After Surgery, Surprise $117,000 Medical Bill from Doctor He Didn't Know - <AUTHOR> http://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html <comment><USER2> Health care -- where Libertarian, free-market ideology goes to die.

The free market simply doesn't work when there is zero price transparency, 3rd parties are often responsible for payment, and purchasers are often in great distress right when they need to be able to negotiate.

Laissez faire market philosophy fails in this case for the same reason it fails during major crises and disasters. Purchasers are nearly powerless but have needs that they must meet immediately; vendors can price-gauge and make out like bandits. A climate of scarcity and desperation prevail over hypothetical rational actors participating in a stable market at equilibrium.

<comment><USER3> There is no free market here.

This isn't a price transparency thing either. This is about having created a culture where every doctor in the country is constantly hustling, committing borderline fraud.

Sociologically, the idea that doctors and medical care workers are always looking out for what's best for their patients helps to mask the idea that they might be doing so from a health perspective but are ignoring any other consideration. And so bringing in a friend who's also a surgeon so he can get a little kickback doesn't really raise any ethical alarms.

But this isn't the fault of the libertarians.

Government has meddled in this industry and even with the ideas that the typical Americans think about for so long that this was inevitable. Nor can government fix it now... the AMA and other quasi-unions won't stand for it. They'll negotiate.

And, as usual, our politicians will sell us down the river.

If you want to fix this (and every other problem), the answer is simple (though not particularly libertarian): outlaw all health insurance. Make everyone pay for their own care. Make them pay out of pocket.

In such a nation at that, none of these shenanigans could continue. Not that I expect anyone reading this to get it. You cry "But NoMoreNicksLeft, how could that man afford $117,000 out of pocket!"

And the answer is that he couldn't. The doctor (if he billed after the fact) might sue, but winning a lawsuit doesn't make someone magically capable of paying. If the doctor insisted on payment up front, then the man would just forgo his particular service (which, since he was unaware that he needed it and it sound like bullshit... wouldn't have mattered).

There aren't enough rich people who can afford to pay the current prices out of pocket for 100% of the doctors to continue to bill/earn what they do currently. Maybe just enough for 1% to continue like that... the other 99% are going to have to shape up, and in a hurry.

They can't hold out prices where they are now (we can't pay that out of pocket), nor can they spitefully punish us and refuse to do it at lower prices. They have bills to pay just like the rest of us, they have mortgages, they need to buy groceries, etc.

Nor will they decide to become plumbers and HVAC repairmen so that they don't have to give away their surgeries for less.

But again, this is lost on anyone I've ever explained it to. You all think it will result in millions of deaths and untold suffering.

> Laissez faire market philosophy fails

Bullshit. There hasn't been a laissez fair in the healthcare industry in the United States in 100 years.

<comment><USER2> > Bullshit. There hasn't been a laissez fair in the healthcare industry in the > United States in 100 years.

True. But why did health care turn away from a completely free-market approach? Why does almost every other industrialized society now support some sort of single-payer system, at least for those who cannot afford private boutique care?

The answer is simple: as a society, we do not accept the results of a truly free-market health care system. 100 years ago, it was accepted that you could become ill at any point in your life, and very possibly die. Being rich was not really a lifesaver, because many if not most major disease categories were at that time untreatable, or the treatments available were palliative at best.

Now, we live in a world where we all know fully well that with enough access, many medical situations that used to be fatal are now treatable with excellent chances of full or near-full recovery. Steve Jobs gets a liver; Dick Cheney gets a heart. My wife's uncle just died of a heart condition similar to Cheney's. Somehow, there was no transplant available for him.

In this world, most people find it unacceptable that your health outcome is directly related to your wealth and social status. The world you suggest -- where everyone simply pays out of pocket -- would be socially regressive in a way that I believe is abhorrent to most civilized people, with the glaring exception of around 50% of the US voting public.

Insurance was developed as a reasonable fair-market way to ameliorate this issue of health care access disparity. If you can afford insurance -- in the US, this typically was through getting a decent job that provided a large risk pool and could therefore negotiate reasonable premiums -- you could at least theoretically rest assured that a major medical crisis would not totally bankrupt you.

But for those outside of the pool of large employers, the insurance companies started doing bad stuff (from a customer's POV) -- dropping the sick, refusing to cover previous conditions etc. In their defense, insurers had the problem that without some sort of mandate, people could just go uninsured until they got sick. So the individual market was destined to be over-represented by older, sicker people.

If you really believe in laissez faire, free-market medicine, you (as a society) have to accept the following:

* People who treat themselves like shit for years and get sick (obesity-related diabetes is a great example) can simply drop dead if they can't afford expensive care and medication.

* If some idiot on a motorcycle without a helmet spins out and breaks their skull, and is not rich, shovel his body to the side of the road, wait for him to die, and call sanitation to remove the body

* If your parents get old and sick, and they fucked up their retirement planning, slip them some clonazepam or watch them wither away painfully over a period of months or years. Be prepared for someone in the family to quit their job and become a nurse, or let Grandma wander around until she falls down and hopefully dies on the spot.

That was basically where everyone was throughout most of history. Only difference is, now we know it can be better. But in a ruthlessly free-market society, only the rich and well-connected would ever have a chance of getting the best possible care.

<comment><USER4> Healthcare didn't voluntarily turn away from a market approach. The US Government invaded the industry in a massive way and began manipulating and regulating it from top to bottom. That has only gotten worse over time.

<comment><USER5> Amen. The collective argument behind our current system forgets the history, namely that our current backasswards way of paying for healthcare originates with a reaction to wage controls during WW2.

</comment></comment></comment></comment></comment><comment><USER6> Ugh. Got hit by this. My insurance company listed a hospital as covered. I took my daughter to the ED...then got a $400 bill in the mail for a physician we saw for 2 minutes. The rest of the visit was covered. He wasn't. Apparently all doctors who work for the hospital are covered by the insurance...but he was a visiting physician. I hate health insurance.

</comment><comment><USER7> There are a lot of really interesting things happening that this article looks at from exactly one angle -- the billing. What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers.

For example, Medicare would have paid only 1% for the assistant's work; that's the market rate that they set. This has all sorts of implications... I assume doctors must have some reason to accept those rates, other than out of some ethical responsibility. It sounds like private insurers are hugely subsidizing Medicare by paying 100x the price. If everyone paid the same rate, Medicare would have to pay a lot more, or there would be a lot less of these procedures.

On the other hand, anyone who actually pays that list price is giving the doctor a gift. If they explained the median price patients pay the doctor out- of-pocket, I wonder if the examples would line up.

It is interesting to read about some patients who went to extraordinary means to discover ahead of time what their costs would be, only to be basically assaulted with an outrageous bill in the end. For a _planned procedure_ and even for an emergency, I think the doctor performing the work should find a way to work with their patient's insurance plan. And insurance plans should have reasonable coverage and customary payment terms which are accepted. The doctors shouldn't get to fleece the insurance companies either.

The level of price discrimination is completely out of control, but I think the legal framework is in place, right now, to protect patients and insurers both from these bills. It's a tax on the rich and middle class, since the doctors collect some small fraction of total billings. It's like a lose-lose double lottery.

<comment><USER8> "What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers."

Steven Brill, in Time, wrote an excellent article on just that topic. The subscriber access is at [http://time.com/198/bitter-pill-why-medical-bills- are-killin...](http://time.com/198/bitter-pill-why-medical-bills-are-killing- us/) while a no cost version is at [http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,Medical...](http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf) .

See also an interview with him at [http://www.pbs.org/newshour/bb/health-jan- june13-healthcare_...](http://www.pbs.org/newshour/bb/health-jan- june13-healthcare_02-25/) .

Brill's thesis is that with most medical care it is impossible to do the comparison shopping that you emphasize should be possible "even in an emergency."

You hypothesize that "private insurers are hugely subsidizing Medicare by paying 100x the price." As [http://www.medscape.com/viewarticle/521175_2](http://www.medscape.com/viewarticle/521175_2) comments, "U.S. hospitals now receive abut [sic] 31 percent of their net revenues from Medicare." Moreover, if you start to read about the US system you would realize that Medicare is prevented, by US law, from negotiating drug prices. Private insurers, on the other hand, can do so. The Brill piece covers that detail. Since your hypothesis doesn't match reality, it must be incorrect.

I am not well informed of this topic, and my knowledge is mostly limited to the popular press. I cannot therefore point to any critical research. There was a recent posting here on HN, at [https://news.ycombinator.com/item?id=8304019](https://news.ycombinator.com/item?id=8304019) , concerning "The Cost of My Mother's Cardiac Care in the United States and India."

The actual article is at [http://www.annfammed.org/content/12/5/470.long](http://www.annfammed.org/content/12/5/470.long) , which starts "When my mother fell ill while visiting me in the United States, I had the opportunity to compare costs of surgical cardiac care in the United States and India. I faced challenges in making well-informed decisions in the United States due to the lack of cost transparency and the minimal flexibility offered in choice of care, whereas in India costs are readily available and allow most people to freely choose their preferred type of care."

It sounds like you are saying that NYT should, in every piece about a topic, give the full details to justify its arguments. That's not how newspapers work. They often give many different pieces; some of which examine the situation, and others which help flesh out details. This is one of the latter. You are supposed to read the newspaper over time to get a better sense of the whole.

Otherwise, you need to look towards the specialist literature, like review papers on the economics of the US health system, to get the answers you're looking for.

