Farmers rushed into hemp, but now face a glut - <AUTHOR> https://www.wsj.com/articles/farmers-rushed-into-hemp-now-they-face-a-glut-11575118801?mod=rsswn <comment><USER2> It really depends how you approached it. CBD flower from the colas is still selling well even if biomass isn't. CBG biomass is still selling at $200-275/lb. An acre costs about $10k to plant and yields 2,000lb of biomass. Most people lost their shirts because

1) they weren't growing on contract and didn't have buyers lined up 2) didn't grow for smokable flower 3) had their plants herm due to bad seed stock or environmental stress 4) their hemp ran 'hot' with THC over the allowable levels and they live in a state where the AG commissioner cares. Was up in Oregon and the farmers were telling me as long as it's under 2.0% THC they get a pass. In more strict states it's 0.3%.

Source: am a shareholder in a large CBD cultivation/manufacturing business.

<comment><USER3> > In more strict states it's 0.3%.

Just to clarify: <=0.3% is the federal cut-off. it's protected by the agricultural whatever act of 2018 - the plant itself is legal to cultivate, and its CBD oil derivatives are likewise loosely regulated. Above that it's considered to be illegal cannabis, and -its- CBD oil derivatives are regulated accordingly.

<comment><USER4> just to clarify: 2018 United States farm bill

[https://en.wikipedia.org/wiki/2018_United_States_farm_bill](https://en.wikipedia.org/wiki/2018_United_States_farm_bill)

</comment></comment></comment><comment><USER5> CBD being the main drive to get into hemp seems misguided. People have been pushing the advantages of hemp fibers in industrial use cases for a long time, but obviously it will take awhile for these products to build up steam since hemp was less common in the past.

<comment><USER6> You've been able to have shipping containers of the stuff delivered from China and other places to your loading dock for decades.

They grow millions upon millions of tons of it each year and have an entire infrastructure of university and government research organizations built up around hemp cultivation.

The industrial products are never coming. Access by US domestic engineers and scientists to hemp on the order of days instead of weeks won't change that.

There are billions of people on earth for which hemp cultivation has never been illegal, where they have grown it for centuries if not millennia.

To think that domestic production will spin up the release of industrial products can only lead to one of two conclusions:

1\. There are no industrial uses of hemp to the degree that advocates claim. (The ludicrous ones) or,

2\. Most of rest of the world, around 3 billion people, are all stupid and/or incompetent and only the smart and industrious US domestic engineers and scientists can figure out how to use hemp for things other than hippy bags.

I've been around the world. I'm going to go with 1.

I'm not saying hemp doesn't have industrial uses.

I'm saying that the claims by some of its more fervent activists, on the order of "hemp fuel will power hemp steel-manufactured flying cars adorned in hemp faux "Rich Corinthian" leather, that land of runways made of hempcrete and it's all going to be carbon neural and organic because hemp violates the laws of thermodynamics and doesn't require fertilizer or pesticide" are wrong.

<comment><USER7> You left out the option that the industrial hemp products are more expensive (at this point) so only niche producers use it. I think hemp will see some industrial usage when it becomes cost effective.

<comment><USER8> How much is industrial hemp used in countries where it has always been legal though?

<comment><USER9> But what countries are that?

As far as I know, most followed US hegemony, and for example in germany it was legal, but very hard to get permission to grow hemp. So only small uses like for making rope and birdfood.

So I also believe demand and supply for various things will grow. I really like for example, that nowdays you can get organic hemp seeds in the supermarket. It gets more in fashion, because it is nice and quite healthy. But no, hemp will probably not disrupt big industries. It might disrupt the alcohol industrie a bit though, when it is widespread legal.

<comment><USER8> The Soviet Union grew it quite extensively, and I believe both Canada, France, and Australia have allowed its growing for a couple decades now. It doesn't seem like in any of those countries it has lived up to the potential pro-hemp boosters claim.

</comment></comment></comment></comment></comment></comment><comment><USER10> [http://archive.is/hmlLz](http://archive.is/hmlLz)

<comment><USER11> I wish paywall/registration bypasses could be the original link by the OP, or at the very least, pinned at the top of the comments.

<comment><USER12> I don't understand why HN finds piracy acceptable for news content. If the post was about a video game or movie release, should we pin a link to the .torrent file?

<comment><USER11> The difference being that you don't need to play the entire game or watch the entire movie in order to take part in the discussion about that game's/movie's release. However, you do need to read the entire article before being able to take part in the discussion about that article. So I think it's fair that OPs should either make sure that the articles the post are accessible to all (and hence the discussion about those articles (which is the entire point of hacker news) is also accessible), or just don't post paywalled articles ...or alternatively post a paywall bypass. Maybe it's not right, but it's a solution.

</comment></comment></comment></comment><comment><USER13> Oh! Is this what the entire "Tegridy Farms" spin-off season of South Park all about?...

<comment><USER14> I think that was more about the rush to jump on the legal cannabis (high-THC for medical/recreational as well as low-THC for CBD and fiber, oil, etc.)

</comment></comment><comment><USER15> Goldmine market mentality (aka investment fad of the year) gets popular and the market is oversupplied, the market corrects.

Business 101

</comment><comment><USER16> Hemp seeds have failed to catch on as food for a simple reason: they're too strongly flavored. The nutrition claims are largely true, and the flavor isn't terrible, but in order for hempseed to provide, say, 15 grams of protein to a meal, you need to eat about a quarter of a cup of hempseeds. Imagine eating a quarter of a cup of sesame seeds. See the problem? I think the missing link here is some kind of fermentation process that produces something more palatable.

As for the fiber, it's a relatively unremarkable cellulosic fiber. It is rather coarse and contains about 8% lignin, which means hemp fabric is relatively stiff and rough, limiting its application to clothing beyond its branding power (and shoes, where it works well). However, it is useful in composites. Hemp is apparently being used to make composite panels for several cars in the present day, although the actual volume in this market is not so high. The asterisk is that there are lots of other similar fibers (jute, linen, lyocell) that work well in composites, and it's the resins (polyester) which tend to be both more expensive and environmentally problematic. If some kind of more eco-friendly resin technology appears (don't hold your breath) it could become more widespread.

Other claims, e.g. hemp as a building material, are just wrong (hempcrete is not structural). Hemp rope was replaced by manila which has better moisture resistance. Hemp as a biodiesel precursor is unremarkable.

<comment><USER17> Trader Joe's has a vanilla hemp protein powder I like (milk-based ones mess with my stomach). I couldn't imagine eating the seeds directly, but they go down very easy in a smoothie.

I'm not familiar with any fermentation process that operates on nuts, or any high-fat food source besides soybeans.

<comment><USER16> There is apparently a semi-standardized process where a hydrated nut butter is fermented with yogurt bacteria for a few days:

[http://www.bccdc.ca/resource- gallery/Documents/Educational%2...](http://www.bccdc.ca/resource- gallery/Documents/Educational%20Materials/EH/FPS/Food/Fermented_Nut_Cheese.pdf)

I'm not sure if this process has been attempted with hempseeds. It's a fast bacterial process, in contrast with the slow fungal fermentation of dairy cheeses. I wouldn't really say it's a commercial-ready process at this point; I'd like to see something done with proper cheese cultures!

</comment></comment></comment><comment><USER18> The WSJ article makes me feel better about strongly urging a family member against an investment in a hemp farm in 2018. They used an unrealistic value for the price of CBD in their projections and didn't account for a decrease in the price over the next few years.

But besides that, it was one of the worst business plans I'd ever seen. I couldn't tell if they were just inept, or were scam artists looking for gullible investors.

</comment><comment> at-fates-hands This reminds me of the ethanol rush in the early aughts by farmers who rushed to pull the crops they were growing to switch over to corn in hopes ethanol and E85 craze would take off.

A decade later and the debate still rages whether ethanol and E85 was even it worth it now with electric vehicles and hybrids are way more common and many stations who had E85 pumps are all but gone now.

</comment><comment><USER19> As another comment noted, biomass is overproduced and prices low but premium smokeable hemp flower is still doing well. I imagine more farmers will shift in that direction next year, assuming the new USDA rules don't destroy the industry.

The new USDA guidelines would make almost all of the current strains of CBD- dominant flower unavailable to grow due to the change in testing to count total THC rather than just delta-9 THC. Some farmers will switch to CBG which is another cannabinoid, but it's not one that is going to have as wide of an appeal.

My small friends and family grows in Southern Oregon and we did ok this year despite the challenges, but there is a lot of uncertainty around what will happen next year due to the potential regulation changes.

</comment><comment><USER20> You know you are in a huge production bubble when all major cannabis producers use as their main metric their production capacity. Aurora cannabis even went as far as to lower their Average net selling price of wholesale bulk cannabis by 4% in the last quarter, due to not finding the demand to keep up with the production boom of the industry.

Reminds me of the scene in the "The Prize: The Epic Quest for Oil, Money, and Power" where oil was booming and production was hardly centralized which led to big fluctuations in the price and an overestimation of the demand, and therefore of the necessary supply.

</comment><comment><USER21> Shame, he didnt grow his crop with tegridy

<comment><USER22> What does this mean?

<comment><USER23> It's a South Park reference.

<comment><USER24> Aren't comments like that against the guidelines?

</comment></comment></comment></comment><comment><USER25> That's unfortunate, because industrial hemp (as opposed to cannabis hemp)is the most efficient way to capture carbon dioxide in the form of biomass. It should be grown for carbon credits alone, but this (cannabis) hemp bubble imploding will taint industrial hemp by association.

