When I was in the fee-for-service system, I felt like I was playing a game of Whac-A-Mole with Medicare. We had to find ways of doing as much stuff to as many people as possible to generate as much revenue just to pay for the computer systems that I needed to bill Medicare so that I could get paid. So I’d have to get more people and I’d have to hire more staff, and then I’d have to see more patients to pay more staff, and it was a snowball. Every time I found a way to generate revenue and prop up this monstrosity that we were required to build, Medicare would knock the knees out from under us and take away that revenue source. Eventually we just said, “No more.
”
It’s the cost of the human labor associated with processing those claims and getting paid. If we eliminate their No. 1 line item expense in their service delivery, we can bring those prices way down. And that’s exactly what we saw. We would see 95 percent discounts on the laboratory services.
@Mu Yixiao:
So health care at $900 per year per person?
Plus insurance on top of that for “catastrophic” conditions.
Which would add up to…?
Though perhaps it would bear down on base costs.
It’s worth noting that US health cost are ludicrously high.
The second highest health spend per capita in the world is Switzerland.
US per capita spend is 42% greater than the Swiss.
Possibly almost any alternative system could reduce costs; they surely couldn’t be much higher!
I’ve been thinking about last week’s discussion on the maximum length of human lifespans.
The first thing to consider is that death seems to be baked in as far as most organisms go, as much as reproduction also seems to be. The second is that natural selection and evolution are blind forces, without goals or objectives past passing along genes (aka DNA or in some cases RNA) farther into the future.
I bring the second up, because we’ve seen what developments best assure such passing on of genes in large animals, and yet these developments are so unlikely they converged on a single genus as far as we know. I’m referring to intelligence and the ability to manipulate objects, or big brains coupled with dexterous enough hands. This we see only in hominids, and to a lesser extent in a few other primates.
So, a species capable of developing technology, like us, reproduces to numbers far above what species incapable of technology can dream of.
Except, we’ve brought along other species for the ride. those we find useful, like crops and livestock, and working animals and pets. Also those species that can establish symbiosis with us (mostly bacteria). And finally parasitic and pathogenic species that can make homes among us (rats, pigeons, pathogens of all kinds, etc.)
This means a species can reap the benefits of technology, in an evolutionary sense, without developing technology itself.
Consider a chordate, large animal, of whatever phylum, that was immortal. It could continue to reproduce indefinitely, for thousands or millions of years. It’s tempting to say it would no longer evolve, but that’s wrong. Mutations in its germ plasm would continúe in itself and its offspring.
We’ve seen one technological species, but no immortal ones (not in chordate large animals). Why not?
I can think of several reasons, but this comment has gone on long enough. I’ll boil it down to it’s even more unlikely than technology, and it may not even be possible given how life wound up evolving.
Supreme Court rules in favor of athletes in NCAA compensation case
The 9-0 decision represents a landmark victory for college players and a significant moment in the history of college athletics, as lawmakers in Congress and statehouses weigh new laws to allow athletes to profit from personal endorsements and sponsorships.
Making tools on purpose for a specific use or purposes (including multiple purposes for one tool, for example a knife), retaining the knowledge of how to make them, and being capable of teaching this knowledge to others.
The Court’s ruling is fairly narrow. Kavanaugh’s concurrence is more interesting, since he expresses the opinion that now it’s settled that antitrust law applies to the NCAA, the NCAA is most likely doing a bunch of other things in violation of those laws.
@Mu Yixiao:
Yes, I read the article.
If that sort approach could get costs down to standard “rich country” levels it would be worth looking at.
But, as noted, you’d need catastrophic/chronic care insurance too.
(Either direct insurance or public scheme)
So to see the overall costs of the system you’d need to calculate that as well.
I leave that as an exercise for health economists; be interesting to see the results though.
As I say, could hardly turn out more costly.
@Mu Yixiao: The flat-fee for a patient model incentivizes provider behaviors to cherry-pick healthy patients. A practice will do better if you have young, healthy people who show up once a year for a physical. And because practices are relatively small, it puts the variability of profit at a level where the profit per patient doesn’t smooth out as the number of patients scales up.
It would also encourage practices to have larger numbers of patients with increasing wait times to see a doctor.
What we’ve seen in health care is that a significant percentage of people either are or will become bad actors. And then patients suffer. You need to align the financial incentives of the doctor to the patient and the public health policies at large.