BTW, you like the word "should" \- you used it three times. The many observations show that the US health care system isn't the way you think it should be. There is no legal framework like what you asserted. This suggests you are basing your opinions more on wishful thinking, rather than trying to understand what is actually a quite complex and well-discussed issue. I hope those links I gave help provide a beginning for you.

<comment><USER7> In the article they cite an example where private insurance paid 100x the Medicare rate. That's not to say private insurers pay, overall, 100x the Medicare rate. It's closer to 2x per procedure in the aggregate. I don't understand why a private insurer would _ever_ pay 100x the Medicare rate in any case.

The article went on to say how Dr. Mu, despite his title as Chief of Neurosurgery, does "probably not very lucrative" work due to low Medicaid rates. So this is a case where private insurance is subsidizing the public system.

Cost shifting is well known in the industry. The 30% of the revenue paid by Medicare corresponds to significantly more than 30% of the services/cost. Operating a hospital is analogous to operating an airline, where you can sell 30% of seats at a price that would be grossly unprofitable if the whole plane sold that way. My hypothesis is that as more care becomes public, the price per procedure that Medicare (or whatever it's called then) will be dramatically higher, because there won't be anyone left to shift the costs onto.

I was able to find some data which demonstrates this; 'Aggregate Hospital Payment-to-Cost Ratios for Private Payers, Medicare, and Medicaid, 1992 - 2012' \- [http://www.aha.org/research/reports/tw/chartbook/2014/chart4...](http://www.aha.org/research/reports/tw/chartbook/2014/chart4-6.pdf). There's a subtle point that this data hides, that the article shows, which is although private payments exceed costs, in aggregate, by ~150%, the billing is highly selective. So some private payers may pay close to the Medicare rate (85% of cost) where some private payers are paying 10,000% the cost, like in the case in the article with Dr. Mu.

It's exactly this highly selective billing which I think people _should_ be protected from. Both from an Dr/ethical standpoint, to the necessary legislation which could more clearly protect against this, rather than relying on more general statutes.

I don't really care to discuss "how newspapers work" but I do think while NYT is trying to tell a story about an industry, all I hear is anecdotes. Anecdotes are important, but in a story about industry billing practices, I also need to know if these anecdotes are crazy outliers, or everyday occurrences. You need to anchor your anecdotes with something if you want to tell a story bigger than the anecdote -- I think that's basic reporting, but yes, perhaps too much to expect.

<comment><USER8> "They cite an example where private insurance paid 100x the Medicare rate"

Is that the line "If the surgery had been for a Medicare patient, the assistant would have been permitted to bill only 16 percent of the primary surgeon's fee"?

If so, Dr. Mu received the $117,000 as a private check from Mr. Drier, and not from a private insurance company. There's nothing which says that Dr. Mu wouldn't have accepted the lower Medicare rate, or that someone else would have been the assistant if Dr. Mu's primary interest was the extra income, or that a private insurance company would had other preconditions in place to prevent a $117,000 bill. It's hard to have an idea in part because Dr. Mu did not respond.

The only other 100x I can find is the out-of-network vs. in-network bills for a muscle and skin graft. But that's not the Medicare rate.

"Probably not very lucrative" is quite far from "subsidizing the public system." If the doctor makes $120K/year with Medicare patients only, and $500K/year with only non-Medicare patients, and the hospital is profitable both ways, then where's the subsidy? While an extra $380K/year is very lucrative.

If what you are saying is true, then there should be a mass wave of hospitals and doctors which don't accept Medicare. While some hospitals and clinics don't accept Medicare, they are relatively few. In fact, hospitals and medical centers will advertise that they accept Medicare. For example, this billboard for a clinic - [http://www.yourwestvalley.com/topstory/article_73ac64db- fc44...](http://www.yourwestvalley.com/topstory/article_73ac64db- fc44-5574-8c2e-cd66059bfa6f.html?mode=image&photo=0) .

It's very hard for me to accept that the payment-to-cost ratio chart you linked to is meaningful. That appears to be the average cost across everyone. A better chart would be the cost of Medicare treatment vs. the reimbursement by Medicare, and the same for the private insurers. Otherwise, this could be showing that Medicare does a better job of cost containment than private insurers, so that private insurers end up paying for more medically needless but profitable procedures than Medicare. (For example, [http://content.healthaffairs.org/content/22/2/230.full](http://content.healthaffairs.org/content/22/2/230.full) argues that Medicare is better at cost containment than private insurers.)

Instead, I find papers like "How Much Do Hospitals Cost Shift? A Review of the Evidence" at [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160596/](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160596/) more persuasive than that chart.

> Most of the analyses and commentary based on descriptive, industrywide > hospital payment-to-cost margins by payer provide a false impression that > cost shifting is a large and pervasive phenomenon. More careful theoretical > and empirical examinations suggest that cost shifting can and has occurred, > but usually at a relatively low rate. Margin changes also are strongly > influenced by the evolution of hospital and health plan market structures > and changes in underlying costs.

Regarding newspapers, I'm saying that you are getting peeved because you don't understand how newspapers work. The old phrases are "if it bleeds, it leads" and "When a dog bites a man, that is not news, because it happens so often. But if a man bites a dog, that is news." and "You never read about a plane that did not crash."

People read a newspaper in part because they want crazy outliers. The good papers try to fit it in a larger context, biased of course by the overall ideology of the editors and writers. (Eg, the WSJ is pro-market.) But complaining about the lack of complete context and details in a newspaper article is like complaining that the sky is blue.

<comment><USER7> Dr. Mu _did not_ received the $117,000 as a private check from Mr Drier.

"When Mr. Drier complained to his insurer, Anthem Blue Cross Blue Shield, that he should not have to pay the out-of-network assistant surgeon, Anthem agreed it was not his responsibility. Instead, the company cut a check to Dr. Mu for $116,862, the full amount."

"If the surgery had been for a Medicare patient, the assistant would have been permitted to bill only 16 percent of the primary surgeon's fee. With current Medicare rates, that would have been about $800, less than 1 percent of what Dr. Mu was paid."

So at least we should agree that this is a perfect example of cost shifting / price gauging.

> If the doctor makes $120K/year with Medicare patients only, and $500K/year > with only non-Medicare patients, and the hospital is profitable both ways, > then where's the subsidy? While an extra $380K/year is very lucrative. If > what you are saying is true, then, there should be a mass wave of hospitals > and doctors which don't accept Medicare

Well, that's the very definition of subsidy, so I don't know quite how to respond. Where's the subsidy? Right there! Very few people become chief neurosurgeons for $120k per year. A lot more become chief neurosurgeons for $500k per year.

As I a said, running a hospital has massive fixed costs, so like an airline, taking on patients which pay 85% of cost is still better for the bottom line, as long as your hospital is running below capacity. So Medicare is an overall good deal for the hospital, even though it pays below cost, as long as it doesn't exceed a certain percentage of the overall patient population. If the patient population was entirely Medicare, then the hospital would _not be profitable_.

> "It's very hard for me to accept that the payment-to-cost ratio chart you > linked to is meaningful. That appears to be the average cost across > everyone. A better chart would be the cost of Medicare treatment vs. the > reimbursement by Medicare, and the same for the private insurers."

The better chart you ask for--the cost of Medicare treatment vs. the reimbursement by Medicare, and the same for the private insurers--is exactly what this chart shows. It shows separately for Medicare, Medicaid, and Private Insurance, what percent of the cost of the procedures is actually paid. Medicare has lately been covering 89% of costs, while private insurance has ballooned to 150% of cost. Here's the full set of charts; [http://www.aha.org/research/reports/tw/chartbook/ch4.shtml](http://www.aha.org/research/reports/tw/chartbook/ch4.shtml)

> Otherwise, this could be showing that Medicare does a better job of cost > containment than private insurers, so that private insurers end up paying > for more medically needless but profitable procedures than Medicare.

Quite clearly Medicare does a fantastic job of containing _its_ costs. You can strike the "medically needless" part from that, since I think it's unsupported. Private insurers absolutely pay for more profitable procedures, as indicated by the chart; private insurance pays 150% of cost overall. But obviously ACA legislation setting a lower payment rate does not inherently make the procedures being paid for actually cost less to perform. But it does certainly force the hospital to search for ways to make up the difference.

> Instead, I find papers like "How Much Do Hospitals Cost Shift? A Review of > the Evidence

I'm somewhat confused by this paper, since it reads like an op-ed. After a bit a searching, it appears Frakt has quite a few editorials claiming hospitals lack the market power to meaningfully shift costs to private insurers, despite abundant and uncontroversial data showing Medicare pays below cost.

Frakt himself has the following to say, quite amusingly, in a editorial titled 'The End of Hospital Cost Shifting and the Quest for Hospital Productivity';

"The ACA will permanently reduce the Medicare payments hospitals would otherwise receive. Its 'productivity adjustment' will scale payments downward by the average rate at which private nonfarm businesses' productivity increases. That rate has been estimated to be 1.1 percentage points per year…Actuaries for [CMS] have estimated that by year 2040, Medicare payment rates to hospitals will be half those of the commercial market, and lower still thereafter."

