#and his uncle tries to use his interest in integrative health against him
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Modern!AU Keith and Maeve: Keith is a Pharmacy student and Maeve works with natural healing. They met when Keith was making a research on the usage of medicinal herbs in alternative therapies.
(thank you @bicayaya meu amor 💖)
#his family owns jade pharmaceuticals#and his uncle tries to use his interest in integrative health against him#keith howell#my maeve#ikepri oc#ikemen prince#ikepri modern!au
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ANSWERING WILDCARD QUESTIONS
For the first time in about a year maybe??? Some of these might be even older than that.
Yes, it is Korka! I definitely want her involved, she’s a wonderful character and there is a *lot* of fun paranormal stuff going on in this setting that she can help them research. Also, I’d just love for her and Nelson to become friends!
Thank you! I love him a lot, and it’s fun to picture him interacting with the other guys. They’d all make for some interesting uncle figures, but they might not be that great in terms of role models.
OHOHO. Devilish laugh. That’s a wonderful idea, and a good way to keep him occupied at some point. He’s a great character, but he’s incredibly powerful, and I want these dudes to solve their own problems whenever possible.
A good question! I don’t remember most of my dreams, but there’s usually a consistent look to the vivid ones. Lots of water, mountains, creeks, and high, winding roads. There are also a lot of buildings that are closely integrated with nature, even though I have almost never seen construction like that.
I had not, but now I have! Here’s a trailer, for anyone else that missed it:
https://youtu.be/33HXHaaagsw
I really like these new models! I’m looking forward to watching a playthrough when that’s available. Just like with Rhombus of Ruin, I don’t think I’ll be able to play this one myself.
DOUBLE FINE, I WISH TO SPEAK WITH YOU- no, I’m kidding! I think great minds think alike. But I’m really excited to learn more about that character and possibly involve them in this whole au eventually.
I’ve actually tried to avoid almost any info about Psychonauts 2 so I can go in mostly-blind, and a lot of the characters are vague to me. It’s fun to look forward to, but it’s also a little harrowing because I don’t know how to anticipate for it!
N...NO..... I NEED TO... Honestly those are old enough that it might be a good idea for me to re-make them, as well as the playing cards I made for the mega playlist cover. I think it’d be nice to remake them as vectors... that might make for a nice art stream sometime. I’ll mention publicly if I start doing that, and sharing any of these conceptual Wildcards arts when they’re done.
And if you’re just curious about what the tarot cards for the other characters are going to be, it’s this:
Eddie: Judgement, The Magician, The Emperor
Manny: Death, Justice, The World
Sam: The Chariot, The Tower, Strength
Max: The Devil, Wheel of Fortune, Joker
Although! I may actually give the Moon card to Max instead of the Devil, and replace the missing card from Nelson’s selection with the High Priestess? 🤔 I’ll decide when I get to it.
Could be! I’ve flip-flopped occasionally on if I want the split-a-cab gang to participate much in the story. I think they deserve a break, and splitting an apartment in New York seems like a good situation for the four of them.
Oh boy, that must be so disorienting for him. The Psychonauts deal with a lot of hippy-dippy weirdness in a seemingly organized way, but it seems like they’re not as paranoid about safety as a real federal organization would be. Not necessarily a good thing, considering one of their camp counselors went AWOL one day, and the head of the Psychonauts got kidnapped the next. They kinda need to get their act together.
Fun fact, in one of the earlier drafts of Chapter 3 I was actually going to make Nelson get scanned by the equivalent of a metal-detector for malevolent thoughts at the door and get really spooked by it, but I decided against it.
YEAH IT’S ON THE LIST
Honestly, a big bulk of the plot in this just regards characters having to face their mental health struggles... via facing it as literal internal demons, unstable powers, etc. It’s going to take a little while for any of Eddie’s teammates to realize how MUCH he has going on under the surface because he does a pretty good job of hiding it. “Needing to help others above ever helping themselves” is a hard issue to notice if you’re not looking for it. But it’s a guarantee that once they find out he needs help, they’ll give it; whether that’s making sure he’s not working himself too hard, or fighting off demonic cultists. Care comes in many forms.
SHE NEEDS TO REST.... POOR SYBIL (on the upside, they don’t TECHNICALLY work there, so she might be fine most of the time.)
Strong Bad isn’t a Psychonaut! He’s just a vlogger and a petty (psychic) criminal. It’s honestly not very different from canon.
Free Country, USA is a smalltown hotbed of psychic activity. Nearly everyone there has some mild capacity for supernatural powers, but nobody really notices or cares. Strong Bad just pops the tops off of cold ones and.... sometimes alters reality, a tiny bit. But mostly just in regards to media. The cartoons, comics, etc, that he invents and talks about have a tendency to suddenly voip into existence and nobody knows how. I swear, there’s actually a line of him saying something to this effect, but I can’t find it anywhere. Don’t worry about it! Nobody in town is ever going to do anything truly nefarious with their powers, so it’s not a high priority on the Psychonauts’ radar, just a weird footnote.
The only reason Homestar is an actual agent is because he seems like exactly the kind of guy to sign up for a job like that on accident and then stick with it. And he’s a talented telekinetic! None of his other friends know about his job or notice his absences.
And just for fun, here’s some weird instances of psychic overpowering that happened in the cartoon:
---
(Poor Strong Sad)
I’ve actually answered this one before! BAM Pretty sure all of it is still accurate.
Nelson: He sees floating sheets of paper containing notes, questions, etc. Anything that he wants to know more about regarding that person. The notes are subject to edits, cross-outs, ripped pages, etc.
Guybrush: He sees the item that the person is carrying that he wants most. As he gets to know people better, he sees them for their useful skills first.
Manny: His view of most living people is not very kind...
The people he’s closest to will eventually look a lot less garish. More like a flattering, camera-ready versions of themselves.
Eddie: Sickass sketch drawings that look like they belong in the margins of a composition book. The illustrations improve as he gets a better picture of where they’d fit in the internal lore of his mental world.
Sam: A lot like Nelson; Sam pictures case files, though his are a bit more in-depth.
Max: Max’s visions of people are highly personal and uncomfortable for those who witness them. He sees Nelson as a puzzle with a piece missing. Guybrush is a ripped up voodoo doll. Manny is a forgotten ofrenda. Eddie is a powder keg with a long, lit fuse. Sam is Sam, but he’s the wrong one.
I also got two questions that were pretty big subjects, or that I didn’t want to repeat, so I’m gonna cover them pretty broadly:
REGARDING [X] CHARACTER OR SERIES INCLUDED IN THE AU
Sure, I support it! I’ve gotten this question a few times in regards to things that I haven’t had time to delve into yet, or I’m not interested in, so I’m not going to include it into the AU myself. But if you want to explore an idea like that, feel free! This AU is pretty dang collaborative.
My main focus is just on the main 6 properties: Psychonauts, Puzzle Agent, Monkey Island, Grim Fandango, Brutal Legend, and Sam & Max.
But my general rule of thumb for “characters that exist somewhere within the background of this story” are any other properties owned by Telltale, Lucasarts, or Double Fine. And considering all of the licensed games that Telltale was getting into before it kicked the bucket, that includes some really weird characters, even up to the Venture Bros. I loved that series, but I’m not really interested in doing anything with them for this story! Partly for my sanity, the canon I’ve picked are already a lot of content to play with.
ASSORTED QUESTIONS ABOUT THE WILDCARD AU DISCORD
There’s no particular criteria needed to join the discord, and it’s not strictly on a need-to-know basis! Because it’s been a long while since anyone has joined, I've been hesitant about adding new people in... But I‘ve decided to try sending invitations again! Everyone who had asked about it in the past will be getting a ping by me in about a day or so, since I want to double-check if you’re still interested. If you’ve been nervous to ask you can reply to this post or message me privately.
Some things to keep in mind before asking or accepting the invite:
If you’re not a friend or a follower I recognize, I will likely double-check your tumblr along with some other current members before sending the invite.
Here’s the Rules page, so you know what to expect before you join:
Be Mindful - Respect other people's boundaries, don't do or say things that would cross the line. If your behavior makes other people feel uncomfortable or unsafe, I will remove you from the chat. In most cases I will try to resolve things with you and offer a chance to do better, but that will depend on the severity of the situation. And if you have any concerns regarding another member of the chat, you can contact me privately.
Health Boundaries - While discussions of mental health do occasionally pop up, do not rely on the chat for help. None of us are equipped to handle serious mental health concerns, and it will only cause distress for everyone. Please seek real help if it is needed! If you rely on people beyond the point that they have asked you to stop, I will remove you from the chat.