We would see 95 percent discounts on the laboratory services.
What’s wrong with a lab provider demanding payment that represents (say) 110% of the actual cost of that service?
Medicare’s advisory board establishes the cost of services (including lab), makes minor adjustments (for geographic and in-house) and approves a 100% reimbursement schedule. (of which the patient is on the hook for ~20%.
I makes no sense that a lab charges 35 dollars for an EKG that the the lab knows (in advance) that Medicare will only approve 14.34 (and the patient pays 2.87).
It also makes no sense that the Dr reading the EKG charges 300 dollars when the Dr knows (in advance) that Medicare (with the assistance of the AMA) will only approve 42.68 (and the patient pays 8.54)
The lab quoted them $1,800 for the blood work. […] That patient was able to get the same exact labs at the same exact facility for $85.
I will happily wager with you that the factor-of-20 markup on the original quote has little to do with the lab’s labor costs for filling out paperwork.
That said, I don’t see where the phrase “free market” in the article’s title comes from. This is not what free market healthcare would look like; it’s what nonprofit healthcare would look like.
As a thought experiment, if all primary care were provided on this model, at $75/month current dollars, what percentage of people in America do you think would participate?
@Bob@Youngstown: The reason that charges are far above the allowable is that Medicare has a “most favored nation” clause that means that you can’t charge anyone less than what you charge Medicare. If 1% of your clients are willing to pay some high number, you charge everybody that rate. Thus the charge is set by what the highest bidder will pay. Often that high bidder has negotiated discounts for other services. The burden of these inflated charges falls on the uninsured who are in no position to negotiate discounts. Thus medical bills contribute to most bankruptcies. https://www.cnbc.com/2019/02/11/this-is-the-real-reason-most-americans-file-for-bankruptcy.html
@Bob@Youngstown: In the 70s, most HMOs were non-profit. And much larger than a single practice. Less profit-motive, and more capable of handling the less healthy.
The flat-fee for a patient model incentivizes provider behaviors to cherry-pick healthy patients.
The people who wrote Obamacare weren’t idiots, they looked to decades of real world experimentation and thought to develop the models. The people that most influenced those programs were physicians and providers who had experience developing cross population programs catering to rich and poor, well and sick and very sick, that had to break even, plus a bit more. So once a patient has a particular disease state the reimbursement is based on norms of practice for that particular particular conditioned and applied only to wide networks where the range of severity and care needed averaged out.
Unfortunately, those programs were nascent and everyone involved understood that if it had a chance it would require constant refinement and tinkering, or else the providers would behave exactly as you described and push the truly sick patients into poorly funded public systems. Once Trump was elected and the Republicans started doing everything they could to sh*t on the programs it was generally recognized those initiatives were dead in the cradle.
Trump and the Republicans caused the death of two different initiatives I was personally involved in, and both were tuned to providing significantly better outcomes, much better quality of life for patients who were severely ill, and a reduction in costs to the system. Remember, the Republicans did everything they could to kill the hospice program. What kind of sick f*cks play politics with that?
I agree that he is not describing a free market system. No one has a functioning model of a free market health care system. Don’t be fooled by talk about Lasik. Direct primary care has been around a while. It looks like it might be able to cut down costs on primary care. A lot of that does come from savings in admin costs, but for people without other insurance they can use their clout, and control of a lot fo pts who need referrals, to get labs to agree to lower costs. Mark ups for labs really can be huge.
However, never forget how health care moneys spent. 50% of health care money is spent on 5% of patients. Its is really the big spending of chronic care and major acute care events (cancer, surgery) that drive spending. The other stat to remember (in the link that follows) is that 50% of people account for only 3% of spending. Direct primary care mostly reduces spending in that 3% area, plus a bit from some of the rest. Not a panacea, you still need insurance, but it has a lot of conveniences. Worth considering just for the less hassle factor.
The first is a comparative study of the US system with 5 proven systems in other places, the second is a comparative study of VA healthcare with our own. The first shows what is possible, the second shows how we’ve already done it at the VA. We adopt any of those five systems and a VA becomes unnecessary. The VA only exists because our regular system is inefficient and grossly overpriced.
Kill the right people to make me king, and you get an election where everybody has to choose one of those five systems, a second election between the top two, and we adopt the winner verbatim.
