This is not inconceivable. The doctor may know her own fee, but is also ordering services such as use of the clinic, assistants, supplies, and so forth. She has never had to pay for any of those things. She doesn't even know what business entities she's dealing with, possibly an impenetrable rats nest of LLC's. I've read that over half of all doctors are self employed, meaning that their salaries are not a good measure of their incomes.

Were I inclined toward cynicism, I'd say that the purpose of the complexity is to make it impossible for anybody to figure out where the money is going, or who is actually gouging whom. Somebody is gouging us, but we'll never know who, and everybody can claim it's somebody else.

In my view, the only way to get to the bottom of where the money is going, is to manage the whole thing. This may be why nationalized systems cost so much less. The people who are gouging would stick out like a sore thumb.