NSFW - Generally speaking, try to keep NSFW talk to a minimum. Swearing and humor is fine, but don't get too explicit please! Discussions should usually keep to a PG-13 / occasional R, but no NC-17.
Spoilers & Censorship - Please use the spoiler function to hide story spoilers, as well as discussions and graphic depictions of gore/excessive blood/body horror/severe psychological horror. Include a content warning so that people know what they could potentially be seeing when they click on the censored content. If the spoilered content is the subject of a back-and-forth discussion, please use another warning when you are switching to a different spoilered topic. (Note that these rules were added to the chat later, so be careful when using the search function or back reading.)
The canon series involved with the Wildcard AU are Psychonauts, Puzzle Agent, Monkey Island, Grim Fandango, Brutal Legend, and Sam & Max. Please be mindful of story spoilers!
Channel Organization - Also be mindful of which channel you're in and move a discussion over if need be! That way they don't get too clogged with unrelated info.
Creative Criticism - When it comes to writing, art, or character creation; try to be open to suggestions from others! Nearly all of the creative work in the chat is collaborative, so input from others is important! Creative criticism is not the same as judgement, and is not a personal attack.
Have fun! - Discussions move quickly in this chat! Don't feel bad if you ever need to step back, whether it's because of the speed or a disinterest in whatever current topic we're focusing on. If you ever want to come back, we're happy to have you and can give quick explanations if you feel out of the loop! :thumbsup:
We’re a group of approx. a half dozen to a dozen people, either posting very very quickly in a span of a few hours or barely anything for a few days. We’ve been in an activity uptick lately and there’s about a year and half of back content, too. If it’s hard to keep up on, not that interesting to read through, or you just have a hard time gelling with the group that's already there, there’s no shame in just lurking or dipping out if you need to.
We also talk a lot about Psychonauts OCs, so anticipate that.
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Character Biography: Alvin
Full name: Alfred Vint Svent
Year of birth: Primia 4278
Place of birth: Elympios – Trigleph
Age: 26
Height:182cm/6'
Family:Leticia Svent + unnamed father (deceased); Gillandor Yul Svent (uncle); Balan (cousin)
Childhood
Alfred was born in the famous Svent family in Elympios. He led a privileged life until he was six, when tragedy struck his family. He had embarked on the E.S.S. Zenethra cruise with his parents and uncle, but the ship was swept to Rieze Maxia when the Elympios army pierced a hole in the schism nearby. His father died during the accident, and the rest of the family, along with many other Elympions, got stuck in an unfamiliar world. [2]
Exodus
At first, the passengers of the Zenethra tried to contact Elympios to call for help, but they were attacked by unknown forces every time they used a powerful spyrix, which included communication devices. The remaining members eventually decided to settle down in Rieze Maxia. However, their inability to use spirit artes branded them as outcasts, making integration so difficult that most of them decided to go back to the Zenethra. Gilbert, an Elympion officer in his late twenties, created the organization "Exodus" as a way for the stranded Elympions to support each other. [4]
However, Alvin's uncle Gilland had other ambitions for the group, and from the time Alvin was 12 he used him to spy on Gilbert, who had taken a liking to Alvin. This resulted in Gilland ousting Gilbert and replacing him as leader of Exodus by exposing his affair with a Rieze Maxian woman. Gilland himself was manipulating Alvin with blackmail and fake promises. He had also started a sexual relationship with Alvin's mother Leticia, though Alvin tried hard to ignore that fact. [4]
Under Gilland, Exodus was reformed to suit his own goals, and several units were created, such as the spy unit which Alvin joined when he was about 14, or the combat unit to which belonged Zeljko, a boy Alvin's age who became his friend. [7]
One Alvin's missions for Exodus was to infiltrate the Travis manor and seduce Aurignac L. Travis in order to steal a letter proving the existence of a secret alliance between House Travis and House Banya to overthrow House Fenn. Gilland used this letter to approach King Nachtigal and get into his good graces. [7]
Failed Coup
Shortly after the mission at the Travis manor, Alvin was given another mission: to join a group of fighters hired as mercenaries by a clan of Auj Oule that was opposing Gaius, who was still in the middle of his conquest of Auj Oule at the time. However, that operation ended in disaster, of which Alvin was the only survivor, having been spared by Gaius, who'd mistaken him for a member of that clan and asked him to relay a message to the clan's leader. [7] [see this post for a translation of that excerpt]
It later came out that someone must have tipped off Gaius about their strategy. It was in fact not the first time Exodus missions had gone awry, and there had been rumors about a traitor for a while. Unfortunately for him, his survival caused Alvin to be suspected of being the traitor, and he was imprisoned by Gilland. [7]
He was rescued by Zeljko, who he thought had perished during the fight against Gaius. Zeljko led him to Gilbert, the former Exodus leader who had been expelled by Gilland. Gilbert wanted Exodus to go back to its roots—to become an organization that supported the stranded Elympions, rather than Gilland's personal militia. For that reason, he decided to plan a coup to overthrow Gilland, and tried to recruit Alvin to his side. [7]
Alvin accepted Gilbert's proposition, but that was a lie. He pretended to show them the way to Gilland's secret hideout, but in fact led them right into a trap where Gilland was waiting for them. There, it came out that Zeljko had been the one to tell Gaius about their strategy despite Alvin being part of the mission, as this was part of Gilbert's plan to discredit Gilland. When they realized Alvin had betrayed them, Gilbert and Zeljko tried to flee, but Gilland and Alvin fought and killed them. Gilland had accused Alvin of being the traitor because he knew Gilbert would try to rescue and recruit him to his side. Alvin had not been privy to Gilland's actual plan, yet still acted in his favor, just as Gilland had expected. [7]
Alvin's goal was to go back to Elympios with his mother, whose mental health had started deteriorating steeply. Her mind was going back to the past, and she often mistook Alvin for his father. He moved her to Xian Du, away from Gilland, and blackmailed a woman named Isla into taking care of her. He believed that she would get better if he took her back to Elympios, and he thus continued to work for Exodus, as Gilland had stated the organization's goal was to find a way to go back home. [7]
Other Missions
Alvin's missions for Exodus eventually led him to Fennmont, where he infiltrated the military. When he was about 21, he was approached by Presa, who was spying for the Aktau tribe at the time. They started living together, and Presa eventually fell in love with him and revealed her identity. Upon getting more details out of her about her colleagues and their activities in the capital, he reported immediately to the Rashugal military, leading to her capture. [9]
He also infiltrated the Labari Research Institute to steal information about the boosters produced there. He was especially interested in the blueprints for the third generation booster, but the only documents he found looked like doodles and he discarded them. During the fight that broke out when he and his team were discovered, he shot Nils Frieden, Wingul's best friend, to death. The institute was abandoned following those events. [10]
He was in Fennmont in Amnis of Trames 2293 (at the beginning of the game), and noticed the commotion happening at the Laforte Research Lab. He sneaked in and witnessed Jude and Milla trying to destroy the Lance of Kresnik. He considered killing Milla there, as he had realized that she was Maxwell and killing her would dispel the schism, but Agria activating the Lance prevented him from acting. He then decided to get close to Jude and Milla to get the Key back from her and gather more information. In Nia Khera, he sold information to Gaius. [5]
He continued to spy on Milla's group for Exodus, believing that this would enable him to go back home with his mother. However, when the Lance of Kresnik was fired during the Battle of Fezebel, it turned out that Gilland was using the Lance to push the Otherworld Reactor Plan rather than a means to bring them back home. Moreover, Alvin soon got news that his mother had passed away. He decided to settle his score with Gilland, and promised Milla and Jude not to betray them again. [2]
When Milla sacrificed herself on the Zenethra, Alvin believed that he would finally be able to go back to Elympios. However, the schism did not disappear, and he realized that he had let her die for nothing. Falling further into despair, he passed a deal with Muzét—she would allow him to return to Elympios in exchange for getting rid of Jude and the others in her place. With that in mind, he tracked down Jude and Leia, and tried to kill Jude, but Leia interfered and she was shot as a result. [6]
Finding His Place
After his fight with Jude, Alvin wandered around until he collapsed from exhaustion. He was rescued by Presa and Agria, who found him by chance near Aladhi Seahaven while they were looking for Muzét. After moping around for a few days, he decided to help them, and he joined them when they went to stop Jude's group on the Nia Khera Hallowmont. Despite initially resolving to fight the group, he eventually sided with them against Presa and Agria. When the fight was over, Presa and Agria fell off the cliff because of an earthquake, but not before Presa told him that she was happy he had found his place. That is when he realized that his place was with Jude and the others, and he decided to truly commit to them. [6]
Though his relations with Jude and Leia were still frosty due to the events that had transpired between them, he tried to earn the group's friendship earnestly. After a heart-to-heart with Elize, she promised to be his friend.
