Insured price $2,758, cash price $521
latimes.com
latimes.com
I refused to pay it. It was the first time I did not pay a debt and the first time I was sent to collections. I refused based on principle, and not because I couldn’t afford it. Collections called me for about 3 months, and every time someone called and said, “is this John Wheeler”, I would never confirm and then go about asking why they are calling for John Wheeler. Eventually, the calls stopped and the collection agency wrote it off to their unpaid reserves (I’m assuming), I never received a ding on my credit report.
Everyone is always asking why US healthcare is so expensive. People blame it on the insurance companies and the hospitals, but my theory is it’s the providers.
I worked at Vanderbilt on their payroll system, and I would regularly see general practitioners making $350,000 a year, and this was 15 years ago! It wasn’t uncommon to see teaching doctors getting paid a million dollars.
As society, we seem to be ok with millennials fresh out of college making hundreds of thousands of $$$ a year for a bunch Javascript that allows people to share pictures of their butt with their friends BUT we are not ok with doctors who literally - save lives - getting paid according to their responsibilities?
Same goes with football/basketball/etc.. players whose sole purpose in life and responsibilities are to throw a ball somewhere and for that, they are covered in gold!
I think doctors should be paid a lot of money and on the other hand, many other professionals should be paid way less compared to what they make now!
That said, this proves, yet another time, how unfair and inefficient this whole health insurance system is.
Health care should be a universal right and should be provided as a public service at a minimum cost for single contributors. People have the right to getting sick and receive the best possible care without going bankrupt or having to sell their houses for it.
It is that simple.
On this, the EU model wins hands down compared to the US one. And it's time for Americans to open their eyes and realize how unfairly they have been treated in this regard for their entire lives.
Programmers only make that because the services they build are extremely scalable, profitable, and wanted by many driving up demand for programmers. Eventually, supply should drive down wages which is fair. I also don't mind doctors making good money but they should not be able to artificially constrain supply just so they can jack up their prices.
When you look at the stock market and you see ludicrous P/E ratios on companies like Google and Amazon it must be acknowledged the only reason money sees them as being so valuable is because governments the world over have awarded them, through employee ingenuity or acquisition, exclusive permanent monopolies to millions of ideas enshrined in copyrights any of which could explode into an infinite money machine on any given Tuesday. Paired with their treasure troves of harvested data on people they are the largest entities in existence not for the actual real world value they produce but for the untenable position they now occupy with the force of the state and international trade standing behind them to preserve their position as the total arbiters of information.
Its really gross, and I have to live every day knowing that I largely do this (the programming, computers, tech, etc) on the back of a power structure enshrined and grown cancerous over centuries with the intent to exploit perpetual monopolies on ideas.
Actually, it feels like with everything hosted server side these days there really isn't a lot of benefit to IP protection to tech companies. Media companies yes, tech companies not really.
Even if all of googles source code was stolen today, and it was legal for people to use it, would that really change anything for google?
FAANG companies make from 500k to over 1 million dollars in revenue per employee.
Paying someone 1/10th to 1/4rd of what they bring in is hardly outrageous.
That is once again a US-centric view. The rest of the world doesn't overpay their programmers to nearly the same degree. It's a comfortable wage. Upper middle class. But the equivalent of "entry-level six figures", not "six figures, then a couple times over beyond that for good measure".
In The Netherlands, psychiatrists have a higher entry level salary than the average CS grad.
On holiday in Rarotonga, our 2 year old got a chest infection.
We made it way up the hill to the hospital. A stray dog watched from the side of the road as we drive into the parking area. No one in sight. Eventually we saw someone who pointed us to a building wherein sat the duty doctor.
Super efficient, trained in new Zealand, she examined the sprog, diagnosed him and gave us the appropriate meds. No waiting, all sorted in less than 20 minutes.
Finally she said apologetically that we would have to pay - $2.50.
She took the money and out it into an old fashioned money box and cheerily sent us on our way.
Doctors should be paid well, and in the case of the Cook Islands I assume they have public institutions providing doctors and medicine. In which case, tax payers are paying for it. Which is almost always the most ethical way to do it, and the only really right way we have working practicably in the world today, but it isn't some impossible efficiency that $2.50 supports the costs of operating the hospital, the cost of the drugs, training the doctor, and paying them a wage to justify their skill and expertise required.
Its largely where many politicians in the US arguing for fundamental change to the system come from - its really hard to imagine anything much worse than what they US has now. It would actually take considerable effort to design a more inefficient, more obfuscated and incomprehensible, more exploitative and harmful way to organize medicine professionally.
People just don't want to acknowledge that the United States federal government is not acting on the behalf of its citizens in its decisions whatsoever. It hasn't for decades, but coming to terms with the dissolution of democracy and the reality that US citizens don't have a meaningful, statistical say in government anymore is a hard pill to swallow, because the answers to the question "what do we do about it, then?" are all ugly.
And certainly if I had a rare cancer I would rather be in the Mayo Clinic, as long as my insurance was all lined up.
Certainly these are difficult problems to grapple with, and bewildering to people outside the US - the current situation and also the extreme proposals currently being touted.
[1] https://www.merritthawkins.com/news-and-insights/blog/job-se...
[2] https://jacksonhealthcare.com/media-room/news/md-salaries-as...
The government has decided it's too stupid to run hospitals. But it's also decided that it needs to ensure both the supply of hospitals, and to maintain standards. So instead of just telling doctors what to do (and paying them enough to ensure a steady stream of high quality medical students) it tries to get all the red tape and subsidies right, while the private sector (hospitals and insurers) try to figure out how to outsmart the government and make the system more expensive.
The US government spends a similar amount (per captia or as a percent of GDP) as Canada on its public funding (Medicare, Medicaid, VA, and so on). But the US system is so fantastically inefficient (due to weird incentives and massive amounts of bureaucracy and profit seeking) that unlike Canada it can't even offer basic universal healthcare (despite spending an insane amount of tax dollars).
As of 2016, Canada's public spending was 7.4% of GDP, the US's was 8.5%; and the US per-capita GDP is higher, too, so I don;t think its really "a similar amount" per capita, and only loosely so per GDP. But, yeah, the big difference is that the US spends even more than the publicly spending in private healthcare spending, while Canada (like most other first-world countries) spends far less privately than the public share.
https://www.healthsystemtracker.org/chart-collection/health-...
i’m less sympathetic to high administrator pay among medical networks, the whole medical records/billing industry, as well as the medical insurance industry. that feels like a very high tax burdened onto healthcare.
Second, another disclaimer: if you were a 1st time parent, I kind of understand!
103F/39.4C is unquestionably a high temperature, but it's almost always part of a viral infection, and ibuprofen and/or paracetamol will almost always reduce it. It's really not particularly unusual for kids to get a high temperature while they're ill, and I literally can't fathom why you'd take a 4yo to the ER for a high temp.
Here in the Europe, we give ibuprofen and/or paracetamol, and wouldn't dream of taking our kids to the ER without a very good reason, such as the meds not bringing the temperature down, or there being a rash, or anything else that raised alarm bells; I'm assuming of course that were there any such circumstances, you would have mentioned them.
At worst in Europe, we'd take them to the GP the same or next day. And the GP would, without doubt, assume you were a 1st time parent and say "it's viral" and (somewhat) politely kick you out. I've literally been there with a child having a 40C temp, and they weren't arsed. I've been there myself with a temp of 41C, and they weren't arsed.