That's _payments rates_ not total payments. I trust the CMS to know exactly how much it's underpaying. [http://www.cms.gov/Research-Statistics-Data-and- Systems/Stat...](http://www.cms.gov/Research-Statistics-Data-and- Systems/Statistics-Trends-and- Reports/ReportsTrustFunds/downloads/2011TRAlternativeScenario.pdf)

I didn't know that the ACA puts downward pressure on rates equal to the average rate at which private nonfarm business productivity increases. Since that productivity rate increases significantly higher than the historical productivity gains in _healthcare_ , and is expected to do so for some time, CMS states this will require new legislation to fix, or else payment rates will be so low as to significantly effect availability and quality of services. That's pretty scary, to have built a failure mode like that into the system.

<comment><USER8> "Dr. Mu did not received the $117,000 as a private check from Mr Drier."

You are correct. I misread it.

I agree that it's price gouging.

"that's the very definition of subsidy,"

A broad definition of subsidy could include a bribe. For example, one interpretation is that people won't become chief neurosurgeons unless you bribe them. In any case, it was an example to illustrate the difference between subsidize and not very lucrative. I'll change the numbers to $500,000 with only Medicare patients (this is about what they make in the UK, so surely enough that people will decide to be chief neurosurgeons) and $3,000,000 with only non-Medicare patients - a very lucrative income indeed.

I see that part of my confusion in understanding the topic is that there are multiple definitions of "cost-shift". In economics - I earlier quoted from an economics paper - it's a "dynamic response by hospitals to a reduction in Medicare payments, in the form of a fully or partially compensating increase in prices charged to private insurers. In the policy debate over Medicare payments, however, cost shifting is defined broadly as payments that fall short of the costs incurred by hospitals in the treatment of Medicare beneficiaries, as measured through negative hospital margins on those patients." (Quote from [http://content.healthaffairs.org/content/30/7/1265.long](http://content.healthaffairs.org/content/30/7/1265.long) )

I was talking about the former, which excludes price discrimination. The chart you link to shows the latter, which is a broader category. Indeed, the paper I just referenced, titled "Hospitals Respond To Medicare Payment Shortfalls By Both Shifting Costs And Cutting Them, Based On Market Concentration" goes into the details. It's quite a lovely paper.

> [Abstract:] The study presents empirical evidence that, faced with > shortfalls between Medicare payments and projected costs, hospitals in > concentrated markets focus on raising prices to private insurers, while > hospitals in competitive markets focus on cutting costs.

> ... Payment rates from Medicare to hospitals have lagged behind the growth > in hospital costs over recent years, leading to negative hospital profit > margins on publicly insured patients.1,2 These negative Medicare margins > have reignited the long-standing debate over whether the public insurance > program is partially responsible for the high prices charged to private > insurers, as hospitals seek to offset losses on one set of patients with > profits from another.3–7

> Recently, however, the Medicare Payment Advisory Commission (MedPAC) staff > has proposed an alternative explanation for negative Medicare margins, one > that reverses the direction of causality and interprets Medicare payment > slowdowns as a means toward the reduction of hospital costs rather than a > shifting of costs from public to private payers.8

As I understand it, the MedPAC model gives an explanation of why the chart you pointed out _isn 't_ an example of cost shifting in the economics sense of subsidy. The paper then assesses the viability of the two models and finds they are complementary strategies. The key factor to choose one over the other is the "degree of concentration or competition in the local hospital market."

I liked the observation about the non-economic factors that go into raising revenue rather than lowering cost:

> It generally is more desirable, from a hospital management perspective, to > increase revenues than to reduce costs, because the former merely alienates > insurers, but the latter alienates employees, physicians, and potential > patients. The cost-shift perspective highlights the revenue-enhancement > hospital response to Medicare payment shortfalls.

The economic model of Frakt and others, which says that in a competitive marketplace there is no cost-shifting in the subsidy sense is not new, so you needn't track down more from that author to investigate any specifically unusual personal bias. See for example [http://www.ebri.org/pdf/briefspdf/1296ib.pdf](http://www.ebri.org/pdf/briefspdf/1296ib.pdf) for a similar paper from 1996, which says:

"Rather than cost shifting [in the subsidy sense], the existing evidence points to hospital competition limiting the provider's ability to raise prices. Whatever market power hospitals once enjoyed is disappearing—and with it the ability to cost shift."

Under this model, the payment shortfall charts are actually a measure of how competitive the hospital environment is.

I read some of the CMS paper you linked to. It comments how "When the Medicare inpatient hospital prospective payment system was introduced in 1984, Congress applied reductions of 0.4 to 3.8 percentage points to the annual payment updates for most of the first 20 years of operation without causing hospital bankruptcies or withdrawal from the Medicare market."

I think that's a very good indicator, though perhaps not the best socially. I therefore think it's odd that they use "Hospitals have been pushing back in recent years against payment reductions aimed at further reducing inefficiency, a signal that much of the achievable gains may have already been made" as a more recent indicator. I know from the 1996 paper that there was a large debate on the topic already in the 1990s, so how does the Office of the Actuary judge if the pushback now is stronger and more meaningful then 20 years ago. Shouldn't they be using the same measure? Has there been an increase in the number withdrawals from the Medicare market?

In any case, I agree with the overall tone of the paper. I agree that there will have to be changes in the Medicare system some time in the next 50 years. I don't agree that the lack of a perpetually effective system is of great concern. If we could do that, we wouldn't need any legislative branch.

</comment></comment></comment></comment></comment></comment><comment><USER9> This almost feels like an Onion article where all the costs are multiplied by 20. What justifies such huge bills?

The article makes it sound like a doctor walked in to ask "How are you feeling?" and then charged $20,000 for doing so.

I've had a few private operations quoted in Australia and the full cost of the operation is usually in the $500-$2000 range. Even a pregnancy through a private hospital was quoted to us at about $4000. (Although we ended up having our first baby delivered for free through a public hospital, which was fantastic.)

<comment><USER10> >>doctor walked in to ask "How are you feeling?" and then charged $20,000 for doing so.

It would have happened, why would you doubt it?

It would have been like he was called in just in case any issue came up. The doctor walks in and asks the most obvious question to the patient "How are you feeling?".

The operation ends without needing any inputs from him. But regardless he would have billed the patient for his time.

The attitude is, he wouldn't have given any inputs but he did give them their time, _which would otherwise be used else where to make the same money_ so you have to pay even if the actual value added by him was zero.

<comment><USER9> I understand the doctor gave her time — that's fine. It's that the cost for that time seems ludicrous. As I said, the pricing seems multiplied by 20.

</comment></comment></comment><comment><USER11> By the way, in xUSSR free healthcare system multiple doctors _often_ discuss serious cases, unlike US. That's not something special for xUSSR doctors to discuss in a concilium complicated cases -- that's daily routine. That's their way to share expertise and improve professionally. In US you may have some chronic disease and one doctor would treat you as she/he believes is right, not discussing it with colleagues, and if you find another doctor, he/she might change the treatment, not even talking with previous doctor.

So it's kinda strange to hear from famous US people that they "found an awesome doctor". I would prefer to find an awesome clinic, and have multiple doctors to discuss my case. That happens, of course, but money keeps that from being natural routine here.

<comment><USER12> Being a son of a physician from former USSR country I can say with the certain degree of certainty that this is not true in our times: you are lucky not to die in a line of 67 patients before you see a doctor in a state clinic. Not mentioning the MRI or X-Rays where patients wait up to 3-4 months in lines in order to get simple diagnosis. Money gives you the ability to go to private clinics and have these things done faster, often by more professional specialists. Doctors in state clinics are underpaid, often unprofessional and with lack of experience (graduated students).

</comment></comment><comment><USER13> To fellow startups claiming to "change healthcare": this is not about nicer online forms. This is about destroying this.

<comment><USER14> > this is not about nicer online forms. This is about destroying this.

Thank you for clarifying this.

<comment><USER14> ... not sure why an honest 'thank you' is downvote material, and am open to being educated on the matter.

</comment></comment></comment><comment><USER15> So this practice is made more obvious in the US, simply because individuals are left with the bill. Although having a single-payer (i.e. universal health care) system might help to identify these patterns and reduce costs, the fact is that it occurs all the time, even in these systems. I'd be willing to bet that it happens more often in single-payer systems, simply because it's easier to justify and get away with. When I volunteered in the ER, I saw it all the time.

In fact, I remember when I was preparing to apply for med school in Canada/Ontario, I had to read a number of articles, journals, and books about medical ethics, and one thing that stood out was the consistent push to have future physicians account for the impact of their decisions on the system as a whole. So not only was it imperative to promote patient health, but it was also important to balance that with the overall cost. A good example is a simple blood test. A full spectrum blood test may help identify potential problems in a patient, but it costs OHIP a lot of money to run those tests (especially since they're done in private for-profit labs). That's why your family doctor should really only order the required tests.

<comment><USER16> > the fact is that it occurs all the time, even in [single payer] systems

The "single payer" has a hell of a lot more leverage than individuals in the US which, as far as I can tell, don't need to consent in any way (hell, they can even explicitly refuse to consent) and get stuck with the bill regardless. That trick wouldn't work so well on an organization the size of the government.

<comment><USER15> I completely agree, but how likely is it that big government will be able to accurately audit whether a procedure was actually required or not? In fact, I'd prefer if big government would stay out of it and just pay for my healthcare to keep me healthy & alive. I am not an expert on the procedures I need, and neither is big government. We put our trust in medical practitioners to make those decisions for us. The problem is that they benefit financially from those decisions.

If you ask me, the answer is to stop conducting these services as fee-for- service. Pay physicians a salary. Pay them well, but keep costs somewhat fixed.