A political newcomer has entered the race for Arkansas governor and the ad announcing his campaign is garnering a lot of attention. Chris Jones, a nuclear physicist, and ordained minister says he is running to take Arkansas into the future:
I’ve never thought that hard about why I enjoy walking.
It just seems like an activity you should enjoy. A thing beneath active probing for intent and benefits.
New sights, new sounds, new smells. All good stuff. Plus, you get to soundtrack your experience easily now.
My proclivity is either early or late. In summer, more moderate temperatures. But, that is my preferred schedule year-round with the slight carve out for January.
It dawned on me suddenly: the quality of the light.
Around dusk or dawn is much more aesthetically pleasing than the harsh full light of 1pm.
A world of long shafts of sunlight and comically stretched shadows is just more pleasant to me.
Plus, the more atmosphere sunlight has to muscle through to reach my eyenalls, the diffuse and varied the effect.
The feeling of noonday sun and dusk sun is profoundly different. I prefer dusklight.
@de stijl: I like dawn because of the energy of a brand new day, full of promise and what-if’s….and dusk feels like a well-earned treat, time to reflect and make a plan for tomorrow.
1 PM is like forever Monday. Harsh, blazing light, heat, thinking in your head “I can’t wait to get out of here!”
Blast from the past. I have a hard time listening to Perfect Circle from the early 2000’s, bad situational memories. My kid picked them up, though, and wanted them played LOUD.
You chose a song to tout I did not expect from you. A slow, mighty, modern day re-imagining of Lennon’s Imagine.
You know, you might might like The Killers. Outta Utah. Solid band, good songs, really interesting lyricist / singer.
Off-kilter people raised Mormon have an interesting take on the world.
Mr. Brighteyes is the meme song (it’s a damn good danceable song). You might want to attempt entry via When You Were Young. That’s a solid song, right there. Their whole back-catalog is really pretty great.
Dustland, out just this last week is pretty epic and features Bruce Springsteen to excellent effect.
@de stijl: The lead singer of The Killers has also covered a number of tunes from the ’80s and is amazingly good. Check out this cover of Electric Blue (originally by Icehouse).
Re: Bette Davis’ Eyes. I spent that summer it came out working at a convenience store trying to forget about bad stuff looming on the horizon.
It was a local guy who owned an independent store not part of a chain. He was a total gent. Best retail boss I ever had I had when I was 17.
No choice on music, we played the poppiest of pop stations, which was not my preferred, go to station or music. That summer, I heard Bette Davis’ Eyes perhaps 10,000 times. No foolin’.
Even at that time in my then, I had to acknowledge that as a well written song expertly performed.
The reason that charges are far above the allowable is that Medicare has a “most favored nation” clause that means that you can’t charge anyone less than what you charge Medicare.
Perhaps I’m dense, but that makes no sense whatsoever.
I seems like you are saying that Medicare requires a provider to charge a patient (regardless of insurance status) more than or equal to what that provider might choose charge to any payer.
It seems to me that the provider’s charge is (or maybe) completely disassociated with the actual cost of the service. So to what end? What is the point?
At least Medicare’s reimbursement schedule is based on some analysis of cost and labor. Fortunately most of the major commercial insurer’s reimbursements are based on a similar analysis.
The only excuse I can imagine for demanding out-of-justification payments to to f**k with the poor uninsured.
It’s why for-profit medical care is not the model adopted by basically all of the planet except us.
It is staggeringly inefficient and does a shitty job at delivering on its primary stated goal.
We have a warped and nonsensical health care delivery system.
For-profit healthcare is a foolish gambit we are currently ham-strung by. It inhibits us.
We would be better served just buying out existing for-profit hospital chains and systems even at exorbitant prices and adopting a European model of health care delivery.
The proven alternate system is there. We are too hide-bound and mulish to accept that we did it wrong and everyone else was right. Just on-going rampant foolishness based on political donations, pull, and tradition.
We could. We should. We won’t. Literally every other advanced nation in the world is better at this than we are.
Maryland had no Covid deaths reported on Sunday. First time since last October.
What free-market health care would actually look like.
”
@Mu Yixiao:
So health care at $900 per year per person?
Plus insurance on top of that for “catastrophic” conditions.
Which would add up to…?