In the US, the journey to become a doctor is made unnecessarily complicated and once people become doctors, they do gatekeeping and make sure it's equally as hard for others to become one. But the reality is that the physicians who treat garden-variety diseases can be trained much less expensively. No wonder physicians make loads of money while complaining about their massive student loan. My gf is a medical resident; my host parents in the US are both doctors; I have so many doctors as acquaintances; and I know that what they do is NOT even remotely difficult in terms of intellectual demand (only physically tiring and emotionally draining sometimes when you have to deal with difficult patients). I, as a programmer, would switch my salary with them in a heartbeat (regret leaving medical school in after second year in my home country, though I hated it at that time because of the sheer amount of rote memorization one had to do) and I do believe what I do everyday requires at least equally tasking mental load than what doctors do.
So, how do you make sure that only garden variety patients see the medical assistant, while seriously sick ones or those who have only telltale signs of a 1-10k illness see the real doctor? If those rare ones don't get to the doc they die.
so, because even the best make mistakes, that's a good reason to let under-trained (relative to an MD) people with even less skill make mistakes? Not following your logic here.
For what is worth, a physician assistant can diagnose quickly (and they can be assisted with a ML/rule-based diagnosis system that is trained on something like "Pocket Medicine: The Massachusetts General Hospital", which is what most doctors in training use as a handbook) and escalate the difficult ones to the specialist doctors.
Equating salary to mental load is also factitious. Manual laborers work harder than all of us, maybe we should switch salaries with them.
I 100% agree with the difficulty of becoming a doctor. I disagree with the gatekeeping however. Ultimately it comes down to residency positions available, and funding is government limited. We're seeing tons of new medical schools opening, acceptance of the DO crowd, and still the system is getting more competitive.
I agree it's the providers which are most at fault. Hospitals (as well as drug companies) are providers too though not just doctors. It's hospitals that are charging $4,000 a night for a hospital room and $50 for 2 tylenol which you can pick up at Walgreens for $4 for a 24-pack. Actual examples from my hospital bill when I had my appendix removed a few years ago. The total came to about $50k, of which I believe the portion that went to doctors and surgeons was about $10-15k.
Later the bills arrived: $1300 from the ER ($1900 minus a $600 uninsured discount) and $600 from the PA who saw us. Insane!
If you’re not bleeding, have a broken limb or other trauma or an expectation of being admitted, you don’t belong in the ER. Take a benadryl.
An ER handles everything from bee stings to shootings or strokes. They’re optimized to deal with those emergencies, not optimize cost for minor dings, especially when most of the minor issues are uninsured people who won’t pay anyway.
Emergency medicine is not a profit center, and is often mandated to exist. You’re paying for all of the lost receivables and capability.
Yeah, and urgent care facilities usually have working hours like 8AM-8PM. Because, you know, those are the only hours people every get minor sicknesses.
"Clark had to decide: Should she take Lily to the emergency room?
She called a poison control hotline and the answer was yes ...
But Clark knew that the emergency room can be expensive.
...
“I’m weighing my options,” Clark says. “She could have a seizure at any moment. It felt terrible, as a parent, to be in the position of having to do that.”
Clark and her husband decided to give Lily some activated charcoal at home and drive to the emergency room. But they wouldn’t go inside.
Instead, they pulled their car into the second row of the parking lot, about 100 feet from the entrance. They start playing The Little Mermaid on the car’s TV screen for Lily to watch. And they waited.
“We were just sitting there, facing the door and watching Lily,” Clark says. “We chose the second row because we wanted to be close to the entrance, but also trying to look inconspicuous.”
The Clarks waited in the parking lot for a few hours, and Lily didn’t show any symptoms. They drove home without setting foot in the emergency room."
I guess if they worked for a public hospital they would, but that’s not all doctors.
The time has come for a complete overhaul of the system. No more primary care doctors. They can be replaced by software and patient service representatives.
Diagnostic services should be the front line of healthcare. You should be able to get whatever diagnostic test you want, whenever you want.
All prices must be 100% transparent to the patient before any services are rendered. Opaque pricing allows for arbitrarily high pricing.
Huge increases in medical school enrollments. Removal of arbitrary licensing caps.
So much more needs to be done but this is a start.
Tests may be less expensive than what we are getting billed, but they aren't free. There are hypochondriacs who I'm sure would order hundreds of tests a year if allowed. There are many people who have hard to diagnose problems, and out of desperation, would order tests which have no possible bearing on their condition, just in case it finds something.
Let's say that you routinely screen everyone for everything, because why not, it's free. What is the burden of not only performing all those tests, but following up on the flood of false positives? It would probably swamp the healthcare system, allocating resources to the wrong places.
With any diagnostic test you need to understand what it tests for, how it tests for it, and when it gives false-positives and negatives.
It's just not possible to understand what's going on without a lot of training and education.
Non-medical and medical collections tend to get different treatment nowadays[1][2]. It may have ended up on your credit but after a super long delay, or it'd disappear entirely if they were able to get something out of your insurance instead. And even if it shows up on your credit report, depending on the specific scoring model being used, it still may not have had much if any impact. [2] details how some of the scoring models treat medical collections.
[1] https://www.experian.com/blogs/ask-experian/can-medical-bill...
[2] https://www.creditkarma.com/advice/i/how-to-remove-medical-c...
Which, incidentally, is the same principle behind most "fix your credit" services. They dispute the accuracy and validity of the entries on your report, and if the reporting entity can't produce the appropriate documentation (such as a loan agreement or equivalent), it'll get dropped from your history. And even if it doesn't, while it's actively in dispute it'll be weighted differently by most scoring models[2].
[1] https://smallbusiness.chron.com/report-bad-debt-credit-burea...
[2] https://budgeting.thenest.com/can-disputed-accounts-affect-c...
They sent me a bill for $15k.
Luckily insurance covered 80% of it... But still! It basically maxed out my out-of-pocket for the year. And for what? An EKG -- at the time -- cost, on average, less than $100...
I remember calling the billing office to try to figure it out. They sent me the bill for $15k directly, so I thought that's what I owed AFTER insurance. Needless to say, I was panicked. I remember telling them, I'd sooner leave the country and move to Europe than pay them $15k, if that's what it came down to. I remember the billing office basically threatening my life. And then when they found out I had insurance (not sure why they didn't know that I did already), they suddenly got much more friendly.
If this is true, then it makes sense that the providers inflate their original bills so that when they get the proportional settlement, the amount they receive is reasonable.
The claim was that individuals settling directly are merely caught in the crossfire.
If this is true, then it's not the providers being unreasonable.
1. The gov't forces them to disclose a price and they can't charge higher than it. Thus, they have every incentive to make it really high, then give preferred customers (insurers) a discount.
2. The system is firmly locked into a cycle of "percent of charges". Basically the insurer says "I know your chargermaster prices are inflated, so let's agree on 20% of that". The following year the hospital jacks up the chargemaster prices during negotiation so they start from a higher initial point.
To be fair, the doctor also cleared your child of having a life threatening emergency. That is one of the critical jobs of an emergency medicine physician and it’s part of what you pay for.
However, for potentially very serious problems (possible heart attack, stroke, serious injuries, etc.) you have no choice - you need to go to the ER and deal with the bill afterwards.
I think most parents would react similarly. Then to turn around and bill $756 is predatory.