<comment><USER17> Turns out medical practitioners are not experts either. There are plenty of health situations where you can get treatment A or treatment B and the only thing deciding that choice is the doctor's personal preference and that might have nothing to do with best patient outcomes.

You need organizations like Cochrane or NICE to provide evidence based guidance.

[http://www.cochrane.org/](http://www.cochrane.org/)

[http://www.nice.org.uk/](http://www.nice.org.uk/)

</comment></comment></comment></comment><comment><USER18> It's a racket. There is one and only way of solving this problem for good. It's for your life insurer to also be your doctor. I wrote an article about it about 4 or so years ago (linked here): [http://housecall.md](http://housecall.md)

<comment><USER19> While I think the subscription idea has some merit it's hardly "one and only way of solving this problem".

I could maybe believe "one and only way of solving this problem without challenging preconceptions and accepting some nuance into free market ideology".

<comment><USER18> Of course, you are right. There are other solutions, but I think this one is the best one. It's Google for health care.

As an aside, I'm really glad Google is getting back into the field with Calico because cheap long tail health care (an obvious externality of the idea) is the ultimate positive use case / justification for their company's total information awareness philosophy / strategy.

</comment></comment></comment><comment><USER20> How interesting. The patient is not in a position where consent is meaningful but is charged an exorbitant amount. At least a little unethical, I think.

<comment><USER21> I would say that not only was this unethical, but also not a valid contract. Without some reasonable semblance of an agreement how can someone say that you owe them $117,000? I would bet that a court would disagree and would be interested to hear why.

<comment><USER22> In the header of the article, it mentioned he signed many forms. Probably one of them agreed to this practice. Enforcement could still be tough though.

<comment><USER21> I get that, but if I sign a contract to buy a car and somewhere in the fine print is says that I owe an extra $117,000 that I am not aware of, that is not a valid contract.

</comment></comment></comment></comment><comment><USER23> It's sad that the only surprising part is "He Didn't Know", not the actual price.

</comment><comment><USER24> what a pile of shitty mess. tl;dr the assistant surgeon,whom he never meet, charged him separately and the price went from 6,200 to 117,000. why? because the assistant was an out-of-network doctor.

" Insurance experts say surgeons and assistants sometimes share proceeds from operations, but Dr. Tindel's office says he and Dr. Mu do not. Dr. Mu's office did not respond to requests for comment."

before you talk to anybody in a medical building yell "Are you in my network!?!?!"

<comment><USER25> That isn't enough. Most doctors have disclaimers that you sign stating that if it turns out they don't take your insurance, even if they say they're in your network, you are still responsible for out-of-network costs. You need to consult with your insurance company and get it in writing, ideally.

</comment></comment><comment><USER26> The other weird thing is the billing happens after the fact with no visibility before hand.

If you're building a house you don't start by saying «let's build a house» and then wait for bills from various contractors you've never met to arrive once the house is built. That would be considered crazy.

Why is it acceptable in health care? What prevents praticians from establishing a budget? What prevents patients from demanding one?

<comment><USER27> I had a recurrence of a medical complaint and have a high deductible insurance. I called around to several odficesbro find out what it would cost to treat if I was correct that it was a recurrence. In every case it took 30 minutes or longer for them to decipher their own costs.

</comment></comment><comment><USER28> >"The notion is you can make end runs around price controls by increasing the number of things you do and bill for," said Dr. Darshak Sanghavi, a health policy expert at the Brookings Institution until recently.

.. like promoting and charging for unnecessary and damaging surgery on baby boys, robbing them of bodily integrity and killing ~200 infants a year from complications.

</comment><comment><USER29> Tangential but hopefully interesting: how much an extra year of life is worth to the NHS: [http://m.bbc.com/news/health-28983924](http://m.bbc.com/news/health-28983924)

</comment><comment><USER30> Yet another example of the ridiculous arms race between payers and providers with patients caught in the middle.

</comment><comment><USER31> Shadowban test

</comment><comment><USER32> The US health system is FUBAR'd, but the right answer isn't a blank check from the government.

<comment><USER33> Thank god nobody has actually proposed giving the healthcare industry a "blank check."

<comment><USER32> That's effectively what Canada et al have done. Yes, I understand the government "negotiates great rates" for the citizens, but it's effectively the same thing as a blank check. It just takes a bit of shenanigans behind the scenes to sell the bureaucrats on your latest rate hikes. If you think pricing is bad now that the big insurance companies have to "negotiate great rates" for their clients, think how it'll be when there's only one party there.

Government-negotiated rates places the pricing totally outside the realm of necessity or reality and makes it a purely political matter, and politics is a messy, fickle thing built on personal favors and tit-for-tat. Not having your political activity interpreted as corruption or bribery mostly depends on not pissing off someone with more power than you.

Health care costs so much because of the insurance leech. The only way to restore sanity is to restore real competition and make the consumer pay directly. Doctors will have to charge reasonable fees to the patients, suppliers and vendors will have to charge reasonable fees to the doctors, etc. It will break the cycle of exorbitant cost in health care. That may be, in some senses, a painful transition, but it's the only sustainable thing in the long term. The cycle will not be broken by saying "Wow, health care sure costs a lot of money. Let's just get the government to print some extra cash and take care of that for us."

Insurance is typically a highly regulated industry because when insurance is involved, people get screwed. The incentives are misaligned; the insurance company only makes money when they _don 't_ give you what you're paying for. Insurance only works in events that are very unlikely. It's extremely likely that everyone will go to the doctor or need medical assistance. Insurance is a very, very bad model for this service.

<comment><USER17> > Government-negotiated rates places the pricing totally outside the realm of > necessity or reality and makes it a purely political matter, and politics is > a messy, fickle thing built on personal favors and tit-for-tat. Not having > your political activity interpreted as corruption or bribery mostly depends > on not pissing off someone with more power than you.

You might want to read how England does it. A national organisation (NICE) gives guidance about what care pathways and treatment should look like. Local CCGs (clinical commissioning groups) decide what they're goong to pay for.

Your description isn't even close to reality in England.

<comment><USER32> From Wikipedia:

>Groups will have, in addition to GPs, at least one registered nurse and a doctor who is a secondary care specialist.

Doctors and clinicians deciding just how much they're going to get paid. Not subject to any kind of market or competitive force that may work toward an equilibrium based on supply and demand. The government has said "Here's a massive amount of money, fight among yourselves about who gets how much, good luck".

Politics _is_ very much at play here, as it is in any system where the prices are determined by committees or small groups instead of the free market. This includes the current system in the US, which is effectively controlled by a handful of paper pushers in the insurance industry, leeching billions out of our system each year without providing any value and ever-inflating the costs for the patient.

There's no reason health care has to be a distorted market. Free market principles are applicable in health care as they are in any other field. While it's true that people _need_ medicine to survive in many cases, people also need food and groceries to survive, but we haven't had to nationalize a grocery chain heretofore. There is enough competition in the space to keep prices low. There would be ample competition in the medical space if we could break the insurance cabals that currently exist.

The powers that be rather like our current system, and they _love_ it now that the ACA has made it a crime to not purchase their product. They would certainly also enjoy the "print money til the doctors are happy" system proposed by many left-leaning persons. The one thing they're most afraid of is the one thing that restores equilibrium and stops their ability to gouge, which is real competition and a true free market undistorted by unfair practices and insurance company leeches.

Non-catastrophic medical insurance should be outlawed and clients should have to pay their doctors directly, forcing doctors to charge a reasonable amount of money or have no clients, forcing suppliers to charge a reasonable amount of money or have no customers, forcing medical schools to charge a reasonable amount of money or have no students. We can't just keep saying "The expensive way of doing this is easy and great, so let's just have the government pay for it." Things must be self-sufficient.

<comment><USER8> I don't want a free market in my health care.

I am not competent enough to judge if the pills I purchase actually contain penicillin and only the inert ingredients listed on the label. We know from the less regulated dietary supplement industry that many manufacturers lie about the contents. I have no reason to believe that the pharmacological drug industry is fundamentally more honest.

There used to be a free market for health care. The FDA started as a political response to the adulteration and misbranding of food and drugs in that market. The early 1900 saw the rise of popular patent medicines containing radium, with so-called "radioactive quackery."

A true free market would have no restrictions on Doramad Radioactive Toothpaste, on the sale of snake oil made of petroleum, or of Bonnore's Electro Magnetic Bathing Fluid as a cure for cholera. The free market of that era produced Elixir sulfanilamide, which killed more than 100 people. The owner of the company justified it because they were "supplying a legitimate professional demand." A free market needs no more justification than that. Anything else is politics, yes?

I don't want to return to that sort of free market. What is your most convincing evidence or argument that your proposed free market will lead to an overall improvement in health consequences? Especially knowing the history of bad actors in the health care era.

You commented that "people also need food and groceries to survive, but we haven't had to nationalize a grocery chain heretofore." You omitted that we have nationalized oversight of the food production system supplying the grocery chains. Again, the FDA started because the free market system of the late 1800s couldn't handle the food safety concerns. People did die because of the adulterated food they ate.

They still do, as you know from various E. coli outbreaks, or the 2008 Chinese milk scandal with an estimated 300,000 victims.

Your argument regarding grocery chains therefore at best means that governments shouldn't own hospitals, not that the state and federal governments should get rid of the 'committees or small groups' which develop the regulations for the hospitals.