After the dispelling of the schism, Alvin started a fruit-selling business with Yurgen, hoping to help bridge the relationship between Rieze Maxia and Elympios in his own way.
Trivia
His concept was "the kind of adult Jude could have become if he had not matured." [2]
He's the character the writers put the most thoughts in. [2]
The letters he claims to be sending to women in the game are actually destined to his mother. [2]
His coat was a present from Gilland. [8]
Most men in his family go bald early. He's afraid it will happen to him too. [8]
His favorite food is peach pie. [2]
He used to be a crybaby and a momma's boy. [2]
The cruise was an idea from his father to cheer his mother up, as she was in bad health. [2]
Leticia married Alvin's father in her late teens and had Alvin at 20. [4]
Alvin's enthusiasm tastes like condensed milk. [3]
Balan is his cousin on his mother's side.
Presa was the one who gave him the idea to start selling fruit. [6]
He got Leia her GHS. [11]
Though their bodies were never recovered, he built a grave for Presa and Agria at the base of the Hallowmont. [6]
He saw Gilbert as a father figure more than Gilland ever was. However, he still ended up choosing blood ties. [7]
He was jealous of Jude's ability to overcome traumatic events and go forward. He realized that Jude was getting more mature than him, and though that is something he hated at first, this is what eventually prompted him to start growing as well. [7]
References
[1] ToX Perfect Guide, p.523 [2] ToX Official World Guidance Book, p.65 [3] ToX Official World Guidance Book, p.86-88 [4] ToX Official World Guidance Book, p.182-190 [5] Alvin Chronicle, ch.1 [6] Alvin Chronicle, ch.2-3 [7] Alvin Chronicle, ch.4-6 [8] ToX Fan's Bible, p.48-53 [9] ToX Fan's Bible, p.201-205 [10] ToX Fan's Bible, p.120 [11] ToX2 Short Story "Rains of Trigleph"
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Democratic debate analysis
I’ve read the transcripts. I read the fact-checkers’ analysis. I have ranked them.
Due to the size of the field, I’ll be splitting my analysis into four groups. This first one will be the Please Do Not Make Me Vote For Them group:
Ryan, Hickenlooper, Williamson, Bennet, Delaney, O’Rourke, and Biden.
Under the break, I’ll be analyzing their debate performance, how effectively they represented themselves on the issues, and how much I hate them, in reverse order of preference. Let’s begin.
20) Biden
Biden is so… so out of touch. Even the moderators asked if he was out of touch, and when the moderators of a debate you’re participating in think you don’t know what you’re talking about? For a career politician, that has got to hurt. Frankly, they were right. Biden thinks that the reason people can’t pay their student loans without sacrificing everything else they want to do with their lives is because we’re not earning more than $25k a year, that freezing payments and interest until the graduated student crosses that threshold would magically make everything ok. If he were right, there’d be no Fight for 15. A $15 minimum wage, assuming full time hours, is more than $30k per year.
His response to accusations of racism was to point to his “black friend,” former President Obama, which… dude. You’ve got to know better than that by now. Please tell me you know having been the first and only black President’s VP does not immediately absolve you of being an old white guy who worked with Southern Segregationists against integrating schools.
His entire platform seems to be “remember when I was a senator/the vice president? Wasn’t I great, back when I had ideas and did things?” and I gotta say, No. No, you weren’t that great, Joe. Even his closing comments were lackluster, talking about “restoring the soul of America,” and “restoring the dignity of the middle class,” and “building national unity.” His answers to simple questions were, frankly, terrible.
Joe, what would you do, day one, if you knew you’d only be able to accomplish one thing with your Presidency? Thanks for asking, I’d BEAT DONALD TRUMP! Joe. Joe, that’s how you get to Day One. Unless you mean “grab him by the collar, haul him out on the White House lawn, and bludgeon him with heavy objects,” you’re not answering the question. Joe, which one country do you think we need to repair diplomatic ties with most? NATO! Joe. Joe, NATO is more than one country. I just… *sigh*
To his credit, Biden trotted out many of the same old campaign promises Democrats have been making for as long as I can remember. Closing tax loopholes, universal pre-K and increased educational funding, let Medicare negotiate prescription drug prices. These are tried and true campaign promises because they’re things we can all generally agree we want. But they’re old, a lot like Biden. They’re not the bold solutions we need. His newer ideas all sound pretty moderate and old, too: free community college (not 4 year public university), creating a public option for healthcare so people can choose between insurance companies and Medicare, rejoining the Paris Climate Accord, and instituting national gun buybacks. His suggestion of requiring all guns to have a biometric safety is also a vague gesture in the direction of a solution.
Biden is too old, too timid, and too arrogant to understand that he’s got nothing to offer in an election where Millenials and Gen Z are going to be the largest portion of the electorate.
19) O’Rourke
Beto, or as I like to call him, Captain Wrongerpants, got off to a roaring start by giving a non-answer in two languages. This incredible display of pandering, and wasting precious time, made him seem pretentious and obnoxious in twice the number of languages most politicians aspire to.
Possibly more than any other candidate, O’Rourke completely failed to answer any question he was asked. He presented a few good ideas, saying that he sees climate change as the most pressing threat to America and calling for an end to fossil fuel use. He supports universal background checks and reinstating the assault weapons ban. He wants comprehensive immigration reform, to reunite families separated by the Trump administration, and to increase the corporate tax rate.
Unfortunately, he wants to increase the tax rate from the new-for-2019 level of 21% to a lower-than-2018 28%. He wants immigration reform to protect asylum seekers, but thinks other immigrants should “follow our laws” and makes no guarantee to decriminalize undocumented border crossings. Like Biden, he supports healthcare “choice,” meaning that for-profit healthcare would continue in this country until everyone, in every city, state, county, and cave, can be convinced that insurance companies don’t care about them.
In short, O’Rourke reaches for relevance and relatability, and lands in pretension and centrism.
18) Delaney
John Delaney is the first candidate on my list to have been caught in a bald-faced lie by Politifact. Good job, John. His lie, by the way, was about Medicare for All. He claimed that the bill currently before Congress required that Medicare pay rates stay at the current levels, and that if every hospital in America had been paid at Medicare levels for all services, every hospital would have to close. The truth? The Medicare for All bill does not require that pay rates stay at current levels, and even if it did no one knows what effect that would have on the country’s hospitals. There is no data to support his assertion, even if he was right about the terms of the legislation being considered.
Unsurprisingly, John is another healthcare “choice” advocate. I think I’ve said enough about why this position doesn’t fly for me, so I won’t rehash it again.
In a discussion of family separation, he interjected that his grandfather was also a victim of family separation, which must make him feel so relevant. He also referred to company owners as “job creators,” a lovely little conservative talking point, and claimed that America “saved the world,” in some vague appeal to American Exceptionalism. He also agrees with Nancy Pelosi about not pursuing impeachment proceedings.
On the “I don’t hate him quite as much as Beto and Biden” front, he’s in favor of tax breaks for the middle class, increasing the minimum wage, funding education, family leave policies, a carbon tax (which he imagines would fund a tax dividend paid to individual citizens, rather than, I don’t know, paying for green infrastructure development?), thinks China is our biggest geopolitical threat, and is scared of nuclear weapons (a very sane, reasonable position, really).
If you want to pick a candidate based on who your moderately conservative uncle will yell about least if they win the White House, Delaney might be your guy. If you want to pick a candidate based on issues like student loan debt and healthcare, keep looking.
17) Bennet
I had never heard of Michael Bennet before the debates. In fact, I just Googled him to find out his first name. After the debates, though? You guessed it: I hate him.
His closing statement was an appeal to the American Dream. He thinks there are too many people in America to make a single payer healthcare system work. Asked to identify one country to prioritize diplomatic repairs with, he named two continents. And he believes the world is looking to America for leadership.
However, he did rate higher than three whole candidates, and here’s why: He supports a path to citizenship for undocumented immigrants. He wants to end gerrymandering and overturn Citizens United. He wants to expand voting rights and electoral accessibility. He considers climate change and Russia to be the biggest threats to America, and he didn’t use any obvious racist dogwhistles. He’s from Colorado, so he’s kinda proud of the state’s marijuana legalization and reproductive health policies, but he’s way too quick to see partnership with private businesses as the ideal path forward.