<comment><USER26> How does this work?

You grow a ton of hemp. It captures X tons of carbon.

People use it for rope or whatever. Eventually throw it away. It decays or is burned. X tons of carb are released back into the atmosphere.

How did that capture any carbon?

<comment><USER27> Sequestration remains an open problem. There are no large scale biomass capture projects in operation. But the science isn't hard: you bury it, basically. Or if you want to be fancy you burn it for biomass energy and capture the resulting CO2 for fancier sequestration techniques. Both are expensive, and no one is willing to foot the bill.

Right now the only realistic way to use photosynthesis to capture CO2 in a long term way is to plant a forest. There's some amount of this going on, though not enough to even cover deforestation elsewhere.

<comment><USER28> We need to start throwing our old newspapers down coal mines (or bury it) rather than recycling it - that will encourage more trees to be grown and solid paper is a great way to sequester carbon

</comment></comment></comment></comment><comment><USER29> Has there been much usage for the fiber? (Paper, rope, textiles, etc.)

</comment><comment><USER30> Guess we're going to have to start exporting it :-)</comment>


12seconds aims to be the true Twitter of video - <AUTHOR> http://venturebeat.com/2008/06/26/12seconds-aims-to-be-the-true-twitter-of-video/ <comment><USER2> interesting perspective

<comment><USER3> I'm curious. I haven't been sold on the micro idea coming from twitter because I think it requires a fair amount of arrogance to think anyone will get something meaningful from 160 characters. But video provides a lot more expression in less time. I think I'd want to increase it to 30 seconds. Alas, they've chosen a name that restricts them in this regard...

<comment><USER2> well 12seconds could be matched to the concept for making short videos(comments) even if they supported more length in new versions.

i think it's interesting because, the time limit will make you record something interesting and will remove the need to wonder, how do i make a more lengthy video (therefore the confussion is avoided and this could endorse more people to make a video comment or some other video)</comment></comment></comment>


Hospital prices are about to go public in the U.S. - <AUTHOR> https://www.ajc.com/news/national/hospital-prices-are-about-public/2jXYHgoR5CObBj6fSJQQUO/ <comment><USER2> Pro tip: I was a neurosurgical anesthesiologist at the University of Virginia Health Sciences Center for twelve years (1983-1995). Every now and then I'd get a call from our billing office that they'd received a letter from a patient I'd cared for who was too poor to pay what our department had billed (usually many thousands of dollars: I had NO IDEA what our charges were, BTW, nor did any of my colleagues in the department). Every time that happened, I'd go over to the billing office and — without bothering to read the letter — tell our billing chief to waive all anesthesia-related charges. In other words, by my initialing a form we had, their balance due us was 0. Try it, you never know, it might work for you.

<comment><USER3> If you are a patient in this situation, there are advocates who can help you. One thing to try is to ask the billing department if they will "accept assignment". What that means is that instead of billing you their fake rate, they would instead bill you as if you were an insurer.

IMO, it is incredibly unethical and dishonest for these medical corporations to charge different fees depending on who you are. Prices should be transparent, and should be the same for everyone.

Some may argue that an organization representing a large pool of people should be able to achieve economy of scale and a better price. This seems false to me, as in reality there is only one pool of people and care provider provide care to that one pool. Its time to kick the middlemen out.

<comment><USER4> When you remove the middlemen, what will you replace them with?

<comment><USER5> Tiny bits of software.

<comment><USER4> What's the purpose of the software?

<comment><USER6> Replacing the middle men

<comment><USER4> Is the software written by people who would not profit from the software?

<comment><USER7> Could be an open standard

<comment><USER4> This is quickly degenerating into... an xkcd comic

</comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER8> I was in a hospital in Singapore recently, and the prices for doctor consultation fees, staying in a room, and even certain tests were listed right at the front of the emergency room desk.

After the patient I was with was stabilized, the nurse confirmed with us verbally what the rough cost should be for the rest of what the doctor prescribed, and asked if we wished to proceed. We could have said no and gone elsewhere if we wanted, since the patient at least was relatively stable and we knew what was wrong.

I want this experience to be the norm in the USA.

<comment><USER9> Where I live you know the cost before you go to the doctor since you will only pay a symbolic sum of 30 USD even if the visit ends up with something like a life long cancer treatment. If you need medicine you will pay at most 120 USD per year regardless of the costs.

The idea that your access to healthcare should be linked to your own or your parents financial is crazy.

<comment><USER10> I agree in principal to an extent - however economics need to be tied to the end product somewhat. Otherwise many people would opt for $100k healthcare cost (at the expense of the public) to extend their life for a few more months, this is not reasonable. Resources are finite - therefore we need appropriate allocation.

In the end I agree that a basic safety net is necessary and serves a greater good - providing things like normal checkups, preventative services, and acute trauma care is reasonable. However $200k for a second heart surgery for someone who hasn't taken heed of earlier exercise or diet advice by a practitioner should not be supported.

<comment><USER11> Serious question: Do you live a perfect life? Do you exercise daily? Do you never eat processed meat (linked to cancer)? Do you never drink soda (linked to metabolic syndrome)? Do you not smoke? Do you not drink any alcohol (linked to cancer)? Do you live close to your work so as to minimize the time spent in a car (car accidents are a major cause of preventable death)? Are you not overweight, even a little? And so on.

Do you think that someone who follows _all but one_ of those rules still deserves healthcare? All but two? What's the moral difference between someone who smokes and someone who hasn't taken heed of diet/exercise advice after getting heart surgery? Where do you draw the line?

It's easy to say, "I don't want to pay for the healthcare of some hypothetical 'slob'". But make it real, consider what this actually means, and I think it's not something most of us want.

None of us is perfect. I'm sure that even olympic athletes occasionally eat bacon. Let he who is without sin cast the first stone, right?

<comment><USER12> > Do you think that someone who follows all but one of those rules still > deserves healthcare? All but two? What's the moral difference between > someone who smokes and someone who hasn't taken heed of diet/exercise advice > after getting heart surgery?

Yes. Yes.

Moral difference no idea, but neither one should expect to have society foot the entire bill for their bad habits.

> Where do you draw the line?

Probably around morbid obesity that's unrelated to genetic/chronic issues.

> Let he who is without sin cast the first stone, right?

By setting an unreasonable standard and saying no one under it has the ability to cast judgment is extremely anti-intellectual. If 2 people were telling you about health habits and one of them was an olympic athlete (who occasionally ate bacon), and the other was a random overweight person from the street, whose advice would you give more weight to?

<comment><USER11> > Probably around morbid obesity that's unrelated to genetic/chronic issues.

The jury is still very much out on how common this is, isn't it? Who is going to make the decision of whether I am "at fault" for my obesity?

Also how many people _actually choose_ to be morbidly obese? Like, suppose I am genetically predisposed to like "unhealthy foods" (scare quotes because we don't really know what that means). Does that excuse my obesity as genetically caused? How are you going to tell the difference between someone who "selfishly likes" unhealthy foods and someone who can't help themselves? More to the point, _is there a difference_?

> By setting an unreasonable standard and saying no one under it has the > ability to cast judgment is extremely anti-intellectual. If 2 people were > telling you about health habits and one of them was an olympic athlete (who > occasionally ate bacon), and the other was a random overweight person from > the street, whose advice would you give more weight to?

In the face of this claim that my argument is anti-intellectual, I think I get to be pedantic and say that this counter-argument is a straw-person and equivocates.

I am saying that I don't think an Olympic athelete should pass _moral judgement_ on other people. But of course an expert can pass _intellectual judgment_ on ideas (e.g. "candy is healthy").

I can't believe I'm here as an athiest defending Jesus, but there you go. :)

<comment><USER12> > Also how many people actually choose to be morbidly obese? Like, suppose I > am genetically predisposed to like "unhealthy foods" (scare quotes because > we don't really know what that means). Does that excuse my obesity as > genetically caused? How are you going to tell the difference between someone > who "selfishly likes" unhealthy foods and someone who can't help themselves? > More to the point, is there a difference?

I'm sorry but this is insane. Are we just abolishing any notion of personal responsibility whatsoever? I can't and won't argue from that first principle so we're going to have to disagree here fundamentally.

What if I can't help myself but grope women? What if I'm genetically predisposed to violence? Or kleptomania? Those things also impose a heavy cost on society, but if I _just can 't help myself_, am I really at fault?

> How are you going to tell the difference between someone who "selfishly > likes" unhealthy foods and someone who can't help themselves? More to the > point, is there a difference?

Of course there's a difference. If your willpower is not sufficient to correct your obesity, then you should take other, more radical steps that do. And if you don't, then you're just selfishly externalizing your problems to society.

> But of course an expert can pass intellectual judgment on ideas (e.g. "candy > is healthy")

Good, at least we can agree on something. So to answer the first part of your post, you should ask an expert on obesity. I'm not one, so if their judgment differs from mine, I'll stand corrected. But until then, I'll be of the opinion that most obesity cases are not genetic.

<comment><USER11> > you should ask an expert on obesity. I'm not one, so if their judgment > differs from mine, I'll stand corrected. But until then, I'll be of the > opinion that most obesity cases are not genetic.

You're saying you have no expertise in this, haven't spent any time reading the literature or consulting with experts, but you nonetheless are going to continue having a strong opinion on this question? What is the basis for this opinion on a question of fact? Hopefully it's not than the fact that fat people are icky and so must be morally at fault for their failings?