All of the examples you gave appear to assume that only the current actors - licensed doctors, regulated medicines, hospitals with government inspections - will be part of the free market system. However, an apolitical free market system must allow anyone to claim to be a doctor, anyone to claim to produce a medicine, and any barbershop, plumber, or auto shop to provide hospital services.

How does an apolitical free market prevent these known historical problems, including deaths, from becoming more common again? Why didn't the free market of the late 1800s come up with a free market solution?

<comment><USER34> A free market does not mean impunity. You are a free to purchase a gun, but you cannot kill without consequences.

<comment><USER8> How does that answer or even address any of my questions?

<comment><USER34> I was addressing your definition of true free market in which you make it sound as if in a true free market anything would go down. Free market still has provisions to protect consumers. The market you describe is not a free but anarchic.

<comment><USER8> The context is "Politics is very much at play here, as it is in any system where the prices are determined by committees or small groups instead of the free market."

My point is that politics is always at play. The only way to remove politics is to have an anarchic free market.

It's 'committees or small groups' which made it illegal to buy radium toothpaste. It's 'committees or small groups' which made it illegal to put drugs on the market without testing. It's 'committees or small groups' which put into place federal meat inspections.

Could you tell me how a free market has provisions which are more effective in terms of health outcomes, than, say, the Nordic or Japanese models? And why it was that those provisions weren't effective in the free market of the late 1800s? Since my reading of history is that the failure of free market to provide protections is what lead to the protectionist system we have today.

<comment><USER32> >It's 'committees or small groups' which made it illegal to buy radium toothpaste. It's 'committees or small groups' which made it illegal to put drugs on the market without testing. It's 'committees or small groups' which put into place federal meat inspections.

You're missing the operative element of my statement, which was "any system _where prices are determined_ ". It refers to the specific corruptibility of artifical governmental price fixing and its devastating effects on a free market. It is true that there will always be some element of politics affecting the marketplace, unless there is no government in place. It's OK to have a government that is interested in neutrality and takes all reasonable precautions to ensure things remain free and fair for both the supply and demand sides of the marketplace. Yes, small committees will have some decisions to make, and yes, they would also be subject to possible corruption or bribery, but as long as the government stays roughly within its provisioned and proper sphere (and it's our job to ensure they do so), it shouldn't have such painful direct ramifications.

I was going to reply with the same thing rokhayakebe did. Regulation and government still exist in a free market. If the vendor intentionally misrepresents the contents of his product, he has committed fraud and should be held criminally liable. There's nothing fundamentally incompatible about a standards and testing body and the free market.

Free markets have rules to keep the playing field even and fair, and to prevent the balance of power from tipping too far in any one direction. A market is not free if it is impossible to enter due to monopolistic forces, and a market is not free if the consumers are mislead or otherwise deprived of the information needed to make an informed purchasing decision. Free markets are not anarchy.

<comment><USER8> I was considering that "illegal to purchase" is equivalent to setting the legal market price to infinity, along with possible illiquid aspects like jail time.

Of course, in practice business will spread over to the illegal marketplace. However, I think you also were excluding the illegal marketplace. Consider that if a committee or small group sets the price of wart removal to, say, $20,000, there will still be an illegal marketplace for that procedure. Vice versa, if the price of heart surgery is set to $1, then there will be no public marketplace for it, but it will still be available in the illegal marketplace.

So in truth there is no such thing as a committee or small group which can absolutely set the price. That said, I, like you, am only considering the public, legal marketplace.

You say "devastating effects on a free market" like it's a universal bad thing. The things I pointed out - the regulation of food and drugs - in truth did have devastating effects on the patent medicine market. I think that's a good thing.

Government price controls on the polio vaccine, and the nearly complete eradication of that disease, caused a collapse of the iron lung manufacturing marketplace. I do not cry over that loss. I don't even think the producers of those iron lungs were seriously distressed about their economic losses.

So I absolutely agree with you that some controls can be devastating. That's, um, why the controls were put into place.

Thus, I think you need to describe specific devastating effects on a specific market, and not make a blanket statement that covers the entire market. I'm happy that the market for 9 year old coal miners has been devastated. (Yes, this was done by prohibition. We could get the same effect by fixing the price of child labor to $1 million/hour.)

"If the vendor intentionally misrepresents the contents of his product"

As I pointed out with Elixir sulfanilamide, which killed 100 people, the producer did not really misrepresent the contents of the product. Quoting from [http://www.fda.gov/%20AboutFDA/WhatWeDo/History/ProductRegul...](http://www.fda.gov/%20AboutFDA/WhatWeDo/History/ProductRegulation/SulfanilamideDisaster/default.htm) "Selling toxic drugs was, undoubtedly, bad for business and could damage a firm's reputation, but it was not illegal."

Read it, to see how difficult it was to track down the 240 gallons of toxic elixir. The only crime, by the way, was the use of the word "elixir". Had they used "solution" instead then the "FDA would have had no legal authority to ensure the recovery of the drug and many more people probably would have died."

You say "There's nothing fundamentally incompatible about a standards and testing body and the free market". Obviously the standards and testing body has to set certain rules. How are those rules determined? Aren't they equally determined by a 'committee or small group' and as corruptible as the Medicare payouts are now?

For example, various states are trying to prohibit the Constitutional right to an abortion by the round-about means of making it extremely difficult and expensive to operate a medical center which carries out abortions. This is done under the guise of improving safety standards at those centers and making sure that the women getting the abortion are fully informed of the details and have had the time to reflect on the decision.

This seems like a prime example of how a standards body can block the free market, even without price controls.

To make up an example using a less sensitive topic than abortion, consider if every purchase of a beer required sitting through a 2 hour video on the negative effects of alcohol, including video of car crashes caused by driving while intoxicated and surgical footage of liver surgery due to liver cirrhosis. It makes sure that consumers are neither mislead nor deprived of information - and yet it's a burden on the free market, no?

So I don't see the difference. One is a financial limit, another is a regulatory limit, but both are limits to a free market.

How does a free market with a standards and testing body supposed to work, and also be significantly less subject to free market manipulation than what we have now?

Lastly, you used the phrase "provisioned and proper sphere". Such a sphere is only defined by politics, because your sphere and my sphere can be very different. Consider a law like the 14th Amendment, Section 4, which says that reparations for "any claim for the loss or emancipation of any slave" were null and void. Why can't an ex-slaveholder say that taking property isn't part of the proper sphere, and insist on getting compensation? Wouldn't that be the 'neutral' position of the market?

</comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER35> Wait did I miss it, he did not have insurance? Otherwise he wouldn't pay 117k. Unless it is one of those EPO plans, but even then you can argue that you could not have known about the oon doctor. It is likely to take a couple of months though

<comment><USER2> His insurer agreed to pay -- but the guy was just bothered by the ridiculous unethical situation and balked at reimbursing the overcharging physician.

Read to the end bro!

<comment><USER35> Ah thah crap missed that one paragraph, thanks

</comment></comment></comment><comment><USER36> Reasons I am dubious of the author's agenda, based on the structure of their arguments:

1\. anchoring to high numbers, without contextualizing how big this issue is: "This contributes to the nation's $2.8 trillion in annual health costs." How much does it contribute?

2\. unequal metrics -- when discussing the expected charges: "Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee." When discussing the out-of-network bills: "Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman's chronic neurological condition." Now we're thinking $133k isn't so bad b/c he'll only pay part of it, but the $250k is frightening because there is no mention of an expected discount. As a counterpoint, the author mentions the insurance company pays the full amount to Dr. Mu for the other anecdote in the story.

3\. fearful language -- 'He was blindsided, though, by a bill of about $117,000 from an "assistant surgeon," a Queens-based neurosurgeon whom Mr. Drier did not recall meeting.' Sounds like a 24-hour-news-cycle headline: "Patients billed by doctors while under anesthesia".

4\. mentioning there are marketing firms who specialize in helping maximize billing with insurance, as if it's an unethical business. This happens every time a provider of a service or product interacts with a bureaucracy -- there is a whole layer of these services for defense contracting, for example.

5\. they mention how the US has more neurosurgeons per capita, then link that (by proximity in the same paragraph) to providing motive by mentioning how neurosurgeon compensation has decreased recently. A more honest article would have given absolute numbers about how the costs of neurosurgery relate to overall health care costs, rather than making the niche appear large relative to the story, so the reader implicitly compares that impact to the $2.8 trillion number.

Medical billing is absurdly complex and byzantine. I'm don't doubt the veracity of the anecdotes, but the structure of the presentation make me suspect the intent of the author.

<comment><USER37> I don't understand what you're getting at. What do you suspect the author's agenda to be? What should we take away from this instead?

<comment><USER36> The takeaway from my comment is to consider the source and agenda for things you read, especially regarding controversial issues. The biases in how the author frames their points, as I outlined in my original comment, indicate to me that the author may have an agenda.

Agendas are a big red flag to me -- they indicate the author is trying to convince me of their P.O.V., rather than presenting the information and allowing me to make my own decision.

Sure, everything has an agenda. But structural biases such as those outlined above, serve to decrease my trust in the author.

That's all. I'm not suggesting a conspiracy. I think health care is incredibly complex, and sometimes suffers from profiteering. I also suspect that the likelihood is low to be screwed like the people covered in the article, but the structure of the article is designed to make me fearful.