16) Williamson
Oh man. Marianne Williamson. I almost threw something every time she opened her mouth. She is like a walking, talking, uninformed Tumblr guilt trip post. At a nationally televised debate, she asked why no one was talking about… something. I didn’t write it down in my notes because I would have had to gouge out my own eyes if I had. According to Google, she is a self-help speaker and that explains So Much.
In her closing statement, Williamson claimed that she would be the candidate to beat Trump, not because she has any plans, but because she will harness love to counter the fear that fuels Trump’s campaign. I am not making this up and I wish I was.
She claimed that Americans have more chronic health issues than anywhere else in the world, and attributed this to all sorts of factors, starting with diet and chemical contamination and extending, I assume, to solar activity and Bigfoot. According to Politifact, the only American demographic with a higher incidence of chronic illness than other countries is senior citizens, and I’m going to guess that has a lot more to do with our crappy healthcare system than it does a lack of detox teas.
When asked what policy she would enact if she could only get one, she said that on her first day in the White House she’d call the Prime Minister of New Zealand and tell her that New Zealand is not the best place in the world to raise a child, America is.
When asked which one country she’d make a diplomatic priority, she said “European leaders.”
By now you must be wondering how she rated higher than the bottom four, and I can sum it up in eight words: She supports reparations and the Green New Deal.
Please, please do not make me vote for Marianne Williamson.
15) Hickenlooper
John Hickenlooper is the former Governor of Colorado, and proudly takes credit for everything good that has ever happened in the state. He is also proud of being a small business owner, a statement that makes me immediately suspicious of any politician.
To his credit, he supports “police diversity,” a charmingly non-specific term that could mean one gay Latine nonbinary single parent in an otherwise entirely white male department, or could mean he wants the demographics of the police force to match the demographics of the population being policed. He also considers climate change a serious threat, and China. The best thing he said all night? He supports civilian oversight of police, a policy which has improved police relations with citizens.
Sounds pretty good, right? Wrong.
He also supports ICE “reform,” as if there is anything redeemable about that agency, and thinks that the worst thing the eventual Democratic candidate could do is allow their name to be connected to anything socialist. He said it twice, it wasn’t an accident.
14) Ryan
That brings us to the last of the worst, Tim Ryan. Tim here cannot stop using conservative dogwhistles, like talking about “coastal elites,” and saying that acknowledging differences between people is divisive. He is a basic ass white boy in the worst, most boring sense.
He wants to bring about a green tech boom, supports decriminalizing border crossing, supports gun reform, and thinks China is a serious threat to America. He also thinks that, in addition to dealing with the issues that allow school shootings to happen, we need to address the trauma kids are growing up with as a result. Unfortunately, he thinks that school shooters are misunderstood victims of bullying.
His confrontation with Tulsi Gabbard was very instructive and possibly the most damning exchange all night. He mis-identified the terrorists who attacked the World Trade Center as being “the Taliban” (they were Al-Qaeda) and said that our military forces have to “stay engaged” for… stability? I guess? As a veteran, I’m with Tulsi on this one: that’s not acceptable.
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Iroh & Zuko: A study in change and healing.
Uncle Iron and Zuko’s relationship is one I find truly interesting. It shows an interesting look into how people can change, how people can help others, the nature of wisdom and addresses healthy relationships that can survive toxicity.
So first change, this is obviously Zuko’s main character arch change and redemption, that’s been talked about ad nauseam, but Iroh also changed beforehand. We can infer he had a period of time that changed him the same way Zuko did over the course of the show.
Iroh isn’t a magically better person, but one of the main reasons he can be a good force in Zuko’s life is his past change. Iroh always had a tendency towards knowledge and mastered the more spiritual part of Firebending. He also seemed to be more comfortable playing Pai Sho and tea than being a leader. I think his quest for knowledge and lack of political ambition allowed for the death of his son to be a moment that pushed him to end his military campaign and not challenges Ozai’s power grab. We also know somewhere around this time he joined the Order of The White Lotus connecting him to a force trying to bring back balance. Had he not dealt with the reckoning of the destruction of his own family and past, as well as work through tragedy he would not have been able to as effectively help Zuko. He understood the pain and trauma but he had learned acceptance. He was of course not perfect but having known the hate and found the peace he wasn’t leading Zuko blind. This means that not only can Ioh mentor him from a place of age, be fatherly after having lost his own child, but more than most people also have an inherent connection to the struggle being had.
Iroh’s important role within the show is as a sage and mentor to primarily Zuko but others as well. Iroh is calm, accepting, generally level headed and steadfast in his beliefs allowing him to be a guidepost and foil to Zuko’s own erraticism. He loves Zuko deeply and wants nothing more than for him to be able to heal and choose his own path but does challenge him as time goes on knowing if Zuko just lives in pain he can never move forward.
He gives education about the cultures, people and bending of the people they see. He tries to give Zuko the power to work through his own issues. This act is crucial even though Iroh knows Zuko can be a danger to himself and others he doesn’t try and totally strip his autonomy or leave him unable to defend himself. I think this is evident with Zhao in the first book and then the Zuko alone arc in book two. Allowing Zuko to fight for himself when possible, and fail when he has to allows learning and gives real power. This is reinforced when multiple times he tells Zuko that in the end he has to choose what he wants, chose his own destiny and honour. If he wanted Zuko to make good choices reinforcing the life of little choice they came from would have done more damage.
Iroh doesn’t leave him without backup ever either. He’s always there for Zuko either physically having his back in battle, talking to him or even trying to help their crew understand where Zuko is coming from. No one has really had his back since his mother left, and it’s debatable how much she was even capable of doing. Trying to help him understand he isn’t alone is so powerful. Someone just being there for you is one of the most healing things a person can have. And I think more than any of the actual lessons just giving unconditional love was one of the strongest legacies you can leave.
Iroh also modelled what he wanted Zuko to learn. Rather it is Firebending being able to take it with your head held up, letting down walls, enjoying the small things, or brewing the best tea. Iroh lived his ideas making it do as I say and as I do in almost all circumstances. This irked Zuko of course as it was periodically embarrassing for him but I think it was why everyone who met him respected him or at least liked him. Even when Iroh was a man of layers and did have a few secrets he wasn’t duplicitous. Being a model of what you want increases trust and can help it easier to actually learn new ways of being.
Iroh is an example of Wisdom and not just knowledge. I think this difference does matter. Iroh was, of course, a master Firebender knew much of history and culture and was at least a decent military man from the way others spoke of him, but his understanding of the intangible is what makes him powerful. He always knew to watch and learn, he invented multiple bending techniques because he let down the arrogance and took in other ideas. Being a member of the White Lotus he knew and respected the connection of all four elements. He was often a third party within the first book, during the siege of the north we see him chose not to fight really for or against the Fire Nation. He acts to protect the spirits, to keep the balance. He is not averse to using violence (even against his brother or niece) but has a respect for the life of all peoples. This kind of understanding and wisdom is more powerful than any spewing of facts. Because this plays into the level of acceptance he has, makes him a formidable foe and gives him an ability to convey complex ideas.
Trying to find your centre and accepting who you are is an act of connection to the world and yourself. He can help many people Toph, Aang and a street beggar can all listen and understand where he comes from. He can help Zuko through his metamorphosis moment because he understands the connection of identity, health and spirituality. When you can bring a whole connection to someone it will always be stronger then listing facts or platitudes.
Zuko and Iroh have a relationship that is a blur of found family and blood ties. He is Zuko's biological uncle but they don’t seem to have been exceedingly close when Zuko was very young but after Iroh returned from war become closer. In the world of ancestors, destiny and bloodlines their relationship matters, but their connection was born from love, time, care, compassion, struggling, loss, fighting, and forgiveness. Neither the story or Iroh force Zuko to forgive Ozai or Azula. Iroh recognizes that his brother was abusive and horrible to his children, and recognizes that Aula can’t be left in power. Zuko chooses how he confronts both of these people, disavowing his father, and facing his sister with Katara. Their relationship comes out of this history of abuse and toxicity but is forged forward because of how much they have grown to care for each other in their own right and how much they grow. Iroh is Zuko’s real father in any important way and Zuko is as much his son as Lu Ten ever was.
Real World Techniques:
Through writing a mentor to someone who is clearly dealing with mental illness (C-PTSD, BPD) real-world psychological and coping strategies end up being employed in a strong connection.