<comment><USER12> I can ask you the same thing, but in reverse. What is your strong opinion on believing that people should have no responsibility for the obesity, when we know it is caused mostly by over-eating?

Why do you presume people are completely hopeless at controlling what they put in their stomach?

How many experts did you consult with to form _your_ opinion?

<comment><USER11> > What is your strong opinion on believing that people should have no > responsibility for the obesity, when we know it is caused mostly by over- > eating?

We don't know that obesity is caused mostly by over-eating.

Many basic questions about diet are unsolved, including the reason(s) that some people gain weight while others don't and the reasons that the vast majority of people can't lose weight. We just do not know to what extent do genetics, gut flora, lifestyle, and diet affect weight. We also don't know what makes for a "good" diet, or whether the same diet is good for everyone.

This is not obscure knowledge. Literally if you google "what causes obesity?" you'll get pages like this: [https://stanfordhealthcare.org/medical- conditions/healthy-li...](https://stanfordhealthcare.org/medical- conditions/healthy-living/obesity/causes.html)

> How many experts did you consult with to form your opinion?

I spend a lot of social time around doctors, and I read a fair amount of medical literature (for someone who isn't in the medical sciences, anyway).

I am not claiming to be an expert, but I am claiming to be somewhat informed, yes.

I am also claiming, more strongly, that _before we as a society punish someone for causing something_ we'd better be pretty damn sure that the person actually did cause the thing, with mens rea and so on. I am claiming that the scientific evidence is not there for obesity.

<comment><USER12> > We don't know that obesity is caused mostly by over-eating.

No, that part is obvious and we do know that more calories results in more weight. There's no debate. The only debate is in what causes over-eating.

> Many basic questions about diet are unsolved, including the reason(s) that > some people gain weight while others don't and the reasons that the vast > majority of people can't lose weight. We just do not know to what extent do > genetics, gut flora, lifestyle, and diet affect weight. We also don't know > what makes for a "good" diet, or whether the same diet is good for everyone.

Also flat out not true. You're creating some ridiculous standard for "knowledge" when in reality, you only have to have "good enough" knowledge in order to be healthy and not obese. Most people can easily adhere to, but for whatever reason, don't.

> This is not obscure knowledge. Literally if you google "what causes > obesity?" you'll get pages like this: > [https://stanfordhealthcare.org/medical-conditions/healthy- > li...](https://stanfordhealthcare.org/medical-conditions/healthy-li..).

Yes, and? The answers are not equally weighted. Just because there are 3 answers, doesn't mean each answer is equally responsible in the cause of obesity.

> I am not claiming to be an expert, but I am claiming to be somewhat > informed, yes.

I am claiming the same. My parents are biomolecular scientists and for them it is not contentious that overeating causes obesity. If we're giving weight to anecdotal evidence, I'm entitled to at least give my own evidence the same weight as you do yours.

> I am claiming that the scientific evidence is not there for obesity.

And there are people claiming that anthropogenic global warming is a myth, despite scientific evidence otherwise. However, I'll take claims that are true (overeating causes obesity - replicated many times), over claims that may or may not be true.

Please realize that you're in the minority on this, but the science is already settled. It's ok to admit that you're wrong.

<comment><USER11> >> Many basic questions about diet are unsolved, including the reason(s) that some people gain weight while others don't and the reasons that the vast majority of people can't lose weight. We just do not know to what extent do genetics, gut flora, lifestyle, and diet affect weight. We also don't know what makes for a "good" diet, or whether the same diet is good for everyone. > > Also flat out not true. You're creating some ridiculous standard for "knowledge" when in reality, you only have to have "good enough" knowledge in order to be healthy and not obese. Most people can easily adhere to, but for whatever reason, don't.

OK, this is a concrete claim that we can test: "most people can easily adhere to a 'good enough' diet/lifestyle to avoid being obese".

If this were true, then there would exist a protocol that "easily" results in lasting weight loss for most people, right?

Does such a protocol exist?

</comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER13> For someone who worked on price transparency in 2013 - I was personally affected with surprise billing - and spent long hours working on a price discovery / transparency tool called pricepain.com, this (first step of an) anti cartel measure brings tears of joy. While it won't solve all issues at once, shining some light into the medical billing mess can only be a good thing, allow market forces to enter the picture somewhat. It's rather sad, that it didn't come from the industry itself - but I guess that speaks volumes already. Florida faced a dilemma with their incredibly broken public school system many decades ago and was stuck in a political gridlock as no party agreed on any measure the other would propose to improve the situation. Finally, the only item both parties did agree on, was to grade schools. Just a single simple letter, a search for more light. The result of a little bit more transparency caused a chain reaction of consequences leading to higher quality of service overall. I hope that similarly this move will spark a quality/performance re-orientation and help create more Surgery Centers of Oklahoma. It's high time.

<comment><USER14> Something I worry about, and that maybe you can help shed some light on, is what the ramifications of such a move would be.

You mentioned the grading of schools leading to higher quality. Do we know if any metric suffered as a result? One guess I have is that teachers started teaching for the test rather than for the foundation.

Take that same question and apply it back to the issue of hospital cost. If there's more transparency, the obvious conclusion is that there will be increased competition and an overall lowering of costs for patients. Does that come at the cost of quality of care? My gut says no, but my brain says that hospital administrators are incredibly talented at cutting costs. Maybe we have other safeguards such as HCAHPS to prevent the worsening of quality.

And as my own comment on this situation - how does this move fit into the insurance realm? My understanding is that hospitals will display the overinflated prices, but not the individual insurance negotiated prices. So how does this increased 'transparency' help?

<comment><USER15> I suspect that with teachers teaching to a test, it improves bad teachers and holds good teachers back a little.

<comment><USER16> It accomplishes little. The tests are a subset of the things the students should have been learning anyway. The idea was that by measuring performance teaching could be improved where needed. The actual result was that the "help" given to classes with bad scores has been to overtrain some tiny neural nets to respond to very specific stimuli without teaching them anything beyond the specifically measured behavior. Even the students that pass often haven't mastered the material. They just can take the test. We opted to replace accountability with process and reaped the usual results.

</comment></comment></comment></comment><comment><USER17> This won't help consumers. The prices (both charges and what Medicare pays) are already effectively public: [https://data.cms.gov/Medicare-Physician- Supplier/Medicare-Pr...](https://data.cms.gov/Medicare-Physician- Supplier/Medicare-Provider-Utilization-and-Payment-Data-Phy/utc4-f9xp)

The problem, as some other comments point out, is that they're way too complicated. The link I posted, for example, is just the provider charges. A hospital visit typically has a facility claim and at least one provider claim. Depending on the type of service received and the agreement between insurance and facility, the facility fees can be billed a variety of ways (diagnosis related groups, ambulatory payment classifications, or HCPCS). Each provider that sees you or performs labs, x-rays, etc can bill separately, and each could have a separate or no contract with your insurance. The latter is how surprise 'out of network' bills happen.

It's a total mess and hopelessly complex for the average consumer.

<comment><USER18> > It's a total mess and hopelessly complex for the average consumer.

Sounds like something the people on this forum can help improve.

<comment><USER19> It's not a technological problem but a political one: the obfuscatory pricing is deliberate.

Maybe you could have "fighting hospital billing as a service", but that's definitely going to need a chunk of human labour on top of whatever AI assistance you apply.

<comment><USER20> Is there any way this could be represented via interactive graph? We were able to tame much complex stuff than deliberate obfuscation by people not aware what tech can do.

I guess there is not enough incentive ($$) to solve this problem.

<comment><USER21> The $$ is being made by the hospitals

See [https://www.vox.com/health- care/2018/12/18/18134825/emergenc...](https://www.vox.com/health- care/2018/12/18/18134825/emergency-room-bills-health-care-costs-america) to start digging into the mess

</comment></comment></comment></comment></comment><comment><USER22> I'd be happier to see regulated business practices. While I agree that the prices are a problem, I've felt more pain from bills that keep coming in for more than a year after a major event. And when I go to complain, they say that someone made a mistake, the insurance took a long time to respond, or some other excuse. Give me a final bill with all charges within 30 days, then 30 more days to resolve any issues with that bill, and then let the billing end so we can move on with our financial lives without wondering if one more bill is going to show up next week, tied to my credit record.

<comment><USER23> I currently use hospital billing as an example when explaining the halting problem. You're never sure if you've paid off an incident or if another bill will show up in a few months...

<comment><USER24> Before we were married my wife had an MRI. Having not met her deductible they sent her a bill for 1.5k. Not ideal but we were able to afford it and paid the bill. 364 days later we received another bill for roughly the same. We thought there was an error. After months of back and forth, even after they had told us for 2months that "they took care of it and we would not be charged" we ended up having to pay another $500. This whole process was beyond infuriating.

The other bill apparently came from the Dr who read the MRI. The fun part was we were never contacted by that Dr about the results. She eventually left the hospital and she canceled our follow up appointment.

</comment></comment></comment><comment><USER25> My guess is that eventually the govt will step in and start regulating prices if providers don't.

One interesting idea (not well thought out at all) would say that all prices need to be +\\- 50% of what Medicare pays.

Medicare pays $20,000 for stent placement? Great! You can charge whatever you want up to $30,000.

A lot of effort goes into setting Medicare rates (and they are based on self reported costs across the country), so forcing providers to be in the ballpark of those might help.

It wouldn't solve the issue, but it would eliminate those ridiculous "why do you charge $10,000 for an MRI when the clinic down the street charges $1,000?".