When I detect an agenda to create fear, I question the motives of the author. In short, I cannot separate the useful information in the article from the author's agenda, and am forced to throw the baby out with the bath water, so to speak. (Apologies if that idiom doesn't make sense -- it just means that I have to throw the signal out with the noise because the author doesn't seem to be sufficiently unbiased.)</comment></comment></comment>


My Mixed Feelings about Ruby - <AUTHOR> http://weblog.raganwald.com/2008/06/my-mixed-feelings-about-ruby.html

<comment><USER2> Good article raganwald.

I'm just learning RoR and I guess my biggest hangup is the prodigious use of colons.

I admire your ability to "rewrite code for Ruby"...

For me it's tough enough to learn one language. There is no way that I would ever attempt anything but a greenfield application with RoR and to finish that I will probably need some help. What attracted me to the language was the impression I got from reviewing descriptive materials from DHH and the 37 signals crew that Ruby has a great deal of elegance when it comes to interacting with databases. And, for me anyways, that's the only kind of elegance I'm really interested in because I think that's where the money is going to be. So far I'm not really good enough with the syntax to say whether it's going to live up to expectations but I haven't really seen anything yet that would cause me to say I've made a mistake in choosing this platform.

</comment><comment><USER3> Blocks may not be able to genuinely accept blocks in Ruby, but I was able to get something pretty close: [http://blade.nagaokaut.ac.jp/cgi- bin/scat.rb/ruby/ruby-talk/...](http://blade.nagaokaut.ac.jp/cgi- bin/scat.rb/ruby/ruby-talk/293232)

</comment><comment><USER4> _To my eyes, Ruby as a language looked a lot like an internal IT app that is built as an aggregation of features. There might be a wonderful, coherent design in the implementation that I can't see, but the interface I use seems like a bunch on one-off features that don't play well together._

Huh? Is this guy talking about Perl? Is he talking about the same Ruby I know? His criticisms don't make any sense. Ruby is well-organized and well thought- out. It's not without its flaws, but it has far fewer than Java or Perl. Hell, Ruby makes Perl look like Java.

(If he hates Ruby this much, I'd hate to imagine what he'd think of the gigantic featuritis-striken kludge called Java or J2EE.)

<comment><USER5> _Ruby is well-organized and well thought-out._

O RLY?

Just kidding. I think Ruby _is_ well thought-out. Just for a chuckle, what does this snippet of code do?

      p = Proc.new { return :to_sender };
      p.call

What about this one?

      l = lambda { return :to_sender };
      l.call

Why and how do they differ? And given that they differ in behaviour, what do you think this should return? False, right?

      c.class == l.class

As for my criticisms, my main point has to do with Ruby not being implemented in terms of itself. Almost everything else that troubles me can be traced back to that issue.

[http://weblog.raganwald.com/2006/11/significance-of-meta- cir...](http://weblog.raganwald.com/2006/11/significance-of-meta- circular_22.html)

[http://weblog.raganwald.com/2007/12/why-rubinius-matters- to-...](http://weblog.raganwald.com/2007/12/why-rubinius-matters-to-rubys- future.html)

[http://weblog.raganwald.com/2008/02/turtles-all-way-down- ple...](http://weblog.raganwald.com/2008/02/turtles-all-way-down-please.html)

p.s. Please remember that the post was not titled "What's wrong with Ruby," it was titled "My Mixed Feelings about Ruby." So it can well be that I have a viewpoint which does not reflect how intelligent people feel about t he language.

<comment><USER6> The main point is that Ruby is not implemented in terms of itself? That surely doesn't come across as the main point of the article, as it is only mentioned in a short 3 sentence paragraph that mostly consists of links to other articles.

I felt the article was a bit content-free. The main point I got out of it was that Ruby isn't elegant like Scheme or Smalltalk. This is the same sort of thing that has been repeated ad nauseum since the dawn of internet discussion. If Ruby is too gauche, Scheme and Smalltalk already exist and provide actual implementations of this strange symmetrical, consistent, mathemagical "elegance" that certain programmers get a boner over. (substitute "OOP" for "mathemagical" in the case of Smalltalk)

Now, I'll derail this thread with some opinions of my own. I used to love Perl. The inconsistency, crypticness, ability to make incomprehensible one- liners that actually did something useful - I truly felt like a wizard. Perl golf was a big hobby of mine. Unfortunately as soon as Java became the next big thing, Perl became totally not cool. To be honest, Perl was never "cool" anyway. The good Perl guys were all old systems administratiors who still posted "rants" to alt.kibology and only had sex when dressed in giant furry chipmunk suits. However, at least they were free-thinking, anything goes weirdos. In contrast, the Java droids who replaced them had the spirit of soviet city planners dressed in khakis and a SUN logo polo shirt... Ugh.

I'm completely indebted to Matz, (and DHH, because ruby wouldn't have taken off as it has without Rails) because he's invented a Perl that is "cool." No longer do I have to make the choice between working with guys still into "the Church of the Subgenius" or guys who actually wear their blackberry in a holster on the outside of their pants. I can now work on fun startup things with cool people who I can actually relate to. There's just enough "WTF" in Ruby to keep me happy, and just enough "OBJECT ORIENTED DESIGN PATTERNZ" stuff to keep those types of people happy. There's even enough Lispy stuff in there to keep those types happy for about 30 minutes until they go back to their real avocation, posting long diatribes to mailing lists about how things aren't as elegant as Lisp.

<comment><USER5> No, the main point of my personal blog post was that I am personally wrestling with the idea that Ruby as a whole might be more than the sum of its inelegant parts.

The main point of the criticism within the point of the post was about Ruby not being implemented in itself, but that is not the point of the post.

<comment><USER6> Ah, well that is a good point. However, many (most?) good things in software have a bit of insanity going on somewhere in the mix. For instance, any computer game is definitely "more than the sum of its inelegant parts."

My main beefs with Ruby are that it is slow, and there is a weird reality distortion field within the community that makes a lot of people respond to legitimate criticisms with tribal defensiveness. However, I won't go into either point as Zed Shaw seems to have covered them quite well.

<comment><USER7> > makes a lot of people respond to legitimate criticisms with tribal > defensiveness.

That's true for pretty much any computer system, whether it's Tcl, Emacs, Ubuntu, Postgres or whatever.

BTW, I loved the descriptions of Perl and Java users - it's not often that I get that good a laugh when reading something. And I agree with you completely about Ruby hitting a 'sweet spot'.

</comment></comment></comment></comment></comment></comment><comment><USER8> Who cares? It isn't like you and ruby are getting married.

If you have a project that ruby seems like a decent fit, use it. You'll get nowhere are learn nothing without actually doing.</comment>


Building Servers for Fun and Prof... OK, Maybe Just for Fun - <AUTHOR> http://www.codinghorror.com/blog/2012/10/building-servers-for-fun-and-prof-ok-maybe-just-for-fun.html <comment><USER2> That article is not just comparing apples to oranges; with that default aws setup, he is comparing apples to a herd of donkeys.

The correct comparison is his server vs a single EC2 High-Memory Double Extra Large instance with a 3 year heavy-utilization reservation. This instance costs $3100 upfront plus $0.14/hour. The total 3 year cost for this server on AWS would be 3100 + (.14 * 24 * 365 * 3) = 6779.2, or about $188.31 per month.

Sure, its more expensive. But AWS provides an insane of value on top of the server. Like instantly being able to provision additional capacity. I wouldn't be at all surprised if, on a full-loaded cost basis, it is extremely competitive with building his server. Heck, the employee salary expense of building your own server will easily drive the cost of the server well beyond the $3100 up front amazon fee.

I love building hardware too (never had a computer I didn't build except for laptops). But my mind boggles at AWS value proposition

<comment><USER3> Wait, so you can basically buy a server at AWS EC2 for a term of 3 years? That's what this heavy utilization reservation sounds an awful lot like.

<comment><USER4> Yeah for the closest possible comparison in your scenario, you want to do a 3 year reserved with heavy utilization.

When you reserve an instance, you are committing to a higher upfront in order to get a lower hourly for the reservation period. The low/medium/high utilization is sort of a knob that allows you to further control this upfront vs. hourly cost. With high utilization you have the highest upfront, but also the lowest hourly cost. If you are planning to run the server 24x7, this will also give you the lowest total cost.

</comment></comment></comment><comment><USER5> I myself like to do this. But only for home servers. I would never do that for a "serious" application. There are several reasons, the most important one being that this is a perfect example where outsourcing the work is both cheaper (economies of scale), more reliable (parts are tested better) and less risky (companies which do that at a larger scale have better risk management). If one the SSDs dies he has to drive there and switch it out, instead of one person simply doing that for the whole data center. This is simply inefficient.

And of course Amazon hosting is more expensive. It is more flexible; you can spin up instances at your whim. You pay for that. It would be better to compare it with standard dedicated server hosting.

<comment><USER6> Have you worked with "professional support" in a colo before?

When a hard drive dies under vendor support, one guy from the vendor drives out there to replace it. Half the time they don't test it after it's replaced unless you request it. Sometimes the parts are duds. Sometimes they bring the wrong part, or it doesn't fix whatever was broken on the server.

If it's the datacenter's remote hands, it can be hours, and on rare occasions days, before somebody starts working on your issue or even answers the phone or e-mail. Same issues come, and you have to have your own spare hardware for the remote hands to use.

It's highly variant based on the datacenter and vendor(s) and other issues. There's no guarantee that outsourcing will be reliable. You have to find the best one possible and build a good relationship.

<comment><USER3> Having done this twice before, I _strongly_ , STRONGLY recommend picking a colocation center that's less than an hour drive from someone who works for the company. Or you.