-Radical acceptance. I skill taught in the framework of Dialectical Behaviour Therapy (DBT). Iroh has learned to accept his past, and the loss he has shown. Iroh works hard to drag Zuko out of obsessive behaviour by trying to get him to accept that past happens, you can not fix that. Iroh himself embodies this behaviour. He doesn’t force non-action though, the acceptance makes you better able to manage future stress and build better lives.
-Meditation A common skill suggested across mental health and general health practice. He tries to instruct Zuko in this ability as one that is key to being able to properly Firebend and to reach in and use innate human power. This concept also connects people to the spirit world built into the mythology of the world.
-taking responsibility w/out victim blaming. Iroh knows Zuko’s backstory built him into this damaged person, but Iroh doesn’t allow him to hurt others through this. Iroh works to teach him to respect his crew, let down boundaries of pride and learn a new way of working in life. But there is never a time Iroh blames Zuko for the abuse he faced. Ozai’s treatment was never Zuko’s fault. They create an ability to simultaneously own your shit but not stew in self-hate
-We also see the structure we often see in productive de-radicalization programs. Zuko is exposed to the people he was taught to hate, facing the humanity and real-world effects of hate usually begin to break through narratives. Iroh lets him into his own point of view that connects all life, he learns the practice of living within balance instead of the belief system jammed into his brain, doesn’t let Zuko uses his past as reason for his behaviour, and acts and expects Zuko to let the humanity of The Earth Kingdom colour his view. The dissidence from his childhood beliefs and the new ones he can’t integrate into his life. This is crucial to his being able to learn the history of the fire nation, even describing the earth kingdom people favourably before his complete transformation.
Learning to use empathy across whole peoples is powerful to deprogram people, he is expected to verbally and through actions show contrition. Zuko is eventually able to connect to this over his indoctrination. The ability to come with humility and not expect the other side to forgive you. Often framed as seeking forgiveness from the people he does not deserve it from. This behaviour can work in reality and seeing played on screen is part of why this arc resonates across the media.
-Iroh helps Zuko find and construct meaning. The loss of a belief system Zuko experiences through his trauma leaves him in horrible confusion. Iroh helps him connect to his past giving a new lens to view the world from. He can’t do so from the position he held before having that structure built for him.
-I mentioned previously Iroh providing Zuko with a degree of control. Long term child abuse often creates either extreme self-reliance or sometimes learned helplessness. Offering both the ability to protect and control his life combined with having his back can combat both of these. Along with the deeply obsessive thought patterns around the avatar.
I truly belive their relationship is hugley important. Two characters who fit simple archetypes at the start are allowed to bloom into deeply strong and complex real feeling characters. Iroh is shown to be powerful, respected, incredibly kind and wise. We can all learn from him, and be shown a powerful love. Zuko’s own arch ahs been seen as groundbreaking for years but without Zuko we wouldn’t have had a person to guide and reflect this. Adding layers to the world and understanding ourslves.
[Requested by nbj on AO3]
#fandom:#atla#avatar the last airbender#topic:#relationships#trauma and media#abuse and media#character:#zuko#uncle iroh#azula#fire lord ozai#ship:#iron & zuko#type:#txt#my post
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Out of Network? Cigna, RICO and where’s the line?
By MATTHEW HOLT
Sometimes you wonder where the line is in health care. And perhaps more importantly, whether anyone in the system cares.
The last few months have been dominated by the issue of costs in health care, particularly the costs paid by consumers who thought they had coverage. It turns out that “surprise billing” isn’t that much of a surprise. Over the past few years several large medical groups, notably Team Health owned by Blackstone, have been aggressively opting out of insurers networks. They’ve figured out, probably by reading Elizabeth Rosenthal’s great story about the 2013 $117,000 assistant surgery bill that Aetna actually paid, that if they stay out of network and bill away, the chances are they’ll make more money.
On the surface this doesn’t make a lot of sense. Wouldn’t it be in the interests of the insurers to clamp down on this stuff and never pay up? Well not really. Veteran health insurance observer Robert Laszewski recently wrote that profits in health insurance and hospitals have never been better. Instead, the insurer, which is usually just handling the claims on behalf of the actual buyer, makes more money over time as the cost goes up.
The data is clear. Health care costs overall are going up because the speed at which providers, pharma et al. are increasing prices exceeds the reduction in volume that’s being seen in the use of most health services. Lots more on that is available from HCCI or any random tweet you read about the price of insulin. But the overall message is that as 90% of American health care is still a fee-for-service game, as the CEO of BCBS Arizona said at last year’s HLTH conference, the point of the game is generating as much revenue as possible. My old boss Ian Morrison used to joke about every hospital being in the race for the $1m hysterectomy, but in a world of falling volumes, it isn’t such a joke any more.
But it’s not as if this is a new issue. Back in 2009 I was writing about Ingenix’s (now called Optum/UHG) problems with trying to figure out what usual customary and reasonable (UCR) prices to pay for medical procedures. Essentially UCR prices (the ones baked into but not defined by Medicare) were made up, and the whole American health system’s cost structure follows along.
It wasn’t supposed to be this way, or at least not by now. The theory, taught to brave young health policy types like me decades ago, was that intelligent buyers would give integrated plan and delivery systems a fixed amount of money per head, and that those organizations (basically Kaiser & Geisinger) would be so much more cost effective that they’d force every other hospital system to become like them. Two decades of M&A later and it’s clear that the alphabet soup of HPO, IDN, ACO et al. has meant little. In practice, local monopoly or oligopoly provider systems have bought up the referring physicians and worked hard to feed the beast—the expensive inpatient procedural services where they make their money. And of course because of their oligopoly status they have been price setters not price takers. The recent $575 settlement for overcharging by Sutter Health is exhibit A of typical health system behavior. But it was presaged two decades ago by similar settlements by Tenet and HCA. The reward for that bad behavior? You get to be Governor/Senator of the great state of Florida!
The casual observer might notice that while the odd case of outright fraud by the little guys gets trumpeted by the DOJ there are no real punishments for the HCA/Sutter level of pricing extortion. No one goes to jail and the cost of the fine is never enough to put the miscreants out of business.
Which gets us back to the present debacle around surprise billing. While everyone can pretend to be appalled, the insurer doesn’t pay directly—the patient or their employer does. Meanwhile the providers are able to stop any real action in Congress. The provider defenders, like Anish Koka writing on THCB last year, say they want a baseball-style arbitration system, and that anyway the problem isn’t as bad as the extreme cases bandied about in the press. They may be right, but they’re just fighting their corner, and they don’t seem to be on opposite sides from insurers in the long run.
But we now have a real doozy. As reported by the folks at consulting company AVYM, one of the BUCAs, in this case Cigna, is being accused of playing both sides off against the middle in an out-of-network billing case.
The lawsuit alleges that CIGNA accepts the out-of-network provider’s claims at the full billed charges and requests the same amount from the self-insured health plan. However, instead of paying the medical provider or member, CIGNA hires a Repricing Company to try and negotiate a reduction. If the provider refuses to negotiate, CIGNA pays the claim at an exorbitantly low level but appears to keep the difference between what was removed from the self-insured health plan and what was paid to the medical providers. In an attempt to conceal this from the patient and self-insured health plan, CIGNA issued Electronic Remittance Advice or paper Explanation of Benefits forms (collectively, the “EOB”) misrepresent the balance as “Discount” to the members, certifying the member is not responsible for the balance, while simultaneously representing the balance to the Plaintiffs as member liability or “Amount Not Covered”. Astonishingly, the complaint alleges that CIGNA, after being advised of these anomalies, not only refused to correct the issues but instructed the medical provider plaintiffs to sue to rectify the situation!
This (allegation) is pretty brazen. Cigna gets the huge bill. It then takes that money from its employer client’s account. But instead of giving it to the provider, it keeps it, covers that up, and tells the provider to sue the employer for the difference that it has already taken.
Uncle Billy gives Potter the Building & Loan’s cash by mistake
Any similarity to the scene in It’s a Wonderful Life where old man Potter keeps the money Uncle Billy accidentally gave him and tries to later bankrupt the Building & Loan seems to be completely intentional.
You have to ask, who here is working in the patient or end buyer’s interest? And the answer seems to be, no one. The lesson of previous decades has been that health care companies can push the line as far as they like, even to beyond what looks like outright fraud, and nothing much will change.
What’s amazing is that the people paying the tab—the employers, the government and the patients themselves—seem to have no understanding that this is going on, and have few weapons to deal with it. Dave Chase and his Health Rosetta movement continue to point out a few cases where employers have figured out the game, but those best practices remain rare exceptions.