<comment><USER26> If you look at healthcare vs GDP, the US is way above the line compared to comparable countries. [https://www.healthsystemtracker.org/chart- collection/health-...](https://www.healthsystemtracker.org/chart- collection/health-spending-u-s-compare-countries/#item-relative-size-wealth-u- s-spends-disproportionate-amount-health)

I think scaling the average costs from other countries accounting for GDP would be a good way to set the rates.

<comment><USER27> This is one of those nice ideas that has some pretty serious hidden costs. You'd struggle to compare healthcare in the US to other countries, because the quality of healthcare available (talking about availability, not accessibility) in the US is generally superior to other countries. So you could end up simply eroding the quality of care in the US. Another thing people tend not to talk about when discussing healthcare in the US is how much the US contributes to medical research and innovation. No other nation on earth even comes close. If you adjust the system so much that you remove the incentive to carry out that research, then the quality of care in literally the entire world would suffer.

<comment><USER28> I disagree about quality/availability. In Japan, Taiwan, Mainland China, Thailand; I've had amazing health care for the fraction of the price. Shit, a full cancer check only cost me 90 dollars in Japan. Getting my eyes fully checked for retinal tears cost me nothing due to national insurance in China.

In some cases, _maybe_ the US has better care. But the cost of that is just way too damn high.

Yes, medical research in the US is superior, but that shouldn't be at the cost of peoples' lives.

<comment><USER27> In the developed world, the price of routine checkups are not what people would generally be referring to when discussing _quality_ of healthcare. Generally speaking, the US has the best facilities, technology, expertise and pharmaceuticals available. Which is why people come from all over the world for procedures that simply aren't available elsewhere. Again, I'm not talking about the problems with accessibility, merely talking about available treatments.

Reducing investment in medical research will absolutely come at the cost of people's lives. More people's infact, as anybody will die from a terminal illness that doesn't have a treatment. As an example the US market constitutes something life 70% of _global_ pharmaceutical profits.

<comment><USER29> This weird argument pops up regularly. In relation to New Zealand (where I am) it's argued that the US is subsidising the cost of drug scripts. It's beyond me quite how NZs drug buying agency is running roughshod over the rights of drug companies that have multiple insurance companies in the US that are bigger customers. What's the agenda behind this argument?

<comment><USER30> The U. S. is the last place drug companies can get away with it, is what the agenda is. Americans are suckers for a good capitalist argument. "U. S. customers pay more because they have to subsidize those filthy socialists." Imma gonna have to call bullshit. You're telling me you sell to NZ at a loss because...New Zealand tanks will roll up to your doorstep if you don't? Does New Zealand even own a tank? No, you sell to NZ because you somehow figured out how to profit from doing so.

But as we see above, plenty are willing to carry the water of the poor, downtrodden drug companies.

<comment><USER27> >No, you sell to NZ because you somehow figured out how to profit from doing so.

The incremental cost of selling drugs you've already developed is quite low, so of course they can still profit from them in less profitable markets. But it's the US that's paying for them to be developed. This isn't even up for debate, R&D in the US dwarfs everywhere else.

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER31> I actually stiffed a doctor once because he refused to give a price up front and when I got the bill it was outlandish. I also made a huge scene in the intake/waiting room about this. I was leaving the United States at the time so I didn't really care about my credit record.

To be slightly more honest: he wasn't the doctor assigned to me on intake, he was another doctor from another hospital across the street as a consultant IMHO trying to get onto my case so he could bill me.

<comment><USER32> Had new insurance and a sore shoulder. Was billed ~$1,400 for a physical therapist to examine it ("evaluation"). No treatment. Very little covered by insurance.

The next day had a chiropractor treat it and shoulder was fine. $25 with coupon. Funny part is, as it was new insurance, I spent over 30 minutes with insurance rep _in advance_ on phone going over options and trying to get an idea of likely costs.

When I had a heart problem and no insurance, we called providers all over town (Minneapolis) to try to get prices in advance. Most would only give estimates over a wide range. Some flat out said it was there policy to _not_ give estimates. Eventually found a cardiologist who worked basically free ($30 plus donation). I bought a Kardio to record my own ECG so I can have more data to improve my communication with cardiologists, who are (understandably) a bit alarmist about what can go wrong and tend to err on the side of (expensive) caution without sufficient data.

Feels like a broken system.

<comment><USER33> So you have insurance but it doesn't cover stuff when you are actually ill? Does your insurance policy actually spell stuff out so that you can predict what will or won't be covered?

Note: I'm from the UK and find the stories about US healthcare insurance grimly fascinating....

<comment><USER34> Not just health insurance, but healthcare is crazy too.

Spent a total of 36 hours on the phone with the hospital to figure out how much something would cost because I knew I had to pay out of pocket. And they weren't even right when they finally gave me a number.

Had a doctor remove a cotton ball from my ear in the hallway. Charged me 2.4k for that. Didn't have insurance either.

My wife's friend delivered her own baby in the hallway and they still sent her a bill for delivery.

My wife had her gall bladder removed, supposedly the most common surgery. Surgeon charged 25k, hospital charged 65k, anesthesiologist charged 3k, and a doctor that talked to her for 25 seconds charged 1.5k. Insurance and the hospital argued over the bill for almost a year, during which time the hospital kept sending me payment due notices.

No one in this industry has my sympathy.

<comment><USER35> I couldn't even get the billing codes for a routine ultrasound. And no one will ever respond to you in writing for anything.

</comment></comment></comment></comment></comment><comment><USER36> One thing I advocate is fixed pricing. It's great to put prices online, but as long as insurance companies and such get to make deals there will be no real transparency or competition. The one downside I see to enforcing the prices is that it would ruin this ability to offer a break to people who need it.

On the other hand, with enforce posted prices those prices would come down to levels similar to what insurance companies pay so the sticker shock to those uninsured would be significantly lower. Still, there will always be those in need.

<comment><USER37> It's a good goal, but this is a very complex system.

For example, if published prices were brought down to slightly-above-insurance rates, fewer people would buy insurance.

Consequently, insurers would have less bargaining power, further erroding their price advantage (and financial solvency).

As an end result, absent regulatory mandate, non-high deductible plans would cease to be market viable.

Providers, insurers, and patients are in a zero-sum competition for the same dollars.

The ultimate question is -- do we want the US medical system to look like the US air travel system?

On the whole, it seems like it would be better than what we've got. But I think we could do better (specifically: smooth boom/bust cycles, increase healthy competition)

<comment><USER38> > _For example, if published prices were brought down to slightly-above- > insurance rates, fewer people would buy insurance._

Would they? I don't buy insurance so my doctor visits are only $20 - I buy insurance so that if something catastrophic happens to me, I'm not on the hook for hundreds of thousands of dollars.

Even if the cost of (e.g., brain surgery, emergency appendectomy, resetting shattered bones) was the same as what insurance pays, I _still_ wouldn't be able to afford it.

<comment><USER37> I would hazard to say that both of us aren't in the demographic where $20 matters.

But for a lot of people, $20 vs $250 is the difference between going to a doctor and not.

Separate from that there's the catastrophic vs no coverage argument. If you're struggling to make rent at the end of the month, it's probably a smarter personal bet not to buy insurance.

But patients without at least catastrophic are corrosive to our medical system, and what the ACA mandate was targeting.

Personally, I think the ACA mandate for a catastrophic policy, with preventative care included, and direct cash subsidies to people at the poverty line (to cover routine care) is the best solution.

I'd expect the ACA designers considered this, and only broadened the mandate requirements as a horse trade to insurers for assuming the risk of offering marketplace plans.

</comment></comment></comment></comment><comment><USER39> Presumably, this is based on ICD10 codes... but there can be 30 different services tied to a code. You still won't know what code is being charged until after the service is rendered, and if it's rack rate you won't know the actual rate your insurance will be charged, until THEY tell you... because that is proprietary information (just like the reason why your treatment was denied coverage).

Imagine you have diabetes and want to know which provider or insurance company will give you better endocrinology rates... it's the best case treatment knowledge scenario, but you can't figure anything out without knowing the secret negotiated rates for each possible coverage pair.

<comment><USER40> Are people really billed based on diagnostic codes? If true, it's not what ICD-10 was designed for.

Patient A can recover from the same procedure for the same diagnosis much quicker and with fewer interventions than Patient B. Would insureco get billed the same for both?

<comment><USER41> They aren't. Prices are based on the HCPCS codes (CPT for clinical charges). For example, a 99213 is a return office visit.

<comment><USER39> Providers often enter ICD-10 codes (required by Epic) and do not know HCPCS or CPT... so how could they tell you what you will be charged? There isn't a way (that even educators know of to get those codes or the pricing)... the prices are handled by billing, which is a separate department and you can't reach them by phone. They will call you back (within 30days), but they do not leave messages.

Clinic and hospital in the heart of silicon valley.

</comment></comment></comment></comment><comment><USER42> This is a start but will be useless unless how these published prices are arrived at are regulated so they can't be gamed behind discounts, copays, deductions, insurer discounts, tacked on items, etc. It'll be like buying a mattress and trying to do price shopping.

The published prices will need to have a readily useful and predictable meaning and interpretation.

<comment><USER43> Exactly. As it is, everytime we end up with a sizable bill I call and ask for a discount, and right away they tend to give a 10% pay in full discount. I've seen this through different providers and insurance plans. I would have never thought about it until someone suggested it to me.