Just in case, but that does come up from time to time and if it's many hours away (or worst of all an airplane ride) you will get hours/days to fix things as you noted.

<comment><USER6> The shop I worked with, we had support on the machines, so Dell would send a tech out to replace a part for the servers that had valid support contracts. We still needed someone on the phone to remote-in to test the fix, of course.

For more complicated problems, our main colo was about 45 mins away from almost all the SAs. We used remote hands for colos that were an airplane ride away, and had varying (read: sometimes really shitty) results.

</comment></comment></comment></comment><comment><USER7> Where's he colocating those servers? Last time I dabbled with colocation, the bandwidth costs per-server were by far the dominant cost. I found it difficult to get anything at all for small quantities of servers.

Looking at he.net at the moment, I see they have a deal for $1/Mbps. Presumably someone like Jeff Atwood can get twice as good a deal as that, so he'd pay around $500/month for bandwidth for those servers. Going by the cheat sheet ([https://blog.cloudvertical.com/2012/10/aws-cost-cheat- sheet-...](https://blog.cloudvertical.com/2012/10/aws-cost-cheat-sheet-2/)), that is within a factor of 2 of a yearly-reserved h1.4xlarge ($2263/month * 0.47 savings = $1199). It's almost equal to the three-year reserved machine ($2263 * 0.30 = $678).

Edit: He probably only needs 1 Gbps for all 4 machines, driving his bandwidth costs down by a factor of 4, but we could start to take power/space/cooling costs into account at that point.

So is he getting a better deal than that? I'd love to know where.

<comment><USER3> A lot of colocation centers offer "unlimited" bandwidth, though I strongly suspect that may depend on whether you're running a porn site / megaupload clone or not. :)

Fortunately bandwidth is one thing that has gotten substantially cheaper over time:

[http://www.codinghorror.com/blog/2007/02/the-economics-of- ba...](http://www.codinghorror.com/blog/2007/02/the-economics-of- bandwidth.html)

<comment><USER7> Dangit, Jeff, you didn't answer my question. Share your secret colocation deals with me! :)

Power is also a big cost as well. To quote the prgmr colo: "Please note; power, generally speaking, is a bigger deal than rack units. I'm more likely to let you slide on an extra rack unit than on extra watts; watts cost me real money."

<comment><USER8> check out fdcservers.net, their prices are almost mind boggling for unlimited bandwidth. they now even offer 10gb unlimited in some areas.

</comment></comment></comment></comment><comment><USER9> Hardware is cheap, programmers are expensive. System admins even more so. For this reason I feel like cloud hosting providers are the way to go for bootstrappers or startups. Once you get big you can do things like FB and create your own datacenter. However the enjoyment and power that comes from having full control over your entire environment should never be over looked.

<comment><USER10> > System admins even more so.

Really? Honest question.

<comment><USER11> _Good_ sysadmins, yes. Keep in mind that the ideal sysadmin is someone who knows the guts of BSD or Linux (typically, not both) inside and out; can troubleshoot the strangest of problems very quickly; is constantly measuring and improving performance; and can hack together shell scripts or Python or even C code as needed.

Linux and BSD are hellaciously complex and prone to very strange behavior once you start taking them into high-performance land.

If you're OK settling with, "can read syslog and look stuff up on the web", those guys are cheap.

<comment><USER12> Note that this doesn't differentiate colocation and something like EC2 though - both benefit from these kind of good sysadmins.

<comment><USER11> Hmm. I have to think about that a bit. On the face of it, EC2 and colocation require completely different skill sets, and those skill sets don't overlap very much.

Being a good Linux sysadmin might be fundamentally harder than being a good EC2 sysadmin; I'm not honestly familiar enough with EC2 to know.

I would point out though that Amazon has a vested interest in making EC2 less hard, so I would be surprised if the general opinion was that EC2 administration was just as hard as Linux administration.

<comment><USER13> EC2 instances are running some OS, whether it's Linux or BSD or Windows or whatever. The only thing that doesn't overlap is hardware tuning and maintenance, and even there you should be using the same tools to figure out if you've got a hardware bottleneck on your EC2 instance as you'd use to evaluate performance on a standalone box.

</comment></comment></comment></comment></comment></comment><comment><USER11> maciej from pinboard has written some useful stuff on this too:

\- The five stages of hosting: <http://blog.pinboard.in/2012/01/the_five_stages_of_hosting/>

\- Building servers: <http://blog.pinboard.in/2012/05/a_cloud_of_my_own/>

\- Going colo: <http://blog.pinboard.in/2012/06/going_colo/>

A bunch of people are probably going to respond to Jeff's article by saying things like, "But VPS hosting means you get other people to deal with problems for you", but in reality all that means is that you're at maciej's "monastery" or "dorm room" stage of hosting, and your needs haven't yet driven you to get "the apartment".

<comment><USER14> I love maciej's footnote:

"""* What is it with these aggro facility names? Rather than Hurricane Electric or Raging Wire, I would much prefer to host with "Calm Multihomed Oasis" or "Granite Mountain" or " Cooling Breezes Pure Sine Wave Mount Bitmore". """

</comment></comment><comment><USER15> _"...you don't need the redundancy, geographical backup, and flexibility that comes with cloud virtualization"_

This is perhaps the single most glossed over topic in the entire article. If I am a 1-5 person shop, maintaining a web app, virtualized hosting pays huge dividends in that I _don't even notice_ if a hard drive or motherboard takes a dump. There are additional costs that come with the benefit of being abstracted away from hardware failure or geographic problems (building fire, power out, etc), and that's something that every business has to evaluate for itself.

<comment><USER3> Well, you'd always colocate enough servers so that you can lose at least one machine without caring. E.g. HAProxy to 2 web tier machines on the back end. HAProxy will fail over to just one server no problem.

(And yes, you can heartbeat so you have two cheap physical HAProxy machines, too. This gets into sub-blade territory, where the 1U server is internally two or more complete low-ish power servers with independent power supplies, etc. )

That's the whole premise behind FOSS, you don't need to worry about all the licenses, and the hardware is so cheap it is effectively free and getting freer by the second, so you throw a lot of cheap hardware at the problem.

But agreed, "lot" in this case means at least two so one can fail and you don't need to care.

<comment><USER15> I guess my bigger point though, would be that when using something like AWS, I don't have to think/spend time on a lot of implementation details. When using colocation services/hardware/failover, I'm just adding a bunch of little things to my daily tasks and responsibilities. Sometimes this is a big deal (like in a bootstrapped two man team) and other times it's not.

Ultimately, I think it comes down to priority instead of possibility. If your company lives and dies on having reliable servers, you should probably roll your own. But if servers are 'just' a technical detail to your overall business model, then a cloud solution can be well worth the additional cost

<comment><USER13> When you're using something like AWS, you absolutely need to think about implementation details. As we've learned a few times now, sometimes AWS has datacenter-wide outages. You need to stripe across multiple availability zones, keep off-site backups, etc.

So yeah, you gotta think about it. A lot of the time, public cloud is the correct solution; however, you should have a solid understanding of what you need to do to run reliably in that cloud, how to build redundancy in the cloud you pick, when you might need to move to a different solution, and how to make those processes easier.

<comment><USER15> I don't think I said that you don't have to worry about implementation details _at all_ , just that a cloud based solution like Amazon is often many orders of magnitude simpler than building/maintaining/repairing/replacing/updating physical machines at a co-location center.

<comment><USER13> We could argue about how many orders of magnitude, but I agree. It's absolutely easier in some ways. I'm just saying that it's easy to fall into the trap of thinking that EC2 (or whoever) is abstracted away from hardware failure/geographic problems when it definitely isn't.

[http://arstechnica.com/business/2011/09/google-devops-and- di...](http://arstechnica.com/business/2011/09/google-devops-and-disaster- porn/) is a bit overdramatized but the final section is a great summary of real stuff you need to think about on EC2, or any other provider. Again, I know you're not minimizing these issues, but some people certainly do.

</comment></comment></comment></comment></comment></comment><comment><USER8> i've known this secret for a while. i went from paying $4k+/month spanning over 10+ servers in amazon ec2, to just 2 dedicated servers < $1k/month in an unlimited 1gig colo. the performance difference i see is huge. i never realized how actually slow EC2 is. their issue is definitely in slow IO, which i think only their SSD instances can fix (which will cost me in the $8k+).

i now have a wicked setup, Xenserver Cloud, SAN, all Highly Available, don't have to worry about bandwidth overcharges, and much much faster .

<comment><USER3> Particularly now that we have 6 GBps SATA and cheap(ish) 512 GB SSD drives, the I/O differential can be _enormous_.

I thought about putting four 512 GB SSDs drives in a Raid 10, which would give me striping performance levels without losing the mirror, but that seemed like a bit too much overkill. These servers have 4 front drive bays, only 2 are filled with the SSD mirror, so we could decide to drop in 2 more drives and rebuild the array if we need even more I/O perf.

</comment></comment><comment><USER16> I much prefer the middle ground of dedicated servers over the hassle of colocation and hardware management. (16GB RAM quad core with 2TB raid1 from OVH for £65 a month are a good affordable level, and very quick and easy to spin up new ones).

<comment><USER17> If bang for your buck is a concern, you might be interested in this offering from Hetzner: <http://www.hetzner.de/en/hosting/produkte_rootserver/ex4s> \- you get double the RAM and a bit more disk space for a little bit less. I only have a month's worth of experience to talk about it, but other than the fact that it's in Germany (timezones) it's been great.