One might assume that a rational nation would look at this and agree on a single or multi-payer fee schedule, as exists in most other fee-for-service based systems like France, Canada, Germany & Japan. Or it’s time to put in a real version of global budgets either by government fiat or managed competition as I was taught years ago. But given the state of American politics, even though the Medicare For All cries are getting louder, no one seems to seriously believe that any rational policy is going to happen.
Instead the logical outcome is that in the pursuit of profit, every participant in the system will keep pushing up to and over that imaginary line. Perhaps there is no line. But unless the buyers completely revolt, not much will change
Matthew Holt is the publisher of THCB.
The post Out of Network? Cigna, RICO and where’s the line? appeared first on The Health Care Blog.
Out of Network? Cigna, RICO and where’s the line? published first on https://venabeahan.tumblr.com
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Out of Network? Cigna, RICO and where’s the line?
By MATTHEW HOLT
Sometimes you wonder where the line is in health care. And perhaps more importantly, whether anyone in the system cares.
The last few months have been dominated by the issue of costs in health care, particularly the costs paid by consumers who thought they had coverage. It turns out that “surprise billing” isn’t that much of a surprise. Over the past few years several large medical groups, notably Team Health owned by Blackstone, have been aggressively opting out of insurers networks. They’ve figured out, probably by reading Elizabeth Rosenthal’s great story about the 2013 $117,000 assistant surgery bill that Aetna actually paid, that if they stay out of network and bill away, the chances are they’ll make more money.
On the surface this doesn’t make a lot of sense. Wouldn’t it be in the interests of the insurers to clamp down on this stuff and never pay up? Well not really. Veteran health insurance observer Robert Laszewski recently wrote that profits in health insurance and hospitals have never been better. Instead, the insurer, which is usually just handling the claims on behalf of the actual buyer, makes more money over time as the cost goes up.
The data is clear. Health care costs overall are going up because the speed at which providers, pharma et al. are increasing prices exceeds the reduction in volume that’s being seen in the use of most health services. Lots more on that is available from HCCI or any random tweet you read about the price of insulin. But the overall message is that as 90% of American health care is still a fee-for-service game, as the CEO of BCBS Arizona said at last year’s HLTH conference, the point of the game is generating as much revenue as possible. My old boss Ian Morrison used to joke about every hospital being in the race for the $1m hysterectomy, but in a world of falling volumes, it isn’t such a joke any more.
But it’s not as if this is a new issue. Back in 2009 I was writing about Ingenix’s (now called Optum/UHG) problems with trying to figure out what usual customary and reasonable (UCR) prices to pay for medical procedures. Essentially UCR prices (the ones baked into but not defined by Medicare) were made up, and the whole American health system’s cost structure follows along.
It wasn’t supposed to be this way, or at least not by now. The theory, taught to brave young health policy types like me decades ago, was that intelligent buyers would give integrated plan and delivery systems a fixed amount of money per head, and that those organizations (basically Kaiser & Geisinger) would be so much more cost effective that they’d force every other hospital system to become like them. Two decades of M&A later and it’s clear that the alphabet soup of HPO, IDN, ACO et al. has meant little. In practice, local monopoly or oligopoly provider systems have bought up the referring physicians and worked hard to feed the beast—the expensive inpatient procedural services where they make their money. And of course because of their oligopoly status they have been price setters not price takers. The recent $575 settlement for overcharging by Sutter Health is exhibit A of typical health system behavior. But it was presaged two decades ago by similar settlements by Tenet and HCA. The reward for that bad behavior? You get to be Governor/Senator of the great state of Florida!
The casual observer might notice that while the odd case of outright fraud by the little guys gets trumpeted by the DOJ there are no real punishments for the HCA/Sutter level of pricing extortion. No one goes to jail and the cost of the fine is never enough to put the miscreants out of business.
Which gets us back to the present debacle around surprise billing. While everyone can pretend to be appalled, the insurer doesn’t pay directly—the patient or their employer does. Meanwhile the providers are able to stop any real action in Congress. The provider defenders, like Anish Koka writing on THCB last year, say they want a baseball-style arbitration system, and that anyway the problem isn’t as bad as the extreme cases bandied about in the press. They may be right, but they’re just fighting their corner, and they don’t seem to be on opposite sides from insurers in the long run.
But we now have a real doozy. As reported by the folks at consulting company AVYM, one of the BUCAs, in this case Cigna, is being accused of playing both sides off against the middle in an out-of-network billing case.
The lawsuit alleges that CIGNA accepts the out-of-network provider’s claims at the full billed charges and requests the same amount from the self-insured health plan. However, instead of paying the medical provider or member, CIGNA hires a Repricing Company to try and negotiate a reduction. If the provider refuses to negotiate, CIGNA pays the claim at an exorbitantly low level but appears to keep the difference between what was removed from the self-insured health plan and what was paid to the medical providers. In an attempt to conceal this from the patient and self-insured health plan, CIGNA issued Electronic Remittance Advice or paper Explanation of Benefits forms (collectively, the “EOB”) misrepresent the balance as “Discount” to the members, certifying the member is not responsible for the balance, while simultaneously representing the balance to the Plaintiffs as member liability or “Amount Not Covered”. Astonishingly, the complaint alleges that CIGNA, after being advised of these anomalies, not only refused to correct the issues but instructed the medical provider plaintiffs to sue to rectify the situation!
This (allegation) is pretty brazen. Cigna gets the huge bill. It then takes that money from its employer client’s account. But instead of giving it to the provider, it keeps it, covers that up, and tells the provider to sue the employer for the difference that it has already taken.
Uncle Billy gives Potter the Building & Loan’s cash by mistake
Any similarity to the scene in It’s a Wonderful Life where old man Potter keeps the money Uncle Billy accidentally gave him and tries to later bankrupt the Building & Loan seems to be completely intentional.
You have to ask, who here is working in the patient or end buyer’s interest? And the answer seems to be, no one. The lesson of previous decades has been that health care companies can push the line as far as they like, even to beyond what looks like outright fraud, and nothing much will change.
What’s amazing is that the people paying the tab—the employers, the government and the patients themselves—seem to have no understanding that this is going on, and have few weapons to deal with it. Dave Chase and his Health Rosetta movement continue to point out a few cases where employers have figured out the game, but those best practices remain rare exceptions.
One might assume that a rational nation would look at this and agree on a single or multi-payer fee schedule, as exists in most other fee-for-service based systems like France, Canada, Germany & Japan. Or it’s time to put in a real version of global budgets either by government fiat or managed competition as I was taught years ago. But given the state of American politics, even though the Medicare For All cries are getting louder, no one seems to seriously believe that any rational policy is going to happen.
Instead the logical outcome is that in the pursuit of profit, every participant in the system will keep pushing up to and over that imaginary line. Perhaps there is no line. But unless the buyers completely revolt, not much will change
Matthew Holt is the publisher of THCB.
The post Out of Network? Cigna, RICO and where’s the line? appeared first on The Health Care Blog.
Out of Network? Cigna, RICO and where’s the line? published first on https://wittooth.tumblr.com/
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Readers around the world largely denounced President Donald Trump’s behavior during his recent European tour.
Here are some of the reactions from our international readers as Trump’s trip unfolded. These responses have been edited and condensed for clarity.
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America ‘Won’t Have a Better Ally’ Than NATO
I am really pessimistic about the future of NATO, let alone a “united West” that shares values and interests.
It’s pretty obvious that Trump does everything he can to destabilize the European Union — from the outside and from within by supporting people like Viktor Orban.
He offered Macron a trade deal if he leaves the EU? He praises the Brexiteers? He tries to blackmail us? The starts of a trade war based on false claims?
Seriously? What else should we Europeans tolerate? What more evidence do we need that he is not an ally? — Mark B., Berlin
One of the reasons Europe spends less on arms is their generous expenditure on national health. Copying that would really make America great. — Paul, Australia
I think that Trump wants to demonstrate to every person on Earth that he can govern successfully by lying and trying to force other nations to do what he wants them to do.
He wants to be different from his predecessors, but in doing this he has just created chaos all over the world, easing the rise of populism in Europe.