I have a similar story from when my first child was diagnosed with T1D. The entire treatment consisted of administering 1 unit of subq insulin and a standard blood test. The bill was coded as intensive care and came to $15k. My OOP contribution was billed as $7k, but I fought it successfully and never paid a dime. Insurance unfortunately paid their full share.
This was Stanford Hospital, which is notorious for over billing, and actually I believe one of the most profitable hospitals in the country.
So we left. They billed us (something around $600?), we sent a letter explaining they didn't do anything, but they still demanded money. We never paid and it eventually went to collections. We explained what happened to collections, and surprisingly they went away.
You didn’t get that bill because you just saw a doctor for 5 minutes. You made use of an organization that has a basic cost-per-hour to exist.
This is a simple way to distill what it costs for that entire hospital to be there ready to see your child at whatever random time and day you need them most. That is very different from just seeing a doctor for 5 minutes. What you didn’t see are the hundreds or thousands of people who have to exist for you to be able to get in your car, drive there and see a doctor for 5 minutes.
That’s not to say our costs are not high. They are. Just saying we need to engage in root cause analysis before passing judgment.
Simple example: Our internal machine shop operates at a nominal rate of $200 per hour. That’s what we deem is the cost to utilize that resource. Larger operations can easily have a cost of $2,000 or $20,000 per hour, whether you use the equipment or not.
If you want to lower our healthcare costs, you have to go after real root causes. No amount of insurance scheme manipulation (public option or medicare for all) is going to fix the system until the fundamental structural issues are addressed.
http://www.david-cummings.com/documents/canadian_hospital_ra...
You pay CAD750-800 for an ER visit if they just take a look at you.
Never heard about it until the collections agency called. I paid it and they still dinged my credit.
Just a lesson for anyone thinking this is a good idea, most likely you will get your credit slapped for this sort of thing.
You instead send them a letter that asks for proof you owe the debt, and ask them to only contact you in writing. Often they won't have their paperwork in order and it will be removed.
Why not at least pay a portion of it that you would have felt was sensible?
On the other hand if an invoice is never realized because it's in dispute, then you have a stronger leg to stand on. A different way to look at is in sit-down dining. You receive service, you are delivered a bill, you are then expected at the moment the bill is delivered to review it and pay it, and if you pay it the bill is settled. If you have a dispute because nobody ordered a diet coke, then the bill is rejected and hopefully sorted out before a final bill is presented and people pay for it. The same sort of logic ends up applying here. If you paid for half the meal and left that has different outcomes compared to not paying the bill and causing a stink.
This would ensure that you (a) wait at least 10 hours to be seen for this and (b) don't interrupt life saving surgery for it. If this is the case you should be charged less, but if you get an actual emergency doctor looking at it then maybe $756 is justified †, as they are a limit resource and there is a high cost of running an ER I would imagine.
† To the extent that non-free emergency healthcare is justifiable.
https://news.ycombinator.com/item?id=19760317
TLDR: Single payer, yesterday!
Perhaps a nit pick, but: Sure it's the providers, but it's a dozen other things too. A problem this enormous doesn't have just one villain!
It isn't uncommon for software developers to make $350,000 a year or even over a million if they get equity in the right company. Maybe the Googles of the world wouldn't have to spy on their users to the same extent if software developers weren't so greedy and taking such a huge slice of the value of their own labor.
Would anyone here agree with that statement? If not, how is it fair to apply that same logic to doctors?
It is also worth noting that doctors have other costs that don't apply to people in the tech industry such as the high cost of the extra schooling they must receive and malpractice insurance which can cost anywhere from a low 5 digits to $150,000+ a year deepening on their specialty.
1. Medical care is not optional when you need it.
2. There aren’t readily available options to choose between.
3. You don’t know how much you’ll be paying when you need it.
4. Band-aids and tongue suppressors costing $30. stuff like that which is unquestionably egregious.
Alone, a fever under 104°F that isn't for an extended duration isn't something you should take an otherwise healthy four-year-old to the ER for.
If you go to an ER for a non-emergency, you are definitely going to overpay for what you get, by an even wider margin than you usually overpay because of the need for those customers that pay to subsidize the costs of those who skip out on bills.
In this day and age when most insurance companies and many primary care practices have 24-hour advice lines, most people have access to the internet, etc., the rate of people who otherwise have access to general healthcare using the ER for non-emergencies should be lower than it is.
A 103°F fever (again, on its own) in your kid as a parent is scary, yes—I’ve been through it with two kids under four in the past week. It's not an emergency, though, and the ER isn't the right place to deal with it. Not only isn't it cost effective, but because the ER mandate is emergency stabilization which a kid in that condition doesn't need it's not plain effective (not even in most of the cases with that degree of fever where medical attention is called for: not only do you pay far more than you will for a primary care visit, you don't get the diagnostic attention you'd get from a proxy care visit.)
The big exceptions are if they’re really young — like still babies — or if they’re not themselves: can’t stand up, overly weak, not eating or drinking.
My main point of contention is around using the internet as a diagnostic tool — much better to call an advice nurse if you have access to one.
The reason why prices are so high is because of the complicated billing system that each insurance provider has. Medical providers have to create positions just for people to bill insurance.
It's gotten to the point where single-payer health care will be cheaper just because of the paperwork it'll save. (Not that I personally advocate for single-payer. We can also lower costs by correctly regulating private insurance.)
By the way, if you're into economics, look into Adam Smith's Wealth of Nations. Kings used to do the same things to keep peasants busy while they profited. This is no different.
It's the same in Canada. Billing doesn't go away under single payer. Sure it's likely less complex, but someone still needs to do it.
Fairly sure Indian doctors make much less than American ones, because I don’t have the empirical evidence of that that you are looking for.
A story. Emergency room visit for moi (super high BP plus PVC that appeared out of nowhere). They hook up an EKG machine, wait an hour, tell me to see my doctor. Since it was a heart thing, I got bumped to the head of the line but forget to fork over my insurance card.
Bill #1 $10k from hospital $2.5k from ER physician
Bill #2 $4k if I pay it right away in cash
Bill #3 $500 (deductible cost) once the insurance people are brought into the picture.
As another poster mentioned, physician salaries account for 8-10% of medical costs, but more importantly decreasing those salaries may not even decrease the cost that patients see.
Let's take the ED as an example... For the past several years, the average salary of an ED provider has been decreasing (due to the increase of physician assistants / nurse practitioners, who are paid less), but the cost-per-visit to an ED increased 235% between 2008-2017 even though ED utilization remained stable [1].
In the last decade, a lot of small physician-owned emergency medicine groups have been bought up by large corporations or health systems. As these large groups proliferate, they raise prices (to the tunes of 2x or more) [2, 3, 4], pay their employees the same or less, and take the rest as profit. So even if provider salaries go down (which these large groups often do anyways after a consolidation), little would change for the patient.
While some of these groups are led by a CEO with a MD, the physicians and other providers who actually see patients do not have a say in how things are run. In fact, some of these groups don't even show the providers how much they are billing for each patient, so it's really hard for them to do much about it [5].
But couldn't physicians/PAs/NPs protest, quit, or even start a competitor--shouldn't they? However, the larger markets (where the majority of patients are) are typically also the most concentrated, so sometimes it's the choice of one large group vs. another large group. I suppose one could move to a different town, but it's hard to uproot a family, and furthermore since these large areas are more desirable there's no shortage of folks who would take their place. And unfortunately for several specialties (EM included) it's very difficult to start a competitor, since one would also need to either secure a hospital contract (not happening if the competitors are health systems) or build their own facility ($$$$$).