<comment><USER16> Yep, have used Hetzner servers too for some things and would use again, but for our customers being 90% in the US, and OVH offer a canadian location (and we may need some EU servers in the future).

<comment><USER17> Fair enough. I'm always curious about why people choose one provider over another - thanks for filling me in on your reasoning. :)

</comment></comment></comment></comment><comment><USER18> Network connectivity is one very big problem. What good is a blazing fast server with 2Mbps (disruptive!) link? This is the very reason a lot of people would hate their own servers. Cloud = _connectivity_ \+ (computing power) Yay! for connectivity.

<comment><USER3> Of course it depends on what you're doing.

Running a porn site or image/video sharing service? You're going to go through a ton of bandwidth and that might end up being your bottleneck way more than performance.

<comment><USER19> > Of course it depends on what you're doing.

This sums up every comment here. Every web app is a unique snowflake and what works for you (EC2/Dedicated, SSD, RAM bandwidth) is just as unique.

Much more important than building your own server, is fully understanding your requirements, and deploying the appropriate solution. But it is still wicked fun to build a server.

</comment></comment></comment><comment><USER20>
        > But not the kind that go in your home. No, that'd be as nuts as the now-discontinued Windows Home Server product.

What's wrong with home servers? I've been wanting to build one for quite some time.

<comment><USER21> In lieu of building a home server, I highly recommend the Synology line of NAS machines. They've got everything you could possibly want out of a home server, with a much faster configuration. Automatic backups, a built in Torrent server, Plex media server, and remote file access all in one container.

Seriously a great product and value if you're looking for a home server.

<comment><USER22> I don't want to come across as a comment crapper, but I've been recommending FreeNAS for years now. ZFS is perfect for home NAS purposes.

<comment><USER21> You're not comment crapping at all, you're offering a great alternative to those who are time rich / cash poor, or who like configuring and want to learn about building servers. For anyone who's cash rich and time poor, the NAS products from Synology are great.

</comment></comment></comment></comment><comment><USER23> What happens when a HDD starts to go out? Do you have to pay & trust colo personnel to replace it, or do you have to pay to have your server shipped back to you?

I could see putting my own server into a colo if it were like a storage locker - carry/cart your server into the building, mount it in the rack you've rented, plug into the provided power and network connections, and lock the security door.

<comment><USER24> Typically you'd pay for the first option. The term of art is "remote hands" service.

There are options where you can install servers in cages. (Some industries/companies require very strict physical access control.) This is more for show than because it meaningfully increases your security against the attack "your colocation provider is secretly The Adversary."

<comment><USER6> If you buy the hardware from a vendor and get their 24/7 support they'll send a tech to your cage to replace the drive. It's a little bit more expensive than the machine he built, but with the knowledge that someone will go fix it when it's broken. Worth the money, still ridiculously cheaper than AWS.

</comment></comment></comment><comment><USER25> Why is Jeff building a server when he can get the EXACT same server at Hetzner [1] for just 79 euro per month.

That translates to literally the exact same 3 year cost as building the server.

[1] [http://www.hetzner.de/en/hosting/produktmatrix/rootserver- pr...](http://www.hetzner.de/en/hosting/produktmatrix/rootserver- produktmatrix-ex)

</comment><comment><USER26> Happy rackmount home server user here, running ESXi with a load of dev instances, staging servers, OpenIndiana for ZFS running decent amount of storage connected to my editing workstations, databases, plus looks after our family video and photos.

I still use our company servers that are co-located but having things at home on the same network where you are developing is very compelling for me.

Its very quiet and cool (latest i7 processor).

But if you are hosting your own production boxes, I usually buy from HP or Dell and know that I rarely need to worry about those machines. Would hardly ever build a box to put into production unless it was something that was rather more specialized.

</comment><comment><USER27> I always say that there got to be an ec2-like solution but with real hardware.

Provisioning physical machines at the same convenience level as ec2 would be awesome.

I ended up doing what Jeff did. Bought my own server and hosted it at HE for $75/month. It's xeon 5650 with 48GB Ram + 1TB disk for $2k. Assuming the machine will last 3 years, it's a $131/month. That's way cheaper than the closest that softlayer offers (<https://www.softlayer.com/Sales/orderServer/41/2087/>)

Most of the times, EC2 is really about convenience and not cost.

<comment><USER13> Dell's Crowbar project: <https://github.com/dellcloudedge/crowbar>

Ubuntu Orchestra: <https://launchpad.net/orchestra>

Or build your own around cobbler & puppet/chef, but you're sort of reinventing the wheel at that point. Still, sometimes that's fun.

<comment><USER28> Also razor from emc/puppet. IMO a large scale cobbler config takes a bunch of work to get right. the provisioning and host management space is just starting to catch on to APIs and SOA. You're going to spend lots of time rolling your own apis, libs, services, and integration.

</comment></comment></comment><comment><USER19> I love building servers, it is amazingly geeky fun. And no doubt colocation with your own servers will give you the best bang for your buck, with renting a dedicated server coming in second. But you do have to be careful about redundancy. If you can't do without a day or two down-time, you'll need 2 or more servers, because when it's a dedicated server it's all up to you (or to someone you hire/pay for) when something fails.

Sadly I live a 5 hour drive from the nearest co-location facility, so I'm forced to rent a dedicated server.

<comment><USER3> Yeah I would never advise colocating just one server. Two at minimum. We'll have five when all is said and done (still building the other four here).

</comment></comment><comment><USER29> The core of this article is that you get more performance for your money by building your own servers and racking them. I think we can all agree there.

The problem with "hardware is cheap and programmers are expensive" is that your hardware will fail when you least expect it and have programmers sitting idle. Hardware is cheap, so have someone else assemble it and rack it.

If you don't need it up all of the time, this is a great way to get a lot of performance -- IO and memory in particular.

</comment><comment><USER30> Here is an incredibly lengthly argument which tries to be more balanced: [http://rossduggan.ie/blog/infrastructure/cloud-vs-metal- infr...](http://rossduggan.ie/blog/infrastructure/cloud-vs-metal- infrastructure/)

Jeff is glossing over a lot.

If you're already massively invested in hardware, in terms of people, processes and hardware, then you could argue that cloud architecture is less valuable in the general case, otherwise, it's usually no contest.

</comment><comment><USER31> I like the part where he builds new servers on a rug. What's the over/under for how long until parts start failing?

<comment><USER3> I have built many dozens of computers over the last 20 years and I've never ever seen any static-related problems. I don't wear a static wrist strap, but I do always touch something metal on the case before touching the internals.

<comment><USER32> I've been saying this as well, but has realised I don't know what problems static electricity could or would cause - long-term nor short-term.

I've stopped saying that I've never ever seen any static-related problems and I'm using the silly bracelet connected to something metal these days.

<comment><USER33> Static does cause damage other than immediate catastrophic failure. It can degrade silicon in subtle ways, resulting in random errors or crashes or even slowness due to retrying transactions. Wearing the wrist strap is cheap insurance against mysterious badness.

<comment><USER3> Yeah, but it's also a little bit voodoo. Unless we can point to specific instances of things going wrong, it's kind of imagineering a problem where one does not actually exist.

That said I always advise touching something metal on the exterior case before touching anything in a computer, and that's how I have always done it.

<comment><USER34> Static damage to a chip may not result in an immediate failure. It may manifest as lessened performance, unreliability, or a shortened lifespan. I've seen this demonstrated in training videos for the electronics industry. (I think EEVblog has a static demo up on YouTube).

The semiconductor industry (i.e., the companies like Intel that made the parts on your circuit boards) spends many millions, if not billions, of $ a year on static-protective mitigations. They're pretty smart folks and also very cost- conscious. They would not be spending all this money if it were pure voodoo.

However, parts mounted on a circuit board are much more resilient than loose chips. I, too, use the "touching metal" method but am very careful about it.

</comment></comment></comment></comment></comment></comment><comment><USER35> Did nobody notice that his AWS figures are totally wrong? AWS is expensive as hell, but even still $1400/month for 3 instances immediately looked incredibly wrong to me.

>The instance types included in the Web Application customer sample are 2 small (for the front end), and 1 large (for the database).

Nope, the instance types are 2 small for web, 2 small for app, and 2 large for DB. That's fully double what he's claiming it is. And he's ignoring the 4 300GB EBS volumes that are in that $1400/month as well as the load balancer and 120GB of bandwidth. And that is entirely on-demand instances, if you are comparing to a colo setup, you should be using the much cheaper reserved instances.

<comment><USER3> We're just comparing the Amazon Web Application template as provided in their calculator, with no changes.

You're right that it is x2 for each EC2 server which I didn't notice until later, but that doesn't change the economics or performance story very much.

<comment><USER35> Yes, we're comparing the web application template as provided. Except you compared less than half of it instead of comparing it. I think "I claimed that AWS is twice as expensive as it actually is" certainly changes the economics much. Your 3 servers is not 6 servers and a load balancer. Reliability counts too, not just performance. Especially since most web apps are going to be 90% idle on the AWS hardware.</comment></comment></comment>


PostgreSQL use case: www.leboncoin.fr (160 cores, 192 disks, etc) - <AUTHOR> http://www.postgresql.fr/en:temoignages:le_bon_coin

<comment><AUTHOR> I'm curious to hear more about people managing large scale PG deployments.</comment>