<comment><USER44> Hah, yeah, I even pad my product prices so that when I run a sale, I still get my profit.

</comment></comment></comment><comment><USER45> The next logical step is to require written estimates in advance, just like the auto repair industry.

<comment><USER46> and require the same price for lone customers as what is negociated with insurances.

<comment><USER47> and then strangle the parasitic insurance companies that are paid handsomely by the consumer to build pointless bureaucracy and safeguard their market position

<comment><USER35> Considering the patients have no idea what is going on and therefore no way to tell if what they are being sold by medical care providers is appropriate or not, insurance (who also have doctors reviewing the cases) is actually the only entity that is auditing the work of the medical providers to make sure they're following the proper procedure and prevent overcharging.

</comment></comment></comment></comment><comment><USER48> Just in time for end of year tax donations, and on a related note, I'm a big fan of RIP medical debt. They buy up medical debt for pennies on the dollar, then forgive it.

It's too late to prevent credit score dings, but at least it gets rid of collectors for someone.

By law, when debt is sold to collectors, the person that owes the debt should have the option to pay the price offered to the collector. In the current system, hospitals are just paying shady crooks to borderline-illegally hassle people.

</comment><comment><USER49> This is almost completely meaningless unless it's paired with some serious help in figuring out the total cost of a visit.

Every service that offers this sort of price transparency I've seen so far lists the prices for single insurance billing codes at a time. A lay person isn't going to understand the total cost of the visit from that, because there's no way to figure out which billing codes are going to be make up everything that's been billed for different types of visits.

An average price also means absolutely nothing, if the variance is significant or the medical care depends on circumstances and can, as an example, vary from a single day hospitalization to a 2 week hospitalization.

While this is positive progress, I would really appreciate more effort put on actually reducing the prices themselves.

I guess the more expensive hospitals could see patients choose less expensive hospitals, and forcing them to lower their prices, but I'm not too optimistic of that happening in any meaningful way.

<comment><USER50> "A lay person isn't going to understand the total cost of the visit from that, because there's no way to figure out which billing codes are going to be make up everything that's been billed for different types of visits."

Another problem is, for many, you won't even know what your ailment and treatments will be until after.

<comment><USER51> > _Another problem is, for many, you won 't even know what your ailment and > treatments will be until after._

Progress is progress, even if it's not perfect. Many people get diagnosed and treated on separate visits, and many more have long-term illnesses that they know relatively well. Soon there will be a proliferation of guides for common long-term illnesses like diabetes, detailing what billing codes you can expect. Eventually, I hope to be able to put a condition (say, pregnancy) along with some personal information into a computer, and get out the flow matrix telling me the probabilities of all possible futures and the costs of each. That's a long way off, but this is the first step.

When medical costs are being discussed, the relatively rare situation of being rushed in to a hospital unconscious for doctors to do a series of completely unpredictable procedures on you tends to get focused on almost exclusively. In reality, a huge fraction of medical expenses go to (comparatively) predictable things like cancer treatments, where an operation will be scheduled out two weeks in advance. Even a day's notice would be enough time for price selection to happen, if all you had to do was look at a list of providers, prices and success rates.

</comment></comment></comment><comment><USER52> How about transparency of medical records - i.e. if I provide some credentials, can I definitively get a copy of my medical history so that I can easily take it with me to another country/hospital?

By definitively I mean within some federal regulation or system that doesn't depend on an employee at a particular hospital getting around to it on their coffee break.

<comment><USER53> You certainly can under HIPAA, and I've done this several times without unreasonable delay. If you've had issues, I'm sure the "sternly worded letter from a lawyer" approach would get the gears turning.

<comment><USER52> Thanks! Are they all interconnected, so that if I use a service like [https://www.medicare.gov/manage-your-health/medicares- blue-b...](https://www.medicare.gov/manage-your-health/medicares-blue-button- blue-button-20) I will get the collected records from different doctor visits at different hospitals?

<comment><USER54> They are not all interconnected. Most providers have some sort of connectivity to a regional health information exchange network, but there are a lot of gaps and interoperability problems.

Blue Button 2.0 is helpful but currently it only gives authorized providers access to your Medicare claims (if you're a Medicare beneficiary), which have limited clinical value. Getting a copy of your full chart requires going through other channels.

</comment></comment></comment></comment><comment><USER55> I take issue with this headline. Hospital prices are _already_ , by law, public in the US. The new rule makes it required to post them _online_ , whereas previously you might have to call/email the hospital to get the price list rather than looking at their website.

This is an important distinction, IMO, because I have seen people saying that this is an important step because "insurance/patients can now negotiate easier with a set price list". The issue with this is that, like mentioned above, the public has already had access to these price lists, so this new rule changes nothing in that regard.

The new rule might make it easier for insurance companies or those collecting pricing information to scrape the price data from the hospitals' websites, which is a good thing, but overall I think this new rule is being overblown in terms of the actual impact it will have.

<comment><USER56> If the only access you have to a price list is through a private comms channel, what guarantee do you have that you are receiving the same prices and service for a given price as someone else?

If the prices were available through a centralized third party (government health agency or similar) then sure, it's not much of a difference, but if the only way before was by directly contacting the hospitals, then it being available online is a big difference in the actual "public" nature of the information.

Also, calling or writing snail mail to multiple individual hospitals for price lists is a barrier in 2018 that not only dissuades, but is possibly physically not viable for affected people.

In my opinion, being posted online is rightfully the baseline for information to be considered "publicly available" (but probably not sufficient) today.

My heuristic is if you can't find out a piece of information by visiting a public library within 5-10 minutes, it's not public information.

<comment><USER55> There's nothing in this ruling that requires the price list, even online, to fit within your heuristic.

The hospital could choose to place the price list at a url of blahblahhospital dot com / 3424kjfksm34. And to get that URL, you have to call the hospital and ask for it. There is nothing in the rule going into effect on Jan 1 that says they have to plaster the price list on their front page or on Google.

For that matter, they still could give separate price lists to different parties, as long as said price lists are 'online' (eg price list for you is at our_prices dot html, whereas someone else's price list is at our_other_prices dot html).

And, beyond all of this, is the fact that even if you do get access to the price list, it is meaningless to you as a patient. The article discusses this. As a patient, if you want to know an actual realistic estimate of your costs, the only way to get that is to call/go into the hospital and ask, or to go through your insurance company estimator, both of which are already available and aren't changed by this new ruling.

Your points are all legitimate and ones I agree with, but I just don't think this new HHS rule does anything to meaningfully address them.

</comment></comment></comment><comment><USER57> One way we could wheedle useful information out of this is how the published prices relate to other providers, especially if there are huge discrepancies.

Telling me an average MRI has an average list price of $1000 at provider A tells me nothing. But if provider B says theirs is $10,000? That could be pointing to something important.

<comment><USER58> The ability to "shop around" for cheaper care sounds fantastic. But could that system actually work for healthcare? Is there anything intrinsic to healthcare that limits the ability of a free market in that arena (morally, economically, etc.)?

<comment><USER57> >Is there anything intrinsic to healthcare that limits the ability of a free market

Oh, lots (the biggest fundamental failing being that a person will generally pay anything to not die or be in pain -- its why extortion and robbery can never lead to an efficient market). But examining costs doesn't mean we have to apply a market-based approach to controlling those costs.

</comment></comment></comment><comment><USER59> I was curious at what determines medical prices after recent stay in hospital, my bill was bizarre and it seemed that different hospitals charge substantially different amounts. So I wrote a medical pricing app to explore hospital bills and medicare reimbursement

I still don't understand why pricing so different throughout the country, but at least there is a pretty app to visualize it

[https://itunes.apple.com/us/app/u-s-medical- prices/id1376580...](https://itunes.apple.com/us/app/u-s-medical- prices/id1376580121)

</comment><comment><USER60> Should be extended to require: * Prices _actually_ paid vs. list price for procedures * All-in prices for the ten most common/expensive procedures (e.g. all associated costs of a heart surgery).

</comment><comment><USER61> Now if we could just get some kind of all payer system in place. so everyone pays the lowest prices offered. but I guess its a start. The problem is there's not enough competition and not enough schools and we don't allow doctors from other countries to test to become a US doctor. with out basically starting over.

[https://innovation.cms.gov/initiatives/Maryland-All-Payer- Mo...](https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/)

</comment><comment><USER62> Some anecdotes related in the comments are scary. I'm wondering, how is the situation for a software engineer working in a big company (say GAFA in silicon valley). Suppose you broke a leg skiing, and need surgery and various medical exams. How much are you expected to pay? what's the administrative overhead? same question for dental care.

<comment><USER63> completely depends on your insurance plan...something like this will definitely be covered, but how much you will pay depends on your deductible, how much you've already contributed to your deductible, what copay or coinsurance you need to pay once you meet it, and your out of pocket max (max you will pay for anything in a given year)

I have supplemental "accident insurance" since I'm relatively young and healthy and the biggest reason why I'd end up in the ER is due to a physical accident. With this insurance it covers more of what I would pay in this situation than my insurance would alone.

<comment><USER35> Also if someone out of network walks into the room.

<comment><USER63> Yeah that's a big one. Also if you have an emergency and go to a in network facility your doctor might be out of network. Most decent insurance plans do say that in emergencies they treat in network and out of network care equally, but definitely not all plans work like that.

</comment></comment></comment></comment><comment><USER64> It's hard to believe how little progress has been made with medical billing.