None of this is meant to dismiss the issue, and I think physicians will continue to feel the brunt of the blame as long as prices remain high, but I hope it sheds a different perspective onto the issue.
Disclosure: Am in healthcare.
Sources: 1. https://www.healthcostinstitute.org/images/pdfs/ARM2019_ER_P... 2. https://www.nytimes.com/2017/07/24/upshot/the-company-behind... 3. https://www.reuters.com/article/us-unitedhealth-envision-hlt... 4. https://www.mass.gov/files/documents/2019/02/20/2018%20Cost%... 5. https://www.aaem.org/resources/key-issues/corporate-practice...
Let's disrupt some stuff here:
First, it is EXTREMELY rare for a physician to be paid a million dollars. You can easily look at most state's open records (California, Texas, Florida) and search the online databases and see that it's usually only several in an entire state and these are people of extreme qualification or unique talent. The Dean of a large/famous medical school (a CEO essentially), a very famous chair of a department (they helped invent some special technology or are well-known leaders in their field), or are simply prestigious to the institution because of notoriety (imagine an Atul Gawande or an Oliver Sacks).
Second, the costs of healthcare have been sliced and diced by countless experts and the numbers tell a different story than your theory--most analyses place physician payments at 10-20% of the total cost of healthcare depending on who is doing the study.
Third, there's no way you received ONE bill that wasn't itemized. Typically you receive two bills--one for the 'facility' and one for the 'professional.' It's usually obvious which is which because an ER might charge $1000 or more for that quick visit, while the physician probably would've charged in the $100-200 range. When you hear about those scary $50,000 bills for a night in the hospital and a $30 box of tissues... that's the hospital bill. It's extremely high because of many complicated reasons... most of which have to do with the fact that it NEEDS to be that high or insurance companies won't pay the negotiated rate of about 40% or less of that--it's an arms race that needs to stop.
I'll give you that there are complicated price gouging issues that come up on the physician side (out-of-network billing, surprise bills, etc) that may be unethical and some states are dealing with this... but it's usually a tenth or less of the total of what is coming from the facility in the same scenario.
So anyway, you could literally pay doctors nothing and you would save maybe 10-20% on all those bills. Does that sound like a viable setup?
You can Google some articles and read studies, but I'll save you the time and give you something to think about that should convince you that the physicians can't possibly be the primary problem:
Many (most?) physicians are now wage earners. They increasingly own less and less of the infrastructure (capital) of healthcare and are less independent than ever (consolidated, hospital owned groups, VC and publicly owned groups like Envision and MEDNAX).
In this kind of capitalist setting, where would your profits go? To your doctor workforce? No! It goes into C-level administration, shareholders/investors AND reinvestment/M&A.
Hospitals and Insurance companies, Drug companies, Device companies.... these are the real power players and their influence in seen all the time as they negotiate sweetheart deals (Medicare Part D for example), continue to consolidate ownership, and literally price gouge from consumers (EpiPen, insulin, etc, where a cheap drug is inflated in price for no reason).
I'm truly sorry for the state of the system in the US, but the fix has to come from Congress. If tomorrow every doctor was perfectly ethicall and paid 50% of what they earn today, all that savings would just end up as dividends for the capital owners and NOT as lower hospital bills.
Providers are the core problem. Various doctor associations (AMA et al) have strangled supply side of healthcare through State licensure and scope of practice laws.
Just read medical forums to get an idea of what an average doctor thinks about competition in the form of midlevels:
https://www.auntminnie.com/Forum/tm.aspx?m=581583
"Don’t teach your mid levels procedures... Ultimately, a mid level that can do procedures, even easy ones, are your competitors."
https://www.auntminnie.com/forum/tm.aspx?m=581130
It's not politically talked about because it's much easier to blame corporations than your neighborhood doctors. There's enough leeches downstream too (insurance, pharma, PBMs, administrators, etc) but gatekeeping at the supply side is what's making it possible.
To add more details to this here's something I recently read about the supply constraint and its origins.
> Then as now, Medicare reimbursed hospitals for a significant share of residents’ salaries. The Balanced Budget Act established limits on those reimbursements, effectively fixing the number of funded residents at 1996 levels. (In 1999 Congress amended the limit for rural hospitals only, increasing the numbers of funded residents at those hospitals to 130 percent of 1996 levels.) Essentially, the law stipulated that if a hospital wanted to expand its pool of residents, Medicare would not pay for it.
How could such a provision make it through Congress? Lawmakers received cover from the American Medical Association (AMA), the Association of American Medical Colleges, and other major stakeholders in American medicine who endorsed caps on funding for residents and other graduate medical education programs. In March 1997, months before the Balanced Budget Act was enacted, the AMA even suggested reducing the number of U.S. residency positions by approximately 25 percent — from 25,000 to fewer than 19,000. “The United States is on the verge of a serious oversupply of physicians,” said the AMA and other physicians’ groups in a joint statement. Since most states require at least some residency training for medical licensure, reducing the number of residency positions would curtail the supply of doctors in the U.S.
Fast forward two decades, and what once seemed like a glut now looks like a shortage. The growth in the number of residency positions — and thus the number of doctors — slowed after the passage of the Balanced Budget Act. From 1997 to 2002, the number of residents in the U.S. increased by just 0.1 percent. Although the number of positions has increased since then, each year thousands of residency applicants fail to secure a position. Factor in an aging population and a projected increase in demand for health care services, and the U.S. is now forecasted to experience a shortage of 46,900 to 121,900 physicians by 2032. Absent a meaningful response from Congress, it will be doctors — particularly residents — and their patients who pay the price.
What is an isn't a high bar is all relative.
I mean software developers doing significantly less work can easily make this money while working half as much right? SW Dev working 8hrs a day can make this, whereas a doctor working probable 60-80 hours a week makes the same?
Not to mention, having an inside look at med school gives you a different perspective on the motivations of most rising doctors. It’s rarely about anything but lifestyle and money. I mean, they are people too, but most med students I’ve met are looking out for number one first, and anything else is a distant second.
I don't blame a Dr for trying to charge 7x the actual value of their time if 6/7 people don't pay them at all (the case in ERs). They're employing the same practice as insurance companies. But when a Dr does it he's a scam artist?
Those same threads have logins like "indebt4life" and "kids2feed", which matches what I've heard from doctor friends: the length and cost of medical training and insurance are so brutal that the folks gatekeeping are themselves in an unhealthy lifestyle and don't want it to get worse. In other words, and benefits of gatekeeping accrue to the school and hospital complex more than the individual practirioners.
Separately, what's the breakdown of specialist labor costs vs drugs and equipment? My experience has been that the crazy bills are for stuff , not people.
We should treat it like the infantry. If you want to drive a tank and blow up people, you don't apply to a college and get a Doctorate in Blowing People Up. You don't buy insurance to cover if you blow up the wrong people. You join the army.
I'd like to see health care reform inspired by military structure. A high-schooler eager to get into medicine joins the Health Corps, and gets their education covered in exchange for n years of working in state-run facilities. There's strongly restricted legal recourse if the Health Corps hospital cuts off the wrong foot-- here's $500 and a really nice wooden peg.