Though perhaps it would bear down on base costs.
It’s worth noting that US health cost are ludicrously high.
The second highest health spend per capita in the world is Switzerland.
US per capita spend is 42% greater than the Swiss.
Possibly almost any alternative system could reduce costs; they surely couldn’t be much higher!
@JohnSF:
And if you read the article, you’ll see that a massive amount of that is coding and other administrative paperwork.
I’ve been thinking about last week’s discussion on the maximum length of human lifespans.
The first thing to consider is that death seems to be baked in as far as most organisms go, as much as reproduction also seems to be. The second is that natural selection and evolution are blind forces, without goals or objectives past passing along genes (aka DNA or in some cases RNA) farther into the future.
I bring the second up, because we’ve seen what developments best assure such passing on of genes in large animals, and yet these developments are so unlikely they converged on a single genus as far as we know. I’m referring to intelligence and the ability to manipulate objects, or big brains coupled with dexterous enough hands. This we see only in hominids, and to a lesser extent in a few other primates.
So, a species capable of developing technology, like us, reproduces to numbers far above what species incapable of technology can dream of.
Except, we’ve brought along other species for the ride. those we find useful, like crops and livestock, and working animals and pets. Also those species that can establish symbiosis with us (mostly bacteria). And finally parasitic and pathogenic species that can make homes among us (rats, pigeons, pathogens of all kinds, etc.)
This means a species can reap the benefits of technology, in an evolutionary sense, without developing technology itself.
Consider a chordate, large animal, of whatever phylum, that was immortal. It could continue to reproduce indefinitely, for thousands or millions of years. It’s tempting to say it would no longer evolve, but that’s wrong. Mutations in its germ plasm would continúe in itself and its offspring.
We’ve seen one technological species, but no immortal ones (not in chordate large animals). Why not?
I can think of several reasons, but this comment has gone on long enough. I’ll boil it down to it’s even more unlikely than technology, and it may not even be possible given how life wound up evolving.
Show Me the Money!
@Kathy:
How do you define “technology”? (As opposed to “tools.”)
@Kylopod:
Making tools on purpose for a specific use or purposes (including multiple purposes for one tool, for example a knife), retaining the knowledge of how to make them, and being capable of teaching this knowledge to others.
@Kathy: Then humans are not the only technological species.
@Mister Bluster:
The Court’s ruling is fairly narrow. Kavanaugh’s concurrence is more interesting, since he expresses the opinion that now it’s settled that antitrust law applies to the NCAA, the NCAA is most likely doing a bunch of other things in violation of those laws.
@Mu Yixiao:
Yes, I read the article.
If that sort approach could get costs down to standard “rich country” levels it would be worth looking at.
But, as noted, you’d need catastrophic/chronic care insurance too.
(Either direct insurance or public scheme)
So to see the overall costs of the system you’d need to calculate that as well.
I leave that as an exercise for health economists; be interesting to see the results though.
As I say, could hardly turn out more costly.
@Mu Yixiao: The flat-fee for a patient model incentivizes provider behaviors to cherry-pick healthy patients. A practice will do better if you have young, healthy people who show up once a year for a physical. And because practices are relatively small, it puts the variability of profit at a level where the profit per patient doesn’t smooth out as the number of patients scales up.
It would also encourage practices to have larger numbers of patients with increasing wait times to see a doctor.
What we’ve seen in health care is that a significant percentage of people either are or will become bad actors. And then patients suffer. You need to align the financial incentives of the doctor to the patient and the public health policies at large.
This doesn’t do it.
@Mu Yixiao:
What’s wrong with a lab provider demanding payment that represents (say) 110% of the actual cost of that service?
Medicare’s advisory board establishes the cost of services (including lab), makes minor adjustments (for geographic and in-house) and approves a 100% reimbursement schedule. (of which the patient is on the hook for ~20%.
I makes no sense that a lab charges 35 dollars for an EKG that the the lab knows (in advance) that Medicare will only approve 14.34 (and the patient pays 2.87).
It also makes no sense that the Dr reading the EKG charges 300 dollars when the Dr knows (in advance) that Medicare (with the assistance of the AMA) will only approve 42.68 (and the patient pays 8.54)
@Gustopher:
Wasn’t that what was called HMOs in the 1970s? I personally know how that worked out when I became temporarily “less healthy”.
link
@Mu Yixiao:
I will happily wager with you that the factor-of-20 markup on the original quote has little to do with the lab’s labor costs for filling out paperwork.