My last standard annual physical was billed at $2.6k, had 30+ line items, and despite being covered my insurance left me with an out-of-pocket of $200+.

I guess I'll take this as a win, albeit small.

</comment><comment><USER50> fyi, Medicare made their reimbursement data available some time ago, including billed vs reimbursed.

[https://www.cms.gov/Research-Statistics-Data-and- Systems/Sta...](https://www.cms.gov/Research-Statistics-Data-and- Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge- Data/Inpatient2016.html)

CEDARS-SINAI MEDICAL CENTER in CA billed on average $2.8 mil for one heart transplant (nearly 50 performed) while Tufts Medical only billed $586k on average for similar number of procedures.

They were reimbursed $345k and $280k per procedure respectively.

Insurance companies should follow suit.

</comment><comment><USER65> I like to see when title mentions the country. National news websites typically don't include the name of the country, which is a definite inconvenience on global communities like hn and some subreddits

</comment><comment><USER66> Can anyone recommend some resources to read up on the US healthcare system? I am looking to spend a good week studying the subject so I can have a more informed opinion on the subject.

<comment><USER67> To have a truly informed opinion, I recommend The economics of Healthcare class on Coursera.

Its only a couple of hours to understand why pricing is so complicated in the US, and why the problems people focus on are usually the wrong ones.

<comment><USER66> Thanks.

</comment></comment></comment><comment><USER68> EMR, Health Information Exchanges, teams of analysts organizing standards for information exchange, and mandates for upgrades should have set the stage for transparency beyond published fictional information by providers.

Would someone please comment about these projects? The affordable care act gave more than a billion dollars away for people to work on the exact same, redundant projects in regions across the United States. Did these initiatives reach production and are they running today?

<comment><USER54> Yes EMRs have been widely deployed, and the majority of providers are now connected to some sort of HIE. This has helped to improve care quality slightly by reducing medical errors and preventing the need for duplicate procedures. However it hasn't had much impact on billing or insurance issues; those will have to be addressed separately.

</comment></comment><comment><USER69> I work for a startup with two people and the other guy can't pay a real salary or benefits. So I can't really afford to live in nice areas of the US or really even afford the health insurance and medication for just me even after subsidies. If I needed to visit a hospital in the US without insurance, I know I would be bankrupt.

So my solution is until business starts making money I am going to continue to live in Mexico and get Mexican health insurance.

</comment><comment><USER70> This is honestly something I look forward to witnessing. Currently it's hard to find detailed financial information for how much a person with whatever diseases ends up being covered per year with costs. I think transparency about coverage is necessary for people being unfairly handled by providers based on their condition being minuscule compared to another disease with a larger population that has better coverage because more advocacy.

</comment><comment><USER71> There is a similarly useless drug price list. What is needed is crowd sourced discount pricing of the insurance companies, per hospital. Leaks would be welcomed.

</comment><comment><USER72> It's funny that co-pay I am paying for a service in the USA is comparable to a full private treatment with the same quality in Poland, where I grew up.

<comment><USER40> It can be difficult for a patient to determine quality of care.

And difficult to compare country against country.

Poland is similar to USA in cardiovascular care, but much worse in cancer : [https://en.m.wikipedia.org/wiki/List_of_countries_by_quality...](https://en.m.wikipedia.org/wiki/List_of_countries_by_quality_of_healthcare)

<comment><USER73> I'm curious about the quality of that source actually.

Based on the pdf linked from the OECD page [0] it looks like they're measuring the reported incidents of cancer based on medical records.

The medical records for the US may be skewed because they only cover the well- off (after all, the poor can't afford healthcare), while in other countries, like Poland, everyone rich and poor receives care and are included in the statistic.

Also, the numbers on wikipedia are stale, but they don't seem to have changed that much on the OEDC website. The ux is garbage so I didn't click around that much.

[0]: [https://www.oecd.org/els/health-systems/Definitions-of- Healt...](https://www.oecd.org/els/health-systems/Definitions-of-Health-Care- Quality-Indicators.pdf)

</comment></comment></comment><comment><USER74> List price $72,588.00

Insurance co pays $5600

OK, maybe I am exaggerating a bit but this is useless. Someone brought unconscious to the hospital should pay reasonable and common fees when they leave the hospital, not whatever the hospital dreams up. What the insurance companies pay the hospital for the procedure, maybe with a 20% increase should be it for everyone.

<comment><USER50> Sadly, I've seen worse billed/reimbursement ratio in reality.

</comment></comment><comment><USER75> I wonder if the prices listed will be shown in a manner that is legible by the average citizen or if they will be so convoluted that no one will be able to make sense of them.

Reading the article it seems as this will be the case. Hopefully that changes down the road.

</comment><comment><USER76> Has there been any precedent of patients saying to the hospital at the start of a visit "I agree to pay 1.5x the medicare reimbursement rate and no more, if you don't agree to this I will go to the next hospital"?

</comment><comment><USER77> Ah, always a surprise to entrenched businesses when freer markets are introduced.

</comment><comment><AUTHOR> Now this is the way it should be:

[https://surgerycenterok.com/pricing/](https://surgerycenterok.com/pricing/)

<comment><USER78> These prices seem reasonable, even though the cost is in the thousands of dollars.

The question is what happens when you try to get your insurance company to pay this quoted price.

</comment></comment><comment><USER79> Why the hell would you allow automatic playing video ads that crash the mobile browser? What a shitty site

</comment><comment><USER80> It's funny how long it took me to figure out the rule, is being pushed through by Trump's HHS appointee.

Some of the only info I could find on him by name is how much of "a distaster" he would be published around the time he was appointed.

I'm getting real sick of what constitutes professional journalism. I don't like Trump, but when accomplishments are effectively hidden, and all speculation is unabashedly negative - there is a problem.

</comment><comment><USER81> Its about damn time</comment>


SAP just bought one of the leading ecommerce platform vendors - <AUTHOR> http://www.hybris.com/en/ Yesterday, hybris announced that they were being bought out by SAP.
Hybris are one of the leading ecommerce platform vendors (along with IBM and Oracle) that are ranked in the top three according to recent Gartner reports.
If you shop online, it's likely that you've interacted with hybris.
I'm not sure what this will mean in the long term for hybris developers, but knowing SAP I imagine hybris will be removed as a cheap (cheaper than Oracle and IBM) option for mid size retailers.
I think it's nice to see stories like this as it shows that you can spend many years building a very profitable company that adds real value rather than trying to build something at the speed of light in an attempt to sell out as quickly as possible. <comment><AUTHOR> It's nice to see a company that spent along time building a solid product that has added value to many business around the world.

A nice change from the stories we hear about startups racing to release something of little real value and trying to sell themselves as quickly as possible.</comment>


Ask HN: My Revenue Model- How does it sound? - <AUTHOR>

Hi, I'm working on a video game start-up in Athens, Georgia. I was asked about our revenue model, so I did a formal write-up and was wondering how it sounds. Any feedback would be greatly appreciated.
Here goes:
Our game will be released in two versions: a free, Lite Version (where users can play endlessly, but upgrades necessary to advance above a certain level are locked) and the Full Version, which will cost one dollar. It is hard to predict sales, but we expect about 50,000 copies in 2012. The App Store keeps 30% of each sale.
The other part of our revenue model is merchandise. One thing that sets our game apart from other restaurant simulations is the simple, expressive, and numerous characters (rather than the boring, generic characters of many other games in this genre). We are focusing on creating popular characters that will re-occur in multiple games and be featured on merchandise. These re-occurring characters will not only boost the familiarity and popularity of each game, but also add to people's desire for merchandise.
In Japan, where I lived, worked, and studied for four years, they have perfected this process; in the development of an animated TV series or video game, for example, there is a large focus on creating high-quality characters (simple, highly graphic, and visually appealing) that can cross over into other media, produce spin-offs, and be featured on merchandise. This ends up generating far more profits than the sales of the original product. I think that many American video game companies do not appreciate the importance and potential of high-quality, appealing characters.
In terms of platforms, our game is planned to be released for the iPhone/iPod Touch, but could easily be ported to the iPad, which is number one on our list. If successful, it could also be ported to the Android. In addition, we would like to make it playable on PCs and Macs, though without the touch-screen, gameplay might take a little reworking.
...So, how does that sound? Thanks in advance for any feedback.
(The game I am talking about is actually an active project on Kickstarter right now, with one day left to go. You can see it here: http://www.kickstarter.com/projects/bts/cafe-murder) <comment><USER2> You do not have access to the channels which make e.g. Naruto a cross-platform megasuccess that captures the mind of half a generation. I would suggest unlockable premium content instead.

<comment><AUTHOR> I don't expect to jump straight to the level of Japanese corporate networks, but it's an area that deserves further exploration. I think that the "cross- platform mega-success" and "merchandise of awesome characters" model can be used at lower levels, too.

<comment><USER2> I wish you every success, but think that you're running a business model based on three unlikely events all resolving in your favor. (#1, game is a hit. #2, massive demand for goods. #3, you turn out to be good at merchandising.)

Any one of these propositions seems sufficiently challenging to focus on, to my point of view.

<comment><AUTHOR> I don't expect our first game to necessarily be a hit, but we'll be working towards what I explained above. It'll probably take time to build up to your 1, 2, and 3 (unless we get lucky and they all resolve in our favor).

</comment></comment></comment></comment><comment><USER3> The model you need to work is different from the freemium model, which says you earn money by getting people engaged enough to pay for upgrades. Here you want to make the game cool enough so that players want accessories to advertise their association with it. It sounds like more of an all-or-nothing proposition to me.