As a self-contained system, I could also imagine it working around some of the structure that's restricting the industry. I'm picturing programmes to advance in both through direct study and training, and where appropriate "field promotions" (think of the 20-year term nurse who knows more than most of the doctors from experience, but will never be able to escape their position without expensive and onerous formal training/certification)
It's gatekeeping that causes that.
There are complex procedures that require a decade of medical training and simpler ones that don't. If you take the doctor with the extensive training and have them do only the complex procedures, it's easy to justify paying them mid six figure salaries that cover their costs.
But if you have regulations that require that same doctor to spend three quarters of their time doing simple procedures that could reasonably be done by a PA or a nurse, the average value of their services drops and they have a harder time commanding a salary that can pay for their schooling and insurance.
Right now in the US you'd be "socializing" the expectation that a doctor should make $300K+ a year, with a very weak upper bound. Which I'm not going to say real good ones shouldn't, but good ones, in my personal experience, are few and far between.
This is something we'd need to deal with before forcing taxpayers to pay for these inflated expectations at gunpoint, _if_ we decide to go the "single payer" route. ACA, ironically, did nothing at all to address the _affordability_ side of things. If I'm forced to give up a good chunk of my income for "free" healthcare, I'd be categorically not interested in paying for yet another beach house some surgeon wants to buy.
Just like all problems involving human motivations, this is a tough one to solve. It's so tough, in fact, that I think the most realistic path forward is gradual automation of everything that can be automated, though technological means, such that we only use doctors where a robot or a computer can't do the job. Someone needs to start another Theranos, but do it for real this time.
This really depends on the forums you read. If you hang out on the whitecoatinvestor forums you'll see that there are plenty of folks who are getting by just fine on their $600k annual salaries and may even be retiring early.
Reading those forums it's clear that there are challenges (not buying a doctor house, avoiding loan debt, budgeting like a resident even once you're in your real earning years) but there are plenty of opportunities, in some disciplines, to be happy with an eight-figure lifetime earnings and a balanced lifestyle.
That could just be an accounting trick, since you're more willing to pay for stuff than people.
(On topic: obviously, there's many reasons for costs, doctors isn't the only one)
I'd be fine with it if it wasn't healthcare. He doesn't even like being a doctor. Something is broken.
It seems like mid level providers are being granted more and more autonomy each year. In fact, they have full practice authority in 20 states (no need to work under a physician). Knowing that, are the AMA et al truly strangling the supply side of healthcare? From the politico article you linked, it seems that the number of specialists we have is unnecessary, so that can't be it.
I'd like to think that most doctors aren't trying to out-compete mid-level providers, and that most doctors are trying to do right by their patients. Maybe that's naïve.
I also agree that the wages for physicians are too high, and that reform from the ground up (education costs, healthcare costs, and reimbursements) is desperately needed. However, to state that providers are the core problem is tremendously naive. The average salary of physicians, even at $250,000/yr, with 1 million physicians in the US is $250 billion/yr. In comparison, the revenue from the health insurance industry was around $1 trillion in 2017. The hospital industry made $970 billion in 2016. The pharmaceutical industry made $450 billion in 2016, I can only imagine that number went up. I can see how the insurance industry and hospital revenue would be tied in physician reimbursements somewhat, and obviously pharmaceutical payments, but the pharmaceutical industry shouldn't be impacted by physician salaries.
As a side note, very few doctors I've had the pleasure of knowing have any idea what their services cost patients. Proceduralists generally have a better idea.
For those of you interested, I'll try to explain what is needed in a residency program. Your program needs to provide you with the training necessary to be proficient at all aspects of that specialty by the end of your training. That means you need the patient volume, mentorship, and variety to meet that standard. It just so happens that it's very difficult to meet that standard unless you're at a larger institution. Community programs do exist, but today the vast majority of programs except for family medicine are at academic centers.
What that also means is that you can't train too many doctors in one place at one time. Especially in the case of surgical specialties - You need as many procedures as you can get in your residency, extra residents take those procedures away from you.
That isn't to say that more family medicine and primary-care track residencies aren't needed, they absolutely are. At the same time, without more Medicare funding for these residencies (per the politico article it takes around $150,000/yr to train a resident physician) hospitals aren't willing to take on the extra cost. A bill is hopefully making its way through the House to increase the funding for more residencies (15,000 new spots over 5 years).
Ultimately, I think the trend is going to be that more and more doctors will specialize, and mid level providers will be mostly nurse practitioner or physician assistants. Hopefully the data will continue to be positive in terms of outcomes, and prove that we just don't need the amount of training we thought we did for those providers.
P.S. While I'm not going into primary care, I loved my family medicine rotation in school. I felt like I had genuine impact on my patients, met some of the most down to earth doctors, and it was an active day with lots of variety.
the medical profession is not easy and i don't begrudge them their fees.
Where? NYC's mayor doesn't even make those numbers.
https://data.cityofnewyork.us/City-Government/Citywide-Payro...
The public sector's pensions have always been a bit of compensation for the sub-market salaries. This bears that out.
If you don’t have insurance, you literally are the problem.
Not true, most people's deductibles are more than what they charged him.
What you are paying for is piece of mind and expert advice.
What would you do if someone wanted your expert advice on something you told them your fee and then solved their problem in 5 minutes and they balked at paying you?
This is the old saw about $1 for the work and $999 to know where to hit the machine with a hammer.
In your example, $999 would be fair, but they're charging $9999.
There are countries where healthcare is free, and doctors get paid well (eg Australia, Canada), and student debt is dramatically less. So you have the wrong idea why you paid so much, the real reason being that American Healthcare is a complex system in catastrophic failure mode.
I’ll give you a perfect example - at the American Society of Clinical Oncology Annual Scientific Meeting this year, the biggest and most important oncology meeting in the world where original research is presented, one of the plenary abstracts was a study showing that Medicaid expansion reduced racial disparities in oncology care. To someone in a single payer system this is blindingly obvious (if you have insurance you get better care), but in the US this counts for groundbreaking research. That is how backward US healthcare is, sadly. From the outside looking in, it is obvious that this is the case.
Some years ago, I thought I might have broken my finger. I went to the doctor and it was actually the physician's assistant who saw me. I'd explained at the front desk that I had a high-deductible policy and I would be paying in full for the visit.
The PA said "Usually we would send someone for an X-ray, but since your insurance won't cover it, there is a quick test we could do and it would just be part of this office visit."
He opened a drawer and pulled out an instrument and asked me if I knew what it was. Being a musician, I said "Yeah, that's a big tuning fork. And with those weights on the end it must vibrate at a very low frequency."
He said, "You got it! The idea is we get the fork vibrating and then hold the end against your finger. If it's broken, it will hurt like the dickens, so just holler and we will stop and you go get that X-ray. If it doesn't hurt much, it's just a sprain, so take it easy and you should be fine."
We did it, and my finger was fine. Saved me a bunch of time and money!
Edit: Thank you everyone for the lively commentary! I would like to mention something that I forgot at first (it was ten years ago) and your comments reminded me of.
The PA didn't pull out the tuning fork until going through a complete set of manual range-of-motion and "does this hurt" tests. All indications were that my finger was not broken, it was just a mild sprain. I'd only gone to the doctor in the first place out of the proverbial "abundance of caution".
So it was my decision not to get the X-ray. Please, everyone, do not blame this on the American medical insurance system! I could have easily afforded the extra $150 for the X-ray, and of course I still had that option after the tuning fork test. But since both the PA and I were both so sure at this point that it was just a sprain, I figured I would same both time and money by skipping it.