That said, I don’t see where the phrase “free market” in the article’s title comes from. This is not what free market healthcare would look like; it’s what nonprofit healthcare would look like.
As a thought experiment, if all primary care were provided on this model, at $75/month current dollars, what percentage of people in America do you think would participate?
@Bob@Youngstown: The reason that charges are far above the allowable is that Medicare has a “most favored nation” clause that means that you can’t charge anyone less than what you charge Medicare. If 1% of your clients are willing to pay some high number, you charge everybody that rate. Thus the charge is set by what the highest bidder will pay. Often that high bidder has negotiated discounts for other services. The burden of these inflated charges falls on the uninsured who are in no position to negotiate discounts. Thus medical bills contribute to most bankruptcies. https://www.cnbc.com/2019/02/11/this-is-the-real-reason-most-americans-file-for-bankruptcy.html
@Bob@Youngstown: In the 70s, most HMOs were non-profit. And much larger than a single practice. Less profit-motive, and more capable of handling the less healthy.
This would be worse.
@Gustopher:
The people who wrote Obamacare weren’t idiots, they looked to decades of real world experimentation and thought to develop the models. The people that most influenced those programs were physicians and providers who had experience developing cross population programs catering to rich and poor, well and sick and very sick, that had to break even, plus a bit more. So once a patient has a particular disease state the reimbursement is based on norms of practice for that particular particular conditioned and applied only to wide networks where the range of severity and care needed averaged out.
Unfortunately, those programs were nascent and everyone involved understood that if it had a chance it would require constant refinement and tinkering, or else the providers would behave exactly as you described and push the truly sick patients into poorly funded public systems. Once Trump was elected and the Republicans started doing everything they could to sh*t on the programs it was generally recognized those initiatives were dead in the cradle.
Trump and the Republicans caused the death of two different initiatives I was personally involved in, and both were tuned to providing significantly better outcomes, much better quality of life for patients who were severely ill, and a reduction in costs to the system. Remember, the Republicans did everything they could to kill the hospice program. What kind of sick f*cks play politics with that?
I agree that he is not describing a free market system. No one has a functioning model of a free market health care system. Don’t be fooled by talk about Lasik. Direct primary care has been around a while. It looks like it might be able to cut down costs on primary care. A lot of that does come from savings in admin costs, but for people without other insurance they can use their clout, and control of a lot fo pts who need referrals, to get labs to agree to lower costs. Mark ups for labs really can be huge.
However, never forget how health care moneys spent. 50% of health care money is spent on 5% of patients. Its is really the big spending of chronic care and major acute care events (cancer, surgery) that drive spending. The other stat to remember (in the link that follows) is that 50% of people account for only 3% of spending. Direct primary care mostly reduces spending in that 3% area, plus a bit from some of the rest. Not a panacea, you still need insurance, but it has a lot of conveniences. Worth considering just for the less hassle factor.
https://www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/#item-start
Steve
On healthcare, whenever I encounter the genuinely curious on the topic of reforming the US HC system I recommend to them two things:
Sick Around The World
and Best Care Anywhere.
The first is a comparative study of the US system with 5 proven systems in other places, the second is a comparative study of VA healthcare with our own. The first shows what is possible, the second shows how we’ve already done it at the VA. We adopt any of those five systems and a VA becomes unnecessary. The VA only exists because our regular system is inefficient and grossly overpriced.
Kill the right people to make me king, and you get an election where everybody has to choose one of those five systems, a second election between the top two, and we adopt the winner verbatim.
We don’t have to re-invent the wheel either.
Democrat’s Ad Goes Viral After Jumping In Governor’s Race Against Sarah Huckabee Sanders
Seriously, watch this ad.
I have weirdly abnormal reflexes where time seems to slow down, but this catch is out of my league
@Teve: THAT’S pretty damn amazing. Has Sarah Sanders responded yet? The attack ads against her write themselves.
@Jax: I haven’t heard her response yet, her handlers are probly trying to get one successful take where she doesn’t refer to him as a “Colored”.
I’ve never thought that hard about why I enjoy walking.
It just seems like an activity you should enjoy. A thing beneath active probing for intent and benefits.