I don't think, pace _patio11_ , that the game needs to be blockbusters to generate decent revenue, but you do need your players to feel that they belong to a community of gamers. I have the impression that merchandising generates decent revenues for some B-list webcomics: you might contact some of these to learn about their experiences. Who knows, maybe you can have your game characters appear as guests in their webcomics and vice versa?

I think being a startup has advantages here, since startups are cooler than corporations.

<comment><AUTHOR> Contacting webcomics was a good idea; thanks. I have already been thinking about cross-promotion through webcomics, too.

It is kind of an all-or-nothing proposition. We just have to hit that sweet spot of a really cool product/game/characters.

And I agree that being a "cool start-up" has some advantage over corporations, too.

<comment><USER4> _We just have to hit that sweet spot of a really cool product/game/characters._

Sounds like you're banking on winning the lottery. If you want to be a world famous creator of this, then that's what you should aim for. However if you want to run a business, and allow yourself to work full time on this, then you don't need to be a rock star. You can, in fact, support your business fulltime without having to 'strike gold'.

<comment><AUTHOR> Well, I didn't necessarily mean being a rock star or the next Angry Birds, but there is a general sweet spot of "cool, desirable product" that I want to hit.

You mean that with a good marketing strategy and a self-sustaining business model, we don't need to have "the next big thing" in order to support ourselves and do this full-time, right?

<comment><USER4> If you charge more than $1 you don't need to be the next big thing, since you need less customers.

I am a little confused by your question about marketing. Do you think marketing and a business model are optional? You aren't going to have a mega hit or a small successful business without marketing.

That doesn't mean you must act out scenes from Mad Men or do boring PowerPoint presentations, you can be unconventional, like notch's "oops my server is broke, everyone gets a free copy", or talking about your business model on HN.

<comment><AUTHOR> To clarify, I don't think marketing or a business model are optional, and I don't expect to have a hit or a small successful business without them. I would like to try something unconventional, so we'll see.

</comment></comment></comment></comment></comment></comment><comment><USER5> is there a way you can enter the users iphone from outside the App Store? If such a hack exists you can price your game say only 50 cents (for some limited levels) so that Apple gets to keep only 15 and open up the remaining levels or in game merchandise by charging the remaining 50 cents after the game has been downloaded. So in effect you can keep 85 cents of the dollar instead of 70 through a bullet subscription...

<comment><AUTHOR> Well, games can't be priced less than 50 cents. What you're suggesting seems to be strictly prohibited by Apple, so that developers can't get around it. They always get 30%, it seems.

</comment></comment><comment><USER6> What's the marketing plan?

<comment><AUTHOR> Still working on that, but making a really fun game seems more important than anything else, since popular iPhone games spread quickly by word of mouth and social networks.

<comment><USER4> _making a really fun game seems more important than anything else_

Really? That's a very rosy-eyed view of the gaming world. "If you build it, they will come"?

<comment><AUTHOR> Do you know any small indie games that succeeded because of an amazing marketing strategy and NOT because of word-of-mouth/social media and the fact that their game is really, really fun?

<comment><USER4> Social media _is_ a marketing strategy. For popular start up game, I'd offer Nashville.

<comment><USER4> The should obviously be "Farmville". Damn you autocorrect.</comment></comment></comment></comment></comment></comment>


Using Pattern Matching in F# – if/else on steroids - <AUTHOR> http://blog.cleartax.in/safer-programming-with-fsharp-pattern-matching/

<comment><AUTHOR> We'd be super stoked to be able to target iOS and Android via F# if that happens with .NET getting open sourced!

We use F# for a fairly large production service, and we'll hang around here answering questions if you have any.

<comment><USER2> Awesome! Great to see more examples of F# being used in production. Have you considered submitting a testimonial to [http://fsharp.org/testimonials/](http://fsharp.org/testimonials/) ?

You can actually target iOS and Android today with F#, via Xamarin Studio, but today's announcements definitely open up even further potential.

<comment><AUTHOR> I'll submit a testimonial - thanks for telling me.

Interesting, we haven't played around with Xamarin studio and F# yet.</comment></comment></comment>


Thanks HN: Goodbye, Golden Handcuffs - <AUTHOR>

I'm a YC '08 Reject underwhelmed by my safe, boring corporate gig.  Regular scans of HN remind me of the excellent things happening elsewhere.  I was particularly struck by the theory that the best example you can set for your kids (0 so far) is to pursue your dreams, not an income.
I quit today, bought the supportive girlfriend a ring, and will start January 2011 as my own boss.  I'm giving myself six months to bootstrap.  Thought you should be the first to know.
Let the fun begin. <comment><USER2> Congratulations on making the most important decision of your life and, secondarily, on opening the business. Words cannot express how much better self-employment is than what I used to do for a living.

<comment><USER3> Well, it's only good if it's making you money...

<comment><USER4> Not necessarily. Neither of the sites that have done the most for my quality of life have ever brought in much in the way of direct income. They have, however, put me out there as a guy who's capable of building products like that, which have led to some really good consulting gigs, thus allowing me to keep traveling the world and doing my thing from a laptop.

So even though it was _years_ before I hit on the first product that generated significant income on its own, there was still a net benefit from having put out my shingle right from the start.

<comment><USER5> _They have, however, put me out there as a guy who's capable of building products like that, which have led to some really good consulting gigs, thus allowing me to keep traveling the world and doing my thing from a laptop._

So indirectly _it's only good if it's making you money..._

:)

</comment></comment></comment></comment><comment><USER6> jriley: Email me firstname.lastname@example.com -- You just got free Mixpanel, good luck when you launch we're here to help.

<comment><USER7> This is some of the best and most simplistic advertising and pr I've seen in a while. I've heard of mix panel probably 50 times but this was the first time I clicked through your website to see what you guys are all about.

Nice product by the way.

<comment><USER8> ha me too

</comment></comment></comment><comment><USER9> > _Thought you should be the first to know._

Good and good luck. Now please tell your fiancée!

</comment><comment><USER10> If I have two pieces of advice I can share,

1\. Pick up some contract work - you can easily turn 6 mths into 12 mths, and then 2 years, then 3...no matter how many projects fail to get off the ground, if you have a bit of side income, it'll help in the long run.

2\. Don't ever forget why you quit - if that is to "pursue your dreams, not an income". Write it on a wall above your monitors and don't ever forget it.

EDIT: Oh, and good luck! :)

<comment><USER11> Be careful with contract work though, it's very easy to fall into the trap of taking on too much and pushing back your own project...

Contract work can be worse golden handcuffs than a job in corporate

<comment><USER12> It beats personal bankruptcy hands down though.

</comment></comment></comment><comment><USER13>
      Once you have mastered time, you will understand how
      true it is that most people overestimate what they can
      accomplish in a year - and underestimate what they can
      achieve in a decade.

      -Tony Robbins

<comment><USER14> How do you master time?

</comment></comment><comment><USER15> _Let the [work] begin._

FTFY I hope you're prepared to work at least five times harder than you did at your safe job, and for little to no guaranteed reward. Actually, if you're only giving yourself six months, make that ten times harder. I would say good luck, but considering around 90% of startups fail, work hard, be persistent and expect difficulty, seems more helpful to say. The success stories appearing on HN can give a skewed impression on how hard it is to succeed. Congratulations, though, for bucking a potential path of regrets.

Edit: A bit more advice is release early, and often. The trick is finding the balance between minimum viability and having enough value for traction. Iterating on an idea is almost always necessary, so be on the lookout for how that can help and possibly even save your endeavor. A six month deadline to succeed means you're really going to be up against it.

<comment><USER16> The comments and/or advice you're giving (and the tone you're using) are the type of things you say to someone before they decide to make the jump if you want them to think long and hard before making a tough decision. When you say it like this to someone who is announcing that his decision is made, you just sound condescending. It doesn't help that you throw in a bunch of advice when you don't even know who he is, what his company/product is about, or what his plan is.

<comment><USER15> I don't mean to sound condescending. I can't help the timing of the decision, either. I'm also guessing he's read HN enough to have more than my comments to weigh for various perceptions of a startup. To my knowledge the failure rate of startups is around 90% (not my doing). In light of that, I felt the best thing I could do if I wanted to truly help, which I do, is try and foster a tough, ready for battle mental mindset. His announcement seemed a bit cheery and optimistic, and I wanted to suggest that, realistically, the road to startup success is not usually a cakewalk. HN is largely a startup community, so I figured others might find value in my comments as well, and if such comments harm his enthusiasm, and are more destructive than constructive then, IMO, he's quite likely to end up in the 90%.

</comment></comment></comment><comment><USER17> Relevant: <http://www.youtube.com/watch?v=jwG_qR6XmDQ>

Rumor is that the "boss" was actually David E. Shaw himself.

<comment><USER18> I already regret not learning serious hacking in high school and university.

I got lots of A's (and B's), mind you, and I did work on projects of my own and everything, but I really saw it as just a hobby. I was always on windows, mostly dependent an IDEs, and I always thought I gotta be doing something more serious, like _gasp_ oil and gas.

Good thing I'm still 25.

But I really feel like I should've started thinking about doing a startup when I was 18 or 20.

<comment><USER19> I am 41 with a product to be launched soon. It is never too late.

</comment></comment></comment><comment><USER20> You might need a lot more than 6 months. But, like my wife always tells me, you don't fail as an entrepreneur until you quit. And the ride is sure worth it. Life is short.

