Comment by paulmd | Hacker News Reader

Comment by paulmd | Hacker News Reader

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They get a couple hundred bucks for a 5 minute office visit to write the prescription, yeah.

I'm fine if there's a serious reason for a physical examination, but a lot of stuff the doctor is effectively filling the role of a pharmacist: telling you side effects and if you have this set of serious side effects then to stop it and/or go to a hospital, here's your script, pay at the front desk. A lot of stuff is unnecessarily shoehorned into Rx-only, and despite a lot of talk about "reducing costs" there is no real drive to actually do so.

A great example is oral contraceptives. You may have to try a couple different blends before you find the right mix for your body. Some of them will be uncomfortable. Some may cause dangerous bleeding and you need to go to a hospital. There is not zero risk here, or with any drug. But the doctor has no way of telling which might be which for your particular body, they are there to tell you the risks, sign the paper and let you try it out. And that's why oral contraceptives specifically are being looked at as something that could be moved out of Rx only and to either OTC or pharmacist-prescribable - but the problem is there are really a lot of drugs that don't belong there.

A pharmacist can read the risks to you just as easily and not charge you $250 for a 15 minute office visit and another $250 for a one-month followup 15 minute office visit.

I have lots of 6-month maintenance visits that are literally 5 minutes. Everything going well? "Yup!" "OK, we'll call in your prescription, pay up front". They're just using their gatekeeping power to extract a check.

They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 - 12.31 work RVUs = $443.64.

All this information is available online. You can look up the physician fee schedule straight from the CMS. https://www.cms.gov/apps/physician-fee-schedule/search/searc... . Here are the cardiology codes - https://myheart.net/cardiology-coding-center/coronary-interv...

To add an additional data point, doing a heart transplant is 89.50 wRVU * 36.0391 = $3225. I don't think doctors are living as well as you think. CPT code 33945.

Providers don't bill Medicare rates to normal patients, so none of that is valid.

Providers in fact make a point that they lose a significant amount of money at Medicare rates and have to limit the number of Medicare/Medicaid patients they see as a result.

I can confirm that a "45 minute" (5 minutes with nurse taking vitals, 25 minutes waiting in office exam room, 15 minutes with doctor) specialist "new" office visit was just billed to me for $246. They didn't charge me half the rate they charge a heart attack, they charge the heart attack patient 100x as much.

I don't think you understand how US billing works. Probably not from the US, or probably not subject to the system due to age (child or senior) or privilege (an engineer on a cadillac PPO plan perhaps).

Anyone who has ever experienced the US system knows that's absolutely normal.

You said physicians get paid a couple hundred bucks for each