It was my call how to proceed with this very minor injury, no one else's.
More worrying is that people support the racket! A tuning fork, like a barefoot doctor in 1950s China might have used is a good idea! You despair about the possibility of sanity in American healthcare.
X-ray imaging on a finger is virtually harmless. Using a tuning fork to vibrate a potentially broken bone and causing a patient to feel pain is not harmless.
If a doctor has a treatment with 80% efficacy that costs $1,000, and another with 90% efficacy that costs $100,000, there is nothing immoral about giving the patient the choice. "Doing Harm" would be prescribing treatment that leaves the patient worse off than they started.
I don't see what harm the tuning fork would have caused me beyond a moment of pain which would show that it was worth my time to get an X-ray.
Feeling a bit of pain is not the worst thing in the world. One time I had a tiny cavity on a lower molar, and my dentist offered to drill and fill it without anesthetic. He said that of course I was welcome to get a shot or two of novocaine as we'd normally done. But the lower jaw takes so much time to recover, and he'd had a small cavity of his own filled without novocaine and it was nice to be immediately back to normal.
He also knew that I was fairly tolerant to pain and he probably wouldn't have made the suggestion otherwise. So I took him up on it, and sure enough, it really hurt for a few seconds. But I had a completely normal mouth when I left the office. None of the usual drooling and tongue biting for the rest of the day. I went right out for a nice lunch!
So that was another tradeoff I was glad for, and hopefully these decisions are mine to make.
I bet hundreds of dollars a month would provide depression and anxiety relief for a significant portion of the population.
Mistreating a broken finger could also leave you with reduced function in the hand. Needless to say that's also a risk.
It wasn't the cost that steered me away from the X-ray, I just didn't want to take the time to wait in line after I felt sure that it was just a sprain and all I needed to do was take it easy on my hand. (I updated my original comment to note some of these details.)
and when you're having heart arrhythmia, since it is too expensive to send you to a specialist and hook you up to one of those EKG devices, why not just do a series of 20 pushups and 20 squats and see if you'll collapse?
alternatively, we could have a system where patients are entitled to some basic care, but hey..
And no one said I couldn't have an X-ray. They merely offered me a faster and less expensive diagnostic procedure at my own option.
While the exact test done may not be common, its very common for any of a variety of broadly similar (in that they work by inducing motion which will almost certainly be quite painful if there is a fracture and but usually be tolerable otherwise) "does this hurt" tests to be used in a similar role with suspected fractures, and an x-ray only ordered if they indicate a likely fracture.
If it looks straight, a hairline fracture will heal properly if unstressed for a few weeks. Probably not a huge risk if wrong.
You could constrain a broken finger yourself if you are any good at looking up information and applying it.
The underlying point is that it'd be nice if you are able to get first world care instead of "lifehacks" for a range of very common conditions, given that you're insured, and not have to pay a giant deductible.
You don't have gas or grocery insurance, do you? If that were a thing would we all expect to pay less for gas and groceries, or would we just be tacking on overhead for routine expenses for no reason?
Using insurance for routine, affordable expenses is one of the problems. But it's a race to the bottom where insurance companies win, because everyone in the U.S. thinks "good" insurance pays for everything and makes a 17% profit out of nothing.
In addition to the transparency the article advocates for, we'd probably be way better off with a universal health care stipend and very high deductible insurance for rare catastrophic events. Insurance should not be involved in routine care.
You could look at health insurance like a buyer's club (we negotiate prices for a large group of customers) plus a true insurance (the unexpected happened, is expensive). The buyer's club portion can be useful in mitigating expenses for the unexpected.
That said, nowhere in here is there a strong incentive to reduce costs (I go into this in more detail in a different comment on this topic). If you really think about it, an insurer just wants predictability, the actual cost is somewhat irrelevant as long as people can pay it. Because insurance is usually "purchased" and subsidized through your employer, you're somewhat disconnected from that price.
Even if you weren't, you don't really have good alternatives. You can choose the private market (often less good plans without as strong a network) or you can choose no insurance at all. These aren't great choices, and frequently when you're making the "purchase" it's very very hard to know what you're buying.
I've shopped around for insurance, it's quite difficult for them to answer, "I think I might need this thing, how much will it cost me with your plan?"
The whole system needs to be rethought. Likely through a combination of forced transparency, mild price controls, breaking up monopoly-like consortia within the industry and forced standardization of some products to make them understandable.
You might say that insurance should cover this kind of condition and not consider it 'routine care', but we see how well this works in the current for-profit medical insurance system. Insurance providers seem to be okay paying out low-frequency high-cost events, since that's the risk profile they model, but they hate paying out recurring care costs. Once you become a recurring cost, it is in their profit interest to reduce your care, or get you off their rolls.
And this is why all of our heated political debates go nowhere in the US. You have Democrats ranting and raving over how they want to provide health insurance for everyone, even if private companies help provide it. (With their supporters full of sob stories.) You have Republicans ranting and raving over how great it is to keep everything private and allow insurers to not cover everyone. (With their supporters pretending its just "insurance" you can live without.)
Meanwhile, its not really "insurance" at all. Its basically a cartel of companies that negotiate a situation where healthcare is effectively unaffordable without them acting as an intermediary.
Some people do have analogous "insurance" for gas or groceries: Anyone with a Sam's Club, Costco, or Amazon Prime membership pays a subscription fee so that they can get a negotiated discount on routine, affordable expenses.
So, yeah, I guess most "health insurance" could be more accurately called "healthcare buyer's clubs (that also happen to include some insurance)". Unfortunately, we're in the late stages of an economy where the buyer's clubs have eaten the entire market and are free to extract fat margins with little consequence.
Say you start out your career making $30K as a barrista and end up making $150K as a middle manager in your 60s. A single surgery can be $150-$300K and you're more likely to have them when you're older. Cancer patients can cost millions in a given year, again you're more likely to have that as you get older. I don't have the number for a diabetes patient off the top of my head but I think it's 10s of thousands a year.
The income growth curve is far shallower than the healthcare cost curve, and the healthcare cost curve is essentially unbounded whereas for most people income doesn't go all that high. Remember median income in the US is something like $55-$60K. Most people won't ever see 6 figures and if they do, they'll see the very low end of that.
Once you know the cash price then you could later say you got insurance but not vice versa.
These are all for services in the $150-300 range, and I was told upfront what the cash price would be, but they couldn't tell me what my negotiated plan rate was. (I inquired because I have a high deductible plan so I'll pay in the end no matter what.)
The negotiated prices were all at least 1/3 lower, and the most expensive one turned out to be free because it was classified as preventitive.
So it's even worse because you never know. It's certainly not a rule at all that cash prices are lower.
There is nothing funny about it. Once you tell the provider that you have insurance, the price they can quote you is in their contract with the insurance company. You need to go somewhere new and tell them you do not have insurance to get the real price.
The doctor had no idea what health plan I had or even if I had one -- they leave that up to their staff to sort out, they couldn't care less personally.
Nope. We pay around what you'd expect given our consumption in other areas. See https://randomcriticalanalysis.com/2018/11/19/why-everything...
The reality is is doctors often have no control over cost. Yes, if you are the increasingly rare private group that is physician owned you do but certainly not if you are employed. These are 100% set by the bean counters who are paid twice my salary and have no idea about what we do on a day-to-day basis.