<comment><USER21> >you don't fail as an entrepreneur until you quit.

I'm not experienced in it, but I imagine that one can fail as an entrepreneur _because_ you didn't quit.

Flogging dead horses and all.

</comment></comment><comment><USER22> It'll be a tough and long road, but if you're really set on it, you'll be happier than ever. Good luck, man.

</comment><comment><USER23> Good luck! One odd piece of advice I have is to recommend limiting the amount of startup advice you read online. It's too generic now that you've committed. Focus on what you're creating, not on making your venture look like the internet's current concept of "startup". Look, for example, at the popular phrase "Minimum Viable Product". You'll find a lot of excitement around the "minimum" part, but the "viable" part matters also and is fully dependent on what you're doing. There are many things that are unique about individual businesses, but generic online advice by necessity exaggerates the shared aspects.

</comment><comment><USER24> Dear fellow HNer,

This is to help you when you visit this page again in a difficult time...

Shit happens... thats completely normal. Awesome things will definitely come your way. You only gotta do one simple thing...

Keep swinging!.. Don't ever give up!

Tattoo this on the back of your hand if you want... it's totally worth the trouble.

With the very best of luck,

SeeJay

PS: And thank me on that day when you read this post again with joy... Oh just for the record, No! I don't have it tattooed on the back of my hand... I make sure I have it on my mind instead. ;-)

</comment><comment><USER25> Congrats :)

If you're in SF, let me know

We have a sweet co-working space for hackers with all of the three C's: coffee, camaraderie, and a fast connection

<comment><AUTHOR> Appreciate it. I'm actually in Austin though, and eager to meet some like- minded folks. I'll be checking out the local bootstrap chapter to start.

<comment><USER26> I can speak from experience when I say that Austin's entrepreneurial community is welcoming, supportive, and full of very sharp folks. You should definitely check out the Lean Startup group (<http://www.meetup.com/Austin-Lean-Startup- Circle/>). Our next meetup is a joint holiday mixer with a lot of other Austin groups (like Austin on Rails), and it promises to be a great way to meet a ton of folks.

Also, I'm not sure if you're looking for a workspace with a lot of people in the same position, but we've really benefited from participation in the Austin Technology Incubator.

Edit: why do I say folks so much?

<comment><USER27> How big is the Austin startup community? Austin seems like a hell of a lot nicer place to live than the Bay Area, but I'm afraid I'd miss the incredible magnitude of the support available to startups here.

</comment></comment></comment></comment><comment><USER28> What are you planning to work on?

<comment><AUTHOR> The original project exists in working order and my partners agreed to let me buy their share. I'll be building out v2 as we designed. We all took 2 weeks off in 2007 to build it, launched it, and hardly ever touched it again. v2 carries it to iPhone, iPad and starts marketing it.

If I have ambition after that I've got a few quick ideas (a short e-book on an area I've developed expertise, an obscure niche how-to site, fixing up my rental property, etc).

<comment><USER29> Well, good luck.

Do not necessarily do one project at a time though. Keep a list of things you want to work on. Whenever you find yourself needing to take a break from the main project, chip away at one of the secondary projects.

You might be surprised to find the idea you deem least important actually giving you the biggest payoff.

</comment></comment></comment><comment><USER30> Firstly...let me say...Congrats.

Secondly, brilliant that you made sure to lock in the girlfriend at the beginning of the journey, not after you started when she realizes what a crazy person you are - and how crappy the emotional roller coaster will be. :)

Thirdly, I wish you all the best. I would recommend that you quickly setup a landing page to ride the support you are getting from the community - collecting emails from people interested in what you are doing. You have to take advantage of all of these opportunities right now, because you officially have a clock strapped to your back (i.e. before you run out of money). So leverage every opportunity to the most you can. On the landing page, put something about the project that people can figure out if they would be interested or not.

Fourthly, definitely keep us posted - even those that might not be interested in your product, will be inspired by your story.

</comment><comment><USER31> 6 mos ain't enough, but otherwise, great idea.

<comment><USER32> Then again, no matter how much time you give yourself, you will find a way to fill it up. Maybe an unrealistic goal is for the best: it might increase productivity, even if it slips.

<comment><USER33> <http://en.wikipedia.org/wiki/Parkinson%27s_Law>

<comment><USER32> Thanks. I forgot the name when posting this.

</comment></comment></comment></comment><comment><USER34> "the best example you can set for your kids ... is to pursue your dreams, not an income"

My father did this, in several ways, and failed massively at all of them, and yet for reasons I can't really articulate I 100% agree with this.

</comment><comment><USER35> I still a student but I'm building my small Internet Empire, so that I don't need to apply for a job when I finish studies (or better, don't think about it). I completed around 35% of my studies and yet, this month, made (around $400) what an Engineer would make in my area.

I'm enthusiastic about the future, especially the next month, when I'll release my Wordpress Premium plugin (and estimate $1K in sales in one month).

Even if you have a nice job, make sure you always have an alternative, in case of... you don't get sucked, by anyone.

</comment><comment><USER36> jriley: Email me firstname.lastname@example.com Would love to intro you to someone you should meet in Austin.

</comment><comment><USER37> This is the best thing you will ever do.

You will look back at this moment and realize it is the defining moment in your life.

</comment><comment><USER38> _Godspeed!_

</comment><comment><USER39> When I kicked off my startup in Jan 2010 I thought in 6 months the bootstrap period will come to an end. Now 12 months into it and still some more time needed. My advice check on the six month bootstrap timing you plan, might be a little short.

</comment><comment><USER40> Glad to hear this kind of stuff. Your words encourage me to do the exact same thing.

</comment><comment><USER41> Congratulations, jriley on not one, but two monumental decisions. The ring for your girlfriend should turn out to be a contribution to your success equal to your decision to leave your job. Good luck to you both!

</comment><comment><USER42> I just did the same thing, albeit - I only gave myself 6 weeks to make acceptable progress on something (anything) before I start working full time again. It's my mental safeguard against procrastination.

</comment><comment><USER43> this is a great way to go.

i left my job with no savings and intending to do the same thing, because i was just not happy with my position at my new employer.

within three months i was completely broke, but with a github account with hundreds of commits.. and then my old boss from my second-to-last job called, and offered me job back, at a huge raise, and allowing me to work remotely, and pursue my own codebase/startup dream on the side.

quitting for the right reasons can have wonderful side benefits. :)

</comment><comment><USER44> Wonderful! Wish you a ton of good luck!

      >>underwhelmed by my safe, boring corporate gig
      I know how it feels! :( And am yet to break those handcuffs.

</comment><comment><USER45> Best of luck, very envious over here!

Do you have a blog?

<comment><AUTHOR> Thanks, no blog yet. Plan to start and post as I learn (Austin places to work/meet, local grants and SBA loans, best library for tech books, etc).

</comment></comment><comment><USER46> Your account is less than an hour old. Did you create a new one since applying to YC in 08?

<comment><AUTHOR> Yes, just created this account. I never posted on the old account, just read.

</comment></comment><comment><USER47> how much cash do you have in savings? i'm thinking of doing the same thing.

<comment><AUTHOR> Living Fat = 3 months, Living Lean = 12+ months. I'll use my 401k but not Roth IRA. Also have some equity/cashflow from a duplex that helps. FWIW, I woke up this morning feeling great on 4 hrs sleep and not worried about money at all - the prior six months mornings were filled with worry and dread.

<comment><USER48> Good for you man, I did the same about a month ago. Amazing how hard I found getting rid of the golden handcuffs.

</comment></comment></comment><comment><USER49> Congrats! Reread pg's essays on how to startup etc ... As u read them this time around, the words will prtain to your immediate situation and will help unwhen things look bleak.

Best of luck.

</comment><comment><USER50> Good deal, I am happy for you! Get some stuff done.

</comment><comment><USER51> Best of luck! If things look grim, don't give in.

</comment><comment><USER52> Good luck and do let us know how it goes!!

</comment><comment><USER53> You only live once!

</comment><comment><USER54> Good luck!

</comment><comment><USER55> Good luck!

</comment><comment><USER56> +1

<comment><USER55> You took a few downvotes from a faux pas; don't worry about it, but keep in mind that here, we just upvote the original post for a direct "+1".</comment></comment>


The cold fusion testing team, real or ringers? - <AUTHOR> http://www.forbes.com/sites/markgibbs/2013/05/24/the-e-cat-testing-team-real-or-ringers/

<comment><AUTHOR> I was surprised to find that it's a somewhat diverse team with a fair amount to lose if the paper turns out to be a fraud.

This leaves the last two possibilities:

\- Rossi was somehow able to hoodwink fairly capable scientists (inject extra power into the E-Cat without them noticing),

\- or he's actually built something interesting.

</comment><comment><USER2> here is what I want to see. A double-blind experiment, where the suppliers provide the E-cat, sealed if need be. The testers will randomly supply the E-cat with either hydrogen gas (H2) or deuterium gas (D2), or deuterium hydride (DH). The magnitude of the measurable difference should suggest the likelihood of the process being nuclear.</comment>


Show HN: Our new – decidedly Nordic – brand - <AUTHOR> https://memory.ai/blog/introducing-our-new-brand <comment><AUTHOR> We've completely redesigned our entire visual language — from logos, colors, icons and typography. It unifies everything we currently do at Memory and sets the stage for what's coming next. Bold, unique and decidedly nordic, this is our new brand and logo.

What do you think?</comment>