this...

</comment><comment><USER20> Science did well before radical ideas could be voted down by peer review.

Would Einstein and Darwin have made it through peer review? I doubt it.

What current day people like that are held up by their "peers"? I fear we'll never know.

<comment><USER21> _> Would Einstein and Darwin have made it through peer review? I doubt it._

Einstein _did_ make it through peer review; his classic 1905 papers were published in Annalen der Physik, the most prestigious physics journal in the world at that time, after being refereed and accepted.

Darwin didn't technically go through "peer review" since he published his results in a book, not a scientific journal. But when he did so, what we now call scientific journals were extremely rare.

<comment><USER22> From what I've read the vast majority of Einstein's work was not peer reviewed.

[http://michaelnielsen.org/blog/three-myths-about- scientific-...](http://michaelnielsen.org/blog/three-myths-about-scientific- peer-review/)

> How many of Einstein's 300 plus papers were peer reviewed? According to the > physicist and historian of science Daniel Kennefick, it may well be that > only a single paper of Einstein's was ever subject to peer review.

</comment></comment></comment><comment><USER23> Peer review is something I've been thinking about a lot lately as an outsider. I've never gone through a formal peer review process or worked in academia, but it's pretty obvious that the process has significant problems.

However, the problem that peer reviews are trying to solve (conferring legitimacy on a paper by the scientific community) is so important that we can't give up on it. Sure, pre-print servers mean science can move faster, but it also means anything can be "science." If we normalize publishing papers as preprints, there's very little stopping conspiracy theorists from publishing a paper and having it look plausible.

The sudden rush of media coverage for COVID research has really exasperated the problem. Journalists should responsibly cover preprint studies, but frankly most don't, and who can blame them when even the scientific community is struggling to review the papers itself.

I volunteer with a group[0] that's trying to address this problem in a small way by creating visual summaries/reviews of popular preprints for mainstream readers. This is a side project, so the review process is just a shared Google doc for each paper, but what I'd like to see:

As a reviewer:

      * View diffs between paper revisions
      * Comment on papers inline, like a pull request
      * +1/-1 a submission, or just leave questions without a decision
      * Gain "karma" for good reviews to build my reputation in the community (like Stack OverFlow)

As a paper author:

      * Reply to comments to understand and explain context
      * Post revisions

As a reader:

      * See visual summaries of papers, with inlined reviews (like Research Explained)
      * Vote on both studies and reviews to surface the good ones
      * Browse profiles of authors and reviewers to understand their qualifications/contributions

I do think [https://distill.pub](https://distill.pub) is on the right track. Their papers are significantly more visual/readable than most, and they require contributors to open a pull request against the distill repo. However, their process isn't approachable for non-technical fields.

[0]: [https://www.researchexplained.org](https://www.researchexplained.org)

<comment><USER24> The problem also works in reverse. Probably the biggest example is Plate Tectonics - this idea took decades longer to be accepted than it needed to because the generation of expert geologists who were the gatekeepers for the journals refused to consider it seriously, and the guy who came up with the idea wasn't a geologist [0].

Scientists are just humans, after all. Subject to human flaws. And the scientific method works "in the end", not immediately.

[0] - [https://en.wikipedia.org/wiki/Continental_drift](https://en.wikipedia.org/wiki/Continental_drift)</comment></comment>


America 2.0 (by Denny K Miu) - <AUTHOR> http://www.lovemytool.com/blog/2008/11/that_one.html

<comment><USER2> Good perspective. The next 4 years will be interesting, at the very least.

</comment><comment><USER3> Appending "2.0" to everything is not very creative.

<comment><AUTHOR> I agree. However, it is really how I feel. Today is not just about electing a new President, it is also about recognizing that America has changed. The old politics of spiting the electorates among various groups really doesn't work anymore. Anyway, I can go on and on about how emotional and inspired I feel ... a sense of renewal and do-over.

</comment></comment><comment><USER4> Can we please not turn HN into reddit?

<comment><AUTHOR> I hope my article doesn't come across partisan. I am not. I am just a struggling entrepreneur who is un-connected with the bigger community. Last night was a great night, even for technologists.

</comment></comment><comment><USER5> love my tool? seriously?

<comment><AUTHOR> It is an online community site for networking professionals who share their first hand experience with both open source and commercial monitoring tools. Most people have gotten over the initial bias and seems to like the name. It is memorable, at least.

</comment></comment><comment><USER6> I love that image...where did that come from?

<comment><AUTHOR> I actually didn't know at first, since I found it on another site. Then a reader points it out to me and I have added the proper reference. It is a great piece of artwork.

<http://www.patrickmoberg.com/></comment></comment>