I have no idea what my services cost and for ethical reasons I don't want to. That inflicts bias and can lead to misdiagnosis.
I sacrificed 10 years of my life and took on over $275,000 of debt that continues to grow thanks to compound interest. I live in an average house and drive an average car because I have this debt to pay back.
Daily I am responsible for not harming dozens of patients while trying to make their lives better. With each decision I make I have the risk of being sued and losing everything I have worked for. All the while, my mid-level providers work relatively liability free because they work under my license and their mistakes are on my back. Adminstration pushes for higher numbers of patients andmore uncompensated work. When was the last time you spoke to a lawyer on the phone or had them complete a 5 page document for free?
Think twice before you criticize doctors and the sacrifices we have made. I didn't do this for the money, I assure you.
https://www.healthcare.gov/health-care-law-protections/rate-...
https://www.nbcnews.com/business/business-news/hospitals-mad...
There's nothing saying a non-profit can't raise prices of service and then expand the hospital to buy a new wing, or better equipment or hire more doctors. They need the money to provide their services.
And while greater transparency is good - not everyone in the public is able - or willing - to understand a medical price-sheet and might opt for a cheaper but medically-inappropriate procedure with similar-sounding-name to the procedure they actually need.
(As anyone who starts an insurance company can attest to.)
This is a common talking point that smells like an oversimplification.
When you have people who exist outside that system of resource reallocation, the doctors have to find ways to ensure they're still getting enough money to cover their costs. One way they can do this is by suing patients who don't pay, but that takes time and more money and doesn't always work. Another option, would be that they then raise their rate to the insurance companies because they know that the insurance companies can afford it since they have such large pools of money. The insurance companies then raise the rates for everyone buying into the resource reallocation pool, and eventually everything spirals out into our current non-system.
Is it more complicated than this: yes, but that's the elevator pitch on it.
This is exactly why Medicare for All is touted as a solution. It would create the largest pool.
It would also reduce the significant overhead presently involved with billing N different insurance companies. Why isn't the conversation about those costs imposed by the current system?
That's what countries with single-payer are like. America needs to give up on this nonsense. There should be riots.
Additionally, lots of employers also love holding their employees hostage via healthcare and they spend millions lobbying to this end.
I have no idea what it costs but I guess out of pocket it would be about $20 "co payment", same as when I had a MR scan for my neck earlier this year. If you're out more than $200ish a year you don't have to pay the "co payments" anymore either, but that's only happened once for me.
If you need to go to hospital it's free regardless.
Norway here, guess we have a tax funded "single payer" system. Wouldn't have it any other way.
Also, the opportunity cost of sitting around with a broken hip waiting to be seen can be higher than going to a privatized country/province and paying for the surgery, in which case you're a super-sucker who paid extra taxes for decades just to end up paying out of pocket for surgery anyways.
Anyways, the US system is probably worse overall but it can work quite well (better than socialized medicine) for upper-middle-class people and above which is why it's still around.
I'm really sick of being told things are impossible in the US that are normal in other developed countries.
This example is bad. New Zealander here: a broken hip will be fixed in reasonable time, and I think if you have private insurance it likely would be diagnosed, fixed, and recuperated in the same hospital.
Private insurance does help if you need a hip replacement. On public, you will wait for a long time, and you will be in pain for a long time. Private is much more proactive at replacing a hip early.
However hip replacement is that common that I strongly suspect you would be financially better off paying for it when you need it (whether poor or rich).
If you are from the US, you should take care before projecting any experience you have of hospitals upon other first world countries. I think your system is so severely broken you cannot reasonably model anything about a foreign system.
The existence of a public system keeps the prices for the private system in line. They can't get too ridiculous because there is always the free option available.
In NZ, I have found that diagnostic on the public system to be plenty fast enough. Then when it comes to treatment option you can weigh a quote of getting it done privately immediately vs waiting for a specified amount of time.
And due to the public system I wouldn't even think twice about going to the doctor as soon as I have any kind of issue at all.
Someone in the dorm next to me in college died of an asthma attack because he couldn't afford the ambulance and took a cab.
The system is still the way it is in the US because of money.
https://www.aan.com/PressRoom/Home/PressRelease/1178
> Previous studies have shown that the average wait times to see a neurologist are increasing. The average wait time for a new patient to see a neurologist in 2012 was 35 business days, up from 28 business days in 2010. The average wait for a follow-up visit in 2012 was 30 days, up from 26 days in 2010.
https://www.beckershospitalreview.com/hospital-physician-rel...
> The average wait for a new patient seeking an appointment with a dermatologist in a major metropolitan area is 32.3 days, according to a recent survey conducted by Merritt Hawkins.
So it's preferable to have a system where people go bankrupt for routine care?
https://ajph.aphapublications.org/doi/10.2105/AJPH.2018.3049...
Why is this so hard to understand? This is how it works when "throw more money at the problem" isn't an option.
... "We can book you in in 10-12 weeks."
Also, don't forget about the malpractices. 10 years down the line, your radiologist friend gets successfully sued for 11 million dollars bc the parents of a child for whom they read a chest radiograph decided to sue because lawyer convinced the parent and jury that radiologist was at fault for not saying the heart is enlarged and somehow that is responsible for all the kids ailments later on in life (the truth is much more complex than that). The radiologist probably got paid 7.50$ for that read, btw. This is actually a true story, look it up in the Boston Globe. Now all providers are on edge and overdiagnosing and overordering everything - who would want to miss a diagnosis.
I believe/am hopeful that since I live in New York, which prohibits out-of-network providers from surprise billing patients without the patient's informed and explicit consent that the procedure would be considered out-of-network [0], that I ultimately won't be held liable for the bill.
Fortunately as a software engineer, I can trivially afford to pay the bill in the worst case. But I shudder to think of the consequences for someone in a much less privileged circumstance.
[0]: https://www.dfs.ny.gov/consumers/health_insurance/surprise_m...
We see a hint of that here: "Cigna gets a contractual discount of just over $1,000 because it’s, well, Cigna." In this particular case, the negotiated discounts didn't bring the price below the cash one, but in many cases it will.
However...I can also understand why paying by cash should much cheaper Adding another company or companies into the transaction, trying to standardize the various medical procedures, invoicing and managing co-pays, deductibles etc adds a significant amount of overhead.
One would hope that the insurance companies would leverage the volume of transactions and the pools of clients to get price improvements but this is not the case.
It's also worth noting that many clinics, if not most, won't actually try to collect the balance here. They'll often go through the motions and forgive the balance after some number of attempts to collect.
There are many times when a practice will quote you a much higher cash price just because you don't have an insurance company negotiating for you.
I have privileged foreign friends with private "worldwide insurance" from a European provider, but it is just a reimbursement scheme. So they appear uninsured to American providers and have to float potentially extremely large costs which might not actually get reimbursed.
And then things like birth control aren't insured by their "worldwide insurance" nor some dental work deemed cosmetic, and these people aren't surprised their great "worldwide insurance" doesn't cover those things because their state run insurance wouldn't cover those things either, but confused why the cost is so high in America.
I have to tell them that "privileged" people in America don't pay those costs, and explain to them how dangerous or ill-advised acting uninsured in America is.
Why would you use insurance for something you know you are going to need? I got new glasses and an eye exam and they were surprised I didn't pay via insurance? Why would I want to pay extra to insure for something I know I will need to get? This makes no sense at all.