New sights, new sounds, new smells. All good stuff. Plus, you get to soundtrack your experience easily now.
My proclivity is either early or late. In summer, more moderate temperatures. But, that is my preferred schedule year-round with the slight carve out for January.
It dawned on me suddenly: the quality of the light.
Around dusk or dawn is much more aesthetically pleasing than the harsh full light of 1pm.
A world of long shafts of sunlight and comically stretched shadows is just more pleasant to me.
Plus, the more atmosphere sunlight has to muscle through to reach my eyenalls, the diffuse and varied the effect.
The feeling of noonday sun and dusk sun is profoundly different. I prefer dusklight.
@de stijl: I like dawn because of the energy of a brand new day, full of promise and what-if’s….and dusk feels like a well-earned treat, time to reflect and make a plan for tomorrow.
1 PM is like forever Monday. Harsh, blazing light, heat, thinking in your head “I can’t wait to get out of here!”
@Kathy:
Immortality would be maladaptive IRT population size and distribution.
Also, immortality sounds extremely boring. Limits beget appreciation. Living forever is a poor population design and poor individual growth factor.
Major religions that hawk eternity spook me. I do not want that. Eternity is hell. Even a blissful one. Perhaps especially a blissful one.
Why would anyone desire that?
Blast from the past. I have a hard time listening to Perfect Circle from the early 2000’s, bad situational memories. My kid picked them up, though, and wanted them played LOUD.
https://www.youtube.com/watch?v=dunKAwRN3P8
@Jax:
You chose a song to tout I did not expect from you. A slow, mighty, modern day re-imagining of Lennon’s Imagine.
You know, you might might like The Killers. Outta Utah. Solid band, good songs, really interesting lyricist / singer.
Off-kilter people raised Mormon have an interesting take on the world.
Mr. Brighteyes is the meme song (it’s a damn good danceable song). You might want to attempt entry via When You Were Young. That’s a solid song, right there. Their whole back-catalog is really pretty great.
Dustland, out just this last week is pretty epic and features Bruce Springsteen to excellent effect.
@Jax:
Dawn is lemony and tart. Dusk is buttery and smooth.
Pick your poison.
@de stijl: The lead singer of The Killers has also covered a number of tunes from the ’80s and is amazingly good. Check out this cover of Electric Blue (originally by Icehouse).
Then listen to his cover of Bette Davis Eyes.
@Jen:
Crikey! I did not know about these. Good call!
Seriously good recommendations.
Re: Bette Davis’ Eyes. I spent that summer it came out working at a convenience store trying to forget about bad stuff looming on the horizon.
It was a local guy who owned an independent store not part of a chain. He was a total gent. Best retail boss I ever had I had when I was 17.
No choice on music, we played the poppiest of pop stations, which was not my preferred, go to station or music. That summer, I heard Bette Davis’ Eyes perhaps 10,000 times. No foolin’.
Even at that time in my then, I had to acknowledge that as a well written song expertly performed.
Brandon Flowers is, and always has been, a very interesting cat.
@Slugger:
Perhaps I’m dense, but that makes no sense whatsoever.
I seems like you are saying that Medicare requires a provider to charge a patient (regardless of insurance status) more than or equal to what that provider might choose charge to any payer.
It seems to me that the provider’s charge is (or maybe) completely disassociated with the actual cost of the service. So to what end? What is the point?
At least Medicare’s reimbursement schedule is based on some analysis of cost and labor. Fortunately most of the major commercial insurer’s reimbursements are based on a similar analysis.
The only excuse I can imagine for demanding out-of-justification payments to to f**k with the poor uninsured.
@Bob@Youngstown:
It’s why for-profit medical care is not the model adopted by basically all of the planet except us.
It is staggeringly inefficient and does a shitty job at delivering on its primary stated goal.
We have a warped and nonsensical health care delivery system.
For-profit healthcare is a foolish gambit we are currently ham-strung by. It inhibits us.
We would be better served just buying out existing for-profit hospital chains and systems even at exorbitant prices and adopting a European model of health care delivery.
The proven alternate system is there. We are too hide-bound and mulish to accept that we did it wrong and everyone else was right. Just on-going rampant foolishness based on political donations, pull, and tradition.
We could. We should. We won’t. Literally every other advanced nation in the world is better at this than we are.