He has withdrawn the U.S. from the Paris climate agreement, from the Iran nuclear deal, and now is threatening to withdraw also from NATO. If we want to stop populism, we heavily need the United States to lead all the democratic world against this threat, because otherwise the game is already lost. — Marco Ghilotta, Italy
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Balloons and Brouhaha in Britain
No wonder The Sun got the interview with Trump, because it’s owned by Rupert Murdoch. The tabloid is a fierce euroskeptic and urged its readers to vote for Brexit. That Trump heaped praise on Boris Johnson, saying he would make a “great” prime minister, sounded like a death knell for Theresa May. Now he makes himself even more unpopular in Britain. But Trump has once again scored points with Putin — to sow discord within the EU and create uncertainty in Britain. — J. Von Hettlingen, Switzerland
In the U.K., we tend to do things a bit differently from Uncle Sam. There will be leftist millennials deciding to wave banners around screaming “Down with Trump” and most of these will be in leftist London or university cities, but the real British people that actually support Trump will do as always and sit at home following Trump on the news programs, agreeing with him and then chatting at work on the Trump visit. The M.S.M. part of the British media will promote everything that the protesters say, but that’s because they are left-leaning, and please remember America, this isn’t the whole of U.K. portraying these views, a lot of the U.K. do support Trump entirely. — Britbazza2, England
I am an 84-year-old woman in England. I have not witnessed any belief or trust in the president’s attitude, apart from those who might seek some advantage for themselves in proclaiming their solidarity. I haven’t seen this hopeful self-deception since Neville Chamberlain’s return from Germany with his “peace in our time” document. That was a frightening time, as is this, but eventually we lived through it. Possibly we shall eventually muddle our way through this, too, somehow. — ETL., U.K.
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‘Stable Genius’ Questions U.S. Intelligence
It would be great if this necessary investigation on foreign interference in U.S. elections, whose freedom was “hard fought,” was accompanied by a comparatively detailed historical investigation of the U.S. interference in elections of so many other countries — totally dismissing other countries’ democratic freedom. I think this should be an integral part of this discourse. — George T., Vienna
It’s not winter (yet), but could this be the proverbial snowball that becomes the so-desperately-needed avalanche? — Francis, Switzerland
This is a total shame. The president of the USA is showing how weak he is. Traditional allies are not allies any more. Empowering enemies is the new American strategy. Russia is strong and ready for becoming what the USSR once was and Europe is divided and under threat. This is the result of electing a president who doesn’t know about history, democracy, liberty, humanity and transparency. Wake up American people! Make America a respectful country again! — Luis, Portugal
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Putin Meeting Stirs Controversy
Is not the principle job of the American president to protect American citizens and American interests and to defend the Constitution? Is that anyone’s interpretation of what just happened in Europe? Or maybe I just missed an amendment to the Constitution wherein the interest of Vladimir Putin and his merry band of oligarchs comes first. — Kevo, Sweden
I agree with our president that there is absolutely no collusion. On the other hand, there was probably collusion. — David U’Prichard, Greece
What I find astonishing is that the most powerful country in the world has allowed itself to be in the position where a real estate salesman and reality TV star, with absolutely no diplomatic negotiating skills or experience, who thinks he doesn’t need to read briefing memos or listen to expert advice, is meeting a man who spent 20 years working as an intelligence agent and then another 18 as a successful and all-powerful leader. If that isn’t a recipe for disaster then what is? — RHR, France
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Fraying Alliances
Donald Trump may be A problem, but he is not THE problem. The real problem is that half of U.S. voters went along with Trump, knowing exactly what kind of clown they were voting for — and that the whole of the GOP is still going along with Trump, in spite of every lie, perverse act, or treachery. You can remove Trump, but you cannot remove that half of U.S. voters who still back Trump nor the Republican Party, who are betraying their country along with Trump, by assuaging everything Trump does, whatever he says and permitting his actions. — Michel Couxijn, Amsterdam
Given that Trump is really just a logical consequence of many long-standing, deep-rooted problems in the U.S. centering on education, worldliness, racism, bigotry, unfettered predatory capitalism, gerrymandering and the Electoral College — all now enhanced by social media — there is no logical reason for assuming that the U.S. will in the future become a stable and reliable partner. — Robert Sanders, Japan
New partnerships are going to be formed all over the world. Those who imagine they can simply dial back the good old days after Trump the Destroyer has finished the job of making America hated again, may be sorely mistaken. We are moving on and may never want to come back.
The next chapter of commerce on this planet will have a more modest and sustainable cast. Economies largely based on consumerism, as in America, or speculation, as in China, will find themselves struggling to find traction with those that function just fine with less.
America cannot be made great again in the manner Trump and those who will not stand up to him imagine. We are giving notice we will not be bought, or bullied, or insulted into enabling their outdated agenda.
History will record that the Trump presidency presaged the decline of the American Empire as we have come to know it. Whether or not America succeeds in joining the rest of us as a decent and less self-serving partner remains to be seen. — Memi von Gaza, Canada
This article originally appeared in The New York Times.
Geneva Abdul © 2018 The New York Times
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Out of Network? Cigna, RICO and where’s the line?
By MATTHEW HOLT
Sometimes you wonder where the line is in health care. And perhaps more importantly, whether anyone in the system cares.
The last few months have been dominated by the issue of costs in health care, particularly the costs paid by consumers who thought they had coverage. It turns out that “surprise billing” isn’t that much of a surprise. Over the past few years several large medical groups, notably Team Health owned by Blackstone, have been aggressively opting out of insurers networks. They’ve figured out, probably by reading Elizabeth Rosenthal’s great story about the 2013 $117,000 assistant surgery bill that Aetna actually paid, that if they stay out of network and bill away, the chances are they’ll make more money.
On the surface this doesn’t make a lot of sense. Wouldn’t it be in the interests of the insurers to clamp down on this stuff and never pay up? Well not really. Veteran health insurance observer Robert Laszewski recently wrote that profits in health insurance and hospitals have never been better. Instead, the insurer, which is usually just handling the claims on behalf of the actual buyer, makes more money over time as the cost goes up.
The data is clear. Health care costs overall are going up because the speed at which providers, pharma et al. are increasing prices exceeds the reduction in volume that’s being seen in the use of most health services. Lots more on that is available from HCCI or any random tweet you read about the price of insulin. But the overall message is that as 90% of American health care is still a fee-for-service game, as the CEO of BCBS Arizona said at last year’s HLTH conference, the point of the game is generating as much revenue as possible. My old boss Ian Morrison used to joke about every hospital being in the race for the $1m hysterectomy, but in a world of falling volumes, it isn’t such a joke any more.
But it’s not as if this is a new issue. Back in 2009 I was writing about Ingenix’s (now called Optum/UHG) problems with trying to figure out what usual customary and reasonable (UCR) prices to pay for medical procedures. Essentially UCR prices (the ones baked into but not defined by Medicare) were made up, and the whole American health system’s cost structure follows along.
It wasn’t supposed to be this way, or at least not by now. The theory, taught to brave young health policy types like me decades ago, was that intelligent buyers would give integrated plan and delivery systems a fixed amount of money per head, and that those organizations (basically Kaiser & Geisinger) would be so much more cost effective that they’d force every other hospital system to become like them. Two decades of M&A later and it’s clear that the alphabet soup of HPO, IDN, ACO et al. has meant little. In practice, local monopoly or oligopoly provider systems have bought up the referring physicians and worked hard to feed the beast—the expensive inpatient procedural services where they make their money. And of course because of their oligopoly status they have been price setters not price takers. The recent $575 settlement for overcharging by Sutter Health is exhibit A of typical health system behavior. But it was presaged two decades ago by similar settlements by Tenet and HCA. The reward for that bad behavior? You get to be Governor/Senator of the great state of Florida!
The casual observer might notice that while the odd case of outright fraud by the little guys gets trumpeted by the DOJ there are no real punishments for the HCA/Sutter level of pricing extortion. No one goes to jail and the cost of the fine is never enough to put the miscreants out of business.
Which gets us back to the present debacle around surprise billing. While everyone can pretend to be appalled, the insurer doesn’t pay directly—the patient or their employer does. Meanwhile the providers are able to stop any real action in Congress. The provider defenders, like Anish Koka writing on THCB last year, say they want a baseball-style arbitration system, and that anyway the problem isn’t as bad as the extreme cases bandied about in the press. They may be right, but they’re just fighting their corner, and they don’t seem to be on opposite sides from insurers in the long run.
But we now have a real doozy. As reported by the folks at consulting company AVYM, one of the BUCAs, in this case Cigna, is being accused of playing both sides off against the middle in an out-of-network billing case.