These are part of your overall “insurance package”, in conversation this is typically called being insured with no regard to whether an insurance company is actually picking up the tab.
I was in this sort of situation once. I needed a CT scan, but it was on a late friday afternoon, and the hospital couldn't get prior approval from the insurance company. They quoted one price that they would bill the insurance company if it was approved, and another much larger priced that I would have to pay if the insurance company rejected the claim. (I ended up getting the CT scan the next day at a hospital that charged a lot less. I think it was covered by insurance.)
The thing about this that's bad is that it's over-charging the people least likely to be able to repay, and (if they can come up with the cash) they're effectively subsidizing the insured customers. This is the other side of narrative that poor people are driving up health care costs for everyone else because they don't pay their bills.
The opening scene features the protagonist iterating over a series of rationalizations for reducing his medical bills to 1/3 of the list price. That this scene was expected to be received by an audience which could relate to the necessity of performing these sorts of arithmetic gymnastics (though perhaps exaggerated for comedic effect) suggests that this was already a well-established norm in 1673:
SCENE I.--ARGAN (_sitting at a table, adding up his apothecary's bill with counters_).
ARG. Three and two make five, and five make ten, and ten make twenty.
"Item, on the 24th, a small, insinuative clyster, preparative and gentle, to soften, moisten, and refresh the bowels of Mr. Argan."
What I like about Mr. Fleurant, my apothecary, is that his bills are always civil. "The bowels of Mr. Argan." All the same, Mr. Fleurant, it is not enough to be civil, you must also be reasonable, and not plunder sick people. Thirty sous for a clyster! I have already told you, with all due respect to you, that elsewhere you have only charged me twenty sous; and twenty sous, in the language of apothecaries, means only ten sous. Here they are, these ten sous.
"Item, on the said day, a good detergent clyster, compounded of double catholicon rhubarb, honey of roses, and other ingredients, according to the prescription, to scour, work, and clear out the bowels of Mr. Argan, thirty sons." With your leave, ten sous.
"Item, on the said day, in the evening, a julep, hepatic, soporiferous, and somniferous, intended to promote the sleep of Mr. Argan, thirty-five sous." I do not complain of that, for it made me sleep very well. Ten, fifteen, sixteen, and seventeen sous six deniers. "Item, on the 25th, a good purgative and corroborative mixture, composed of fresh cassia with Levantine senna and other ingredients, according to the prescription of Mr. Purgon, to expel Mr. Argan's bile, four francs." You are joking, Mr. Fleurant; you must learn to be reasonable with patients; Mr. Purgon never ordered you to put four francs. Tut! put three francs, if you please. Twenty; thirty sous. [Footnote: As usual, Argan only counts half; even after he has reduced the charge.]
"Item, on the said day, a dose, anodyne and astringent, to make Mr. Argan sleep, thirty sous." Ten sous, Mr. Fleurant.
(the above is just the first half of Argan's recitations - they go on for another paragraph or two!)
Why is it that someone who is a new customer for service X gets a sweetheart deal but those of us who have faithfully paid for months/years are charged a premium?
Why is it that 2 people in a hospital pay entirely different prices for the exact same thing?
on and on the insanity goes.
I am, of course, not talking about packages/bundles etc. Yes it makes sense that someone who buys 10 could get a better price than someone who buys 1.
Also the new customer doesn’t permanently get a sweetheart deal, it’s always a temporary incentive to join, which doesn’t seem unfair to me at all. However, as a buyer, if you’re not always shopping around, expect to pay more than someone who does. That’s just how the game works.
I agree that you're talking about an optimal analysis of the current game.
However, one of the roles of government is to alter games which are suboptimal for society. For example cartels are illegal despite them being optimal for the sellers.
Doctor's fee $750
Anesthetician's fee ~$150
Hospital facility fee ~$24,000
Hospital facility fee, cash price ~$9,000One of my family members once told me he is against socialized medicine because it subsidizes the bad choices of the poor. True enough, but that’s no different from the current situation (since hospitals can’t refuse to treat) except that the one we have is opaque.
Huh, that's odd.
A friend who asked how much the retina re-attachement would cost. Weighing her options.
I'm just sad that healthcare seems like such a luxury.
I do enjoy stories of friends not just being complacent. Going out of country for dental procedures. Getting good results for 1/10 the price.
https://youtu.be/pY-BGNjI2Rg?t=281
Should you have to do this? No.
No one in American healthcare knows how much it costs to deliver care. And as a result, the bills are more like: "They look rich. Let's see if they'll just pay it."
https://www.joelonsoftware.com/2004/12/15/camels-and-rubber-...
The other trend along these lines are concierge doctors. They don't accept insurance, and typically operate on a subscription basis (X dollars per month).
It's pretty hard to pull off an external company since many hospitals won't even tell you what their negotiated rates are (I have an HDHP where I'd think the point is to shop around, but can't because of the lack of price transparency).
For what it is worth, goodrx.com is doing a variant of this with drugs.
It's tough to figure out the plan that works well for non-routine things. But then again, bigger operations are tough for everyone who doesn't have the best employer-based HMO/PPO plans.
It aims to present users with the highest quality and lowest price hospitals in your area:
2. All prices have to be posted on your website.
3. Patient has to agree on the bill beforehand.
(ER is the exception obviously)
There is no party in the current healthcare system whose incentive is to lower prices. Medicare/Medicaid can achieve low costs by fiat, but it's broadly accepted that the whole system as structured today couldn't operate on those prices [1]. This means private insurance picks up the delta.
Doctors, Hospitals, Pharmacies, Drug companies, Medical device companies all have zero incentive to lower prices. You might think technology that makes doctors visits (to pick one example) would just win out in the marketplace, but there's a flawed assumption there. Most people are insured, so most people are paying the insured cost. For something like a doctor's visit, you pay your copay (say, $25) and the insurer pays the rest (lets say up to $70). Assume you could get an app or a technology that gets that price down to $35. This would be a huge achievement and you'd go out of business because it's more expensive than what the consumer sees.
Ah yes, but maybe you can pitch to insurers, surely they would love a lower cost! Probably not. You're small so you can't reduce their costs across the board. Even if you succeed, they have caps on how many profits they can take (usually something like 15-20%) so if you drop their costs, that might actually force them to refund customers. Good, but not the primary driver for profitability.
Let's even grant that the above isn't true. You're still a small player, you basically need to fit inside their (extremely cumbersome) protocols to be able to bill them. Now you have to do all sorts of billing and management, maybe you need to hire extra staff to run billing. That $35 now financially doesn't make sense, maybe it's now $55. Still cheaper but now you're in the system and don't have much of a competitive advantage that's visible to the consumer. Now you differentiate by offering better services, maybe a good online portal, that costs more engineers, and now we're back up to $70. Insurer doesn't care much, you're just another provider, they'll pay, you'll make money, and we're back to square one.
We're not even considering the, "Is the cancer doc that costs 25% less the same value as the other guy?" problem, which is damn hard on its own.
Healthcare is really hard, and the incentives across the board are perverse. I'm increasingly skeptical a solution that doesn't dramatically reshape the market is likely to make a difference.
[1] https://www.healthcarefinancenews.com/news/mgma-majority-pra...
Medicine does not work with market principles.
Most people do not currently make any of those evaluations anyway, so as far as the consumer is concerned, they are de facto substitute goods since they have no rationale for making a choice.