The lawsuit alleges that CIGNA accepts the out-of-network provider’s claims at the full billed charges and requests the same amount from the self-insured health plan. However, instead of paying the medical provider or member, CIGNA hires a Repricing Company to try and negotiate a reduction. If the provider refuses to negotiate, CIGNA pays the claim at an exorbitantly low level but appears to keep the difference between what was removed from the self-insured health plan and what was paid to the medical providers. In an attempt to conceal this from the patient and self-insured health plan, CIGNA issued Electronic Remittance Advice or paper Explanation of Benefits forms (collectively, the “EOB”) misrepresent the balance as “Discount” to the members, certifying the member is not responsible for the balance, while simultaneously representing the balance to the Plaintiffs as member liability or “Amount Not Covered”. Astonishingly, the complaint alleges that CIGNA, after being advised of these anomalies, not only refused to correct the issues but instructed the medical provider plaintiffs to sue to rectify the situation!
This (allegation) is pretty brazen. Cigna gets the huge bill. It then takes that money from its employer client’s account. But instead of giving it to the provider, it keeps it, covers that up, and tells the provider to sue the employer for the difference that it has already taken.
Uncle Billy gives Potter the Building & Loan’s cash by mistake
Any similarity to the scene in It’s a Wonderful Life where old man Potter keeps the money Uncle Billy accidentally gave him and tries to later bankrupt the Building & Loan seems to be completely intentional.
You have to ask, who here is working in the patient or end buyer’s interest? And the answer seems to be, no one. The lesson of previous decades has been that health care companies can push the line as far as they like, even to beyond what looks like outright fraud, and nothing much will change.
What’s amazing is that the people paying the tab—the employers, the government and the patients themselves—seem to have no understanding that this is going on, and have few weapons to deal with it. Dave Chase and his Health Rosetta movement continue to point out a few cases where employers have figured out the game, but those best practices remain rare exceptions.
One might assume that a rational nation would look at this and agree on a single or multi-payer fee schedule, as exists in most other fee-for-service based systems like France, Canada, Germany & Japan. Or it’s time to put in a real version of global budgets either by government fiat or managed competition as I was taught years ago. But given the state of American politics, even though the Medicare For All cries are getting louder, no one seems to seriously believe that any rational policy is going to happen.
Instead the logical outcome is that in the pursuit of profit, every participant in the system will keep pushing up to and over that imaginary line. Perhaps there is no line. But unless the buyers completely revolt, not much will change
Matthew Holt is the publisher of THCB.
The post Out of Network? Cigna, RICO and where’s the line? appeared first on The Health Care Blog.
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World: Around the world, readers react to shifting U.S. Alliances
Readers around the world largely denounced President Donald Trump’s behavior during his recent European tour.
Here are some of the reactions from our international readers as Trump’s trip unfolded. These responses have been edited and condensed for clarity.
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America ‘Won’t Have a Better Ally’ Than NATO
I am really pessimistic about the future of NATO, let alone a “united West” that shares values and interests.
It’s pretty obvious that Trump does everything he can to destabilize the European Union — from the outside and from within by supporting people like Viktor Orban.
He offered Macron a trade deal if he leaves the EU? He praises the Brexiteers? He tries to blackmail us? The starts of a trade war based on false claims?
Seriously? What else should we Europeans tolerate? What more evidence do we need that he is not an ally? — Mark B., Berlin
One of the reasons Europe spends less on arms is their generous expenditure on national health. Copying that would really make America great. — Paul, Australia
I think that Trump wants to demonstrate to every person on Earth that he can govern successfully by lying and trying to force other nations to do what he wants them to do.
He wants to be different from his predecessors, but in doing this he has just created chaos all over the world, easing the rise of populism in Europe.
He has withdrawn the U.S. from the Paris climate agreement, from the Iran nuclear deal, and now is threatening to withdraw also from NATO. If we want to stop populism, we heavily need the United States to lead all the democratic world against this threat, because otherwise the game is already lost. — Marco Ghilotta, Italy
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Balloons and Brouhaha in Britain
No wonder The Sun got the interview with Trump, because it’s owned by Rupert Murdoch. The tabloid is a fierce euroskeptic and urged its readers to vote for Brexit. That Trump heaped praise on Boris Johnson, saying he would make a “great” prime minister, sounded like a death knell for Theresa May. Now he makes himself even more unpopular in Britain. But Trump has once again scored points with Putin — to sow discord within the EU and create uncertainty in Britain. — J. Von Hettlingen, Switzerland
In the U.K., we tend to do things a bit differently from Uncle Sam. There will be leftist millennials deciding to wave banners around screaming “Down with Trump” and most of these will be in leftist London or university cities, but the real British people that actually support Trump will do as always and sit at home following Trump on the news programs, agreeing with him and then chatting at work on the Trump visit. The M.S.M. part of the British media will promote everything that the protesters say, but that’s because they are left-leaning, and please remember America, this isn’t the whole of U.K. portraying these views, a lot of the U.K. do support Trump entirely. — Britbazza2, England
I am an 84-year-old woman in England. I have not witnessed any belief or trust in the president’s attitude, apart from those who might seek some advantage for themselves in proclaiming their solidarity. I haven’t seen this hopeful self-deception since Neville Chamberlain’s return from Germany with his “peace in our time” document. That was a frightening time, as is this, but eventually we lived through it. Possibly we shall eventually muddle our way through this, too, somehow. — ETL., U.K.
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‘Stable Genius’ Questions U.S. Intelligence
It would be great if this necessary investigation on foreign interference in U.S. elections, whose freedom was “hard fought,” was accompanied by a comparatively detailed historical investigation of the U.S. interference in elections of so many other countries — totally dismissing other countries’ democratic freedom. I think this should be an integral part of this discourse. — George T., Vienna
It’s not winter (yet), but could this be the proverbial snowball that becomes the so-desperately-needed avalanche? — Francis, Switzerland
This is a total shame. The president of the USA is showing how weak he is. Traditional allies are not allies any more. Empowering enemies is the new American strategy. Russia is strong and ready for becoming what the USSR once was and Europe is divided and under threat. This is the result of electing a president who doesn’t know about history, democracy, liberty, humanity and transparency. Wake up American people! Make America a respectful country again! — Luis, Portugal
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Putin Meeting Stirs Controversy
Is not the principle job of the American president to protect American citizens and American interests and to defend the Constitution? Is that anyone’s interpretation of what just happened in Europe? Or maybe I just missed an amendment to the Constitution wherein the interest of Vladimir Putin and his merry band of oligarchs comes first. — Kevo, Sweden
I agree with our president that there is absolutely no collusion. On the other hand, there was probably collusion. — David U’Prichard, Greece
What I find astonishing is that the most powerful country in the world has allowed itself to be in the position where a real estate salesman and reality TV star, with absolutely no diplomatic negotiating skills or experience, who thinks he doesn’t need to read briefing memos or listen to expert advice, is meeting a man who spent 20 years working as an intelligence agent and then another 18 as a successful and all-powerful leader. If that isn’t a recipe for disaster then what is? — RHR, France
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Fraying Alliances
Donald Trump may be A problem, but he is not THE problem. The real problem is that half of U.S. voters went along with Trump, knowing exactly what kind of clown they were voting for — and that the whole of the GOP is still going along with Trump, in spite of every lie, perverse act, or treachery. You can remove Trump, but you cannot remove that half of U.S. voters who still back Trump nor the Republican Party, who are betraying their country along with Trump, by assuaging everything Trump does, whatever he says and permitting his actions. — Michel Couxijn, Amsterdam
Given that Trump is really just a logical consequence of many long-standing, deep-rooted problems in the U.S. centering on education, worldliness, racism, bigotry, unfettered predatory capitalism, gerrymandering and the Electoral College — all now enhanced by social media — there is no logical reason for assuming that the U.S. will in the future become a stable and reliable partner. — Robert Sanders, Japan
New partnerships are going to be formed all over the world. Those who imagine they can simply dial back the good old days after Trump the Destroyer has finished the job of making America hated again, may be sorely mistaken. We are moving on and may never want to come back.
The next chapter of commerce on this planet will have a more modest and sustainable cast. Economies largely based on consumerism, as in America, or speculation, as in China, will find themselves struggling to find traction with those that function just fine with less.
America cannot be made great again in the manner Trump and those who will not stand up to him imagine. We are giving notice we will not be bought, or bullied, or insulted into enabling their outdated agenda.
History will record that the Trump presidency presaged the decline of the American Empire as we have come to know it. Whether or not America succeeds in joining the rest of us as a decent and less self-serving partner remains to be seen. — Memi von Gaza, Canada
This article originally appeared in The New York Times.
Geneva Abdul © 2018 The New York Times
source https://www.newssplashy.com/2018/07/world-around-world-readers-react-to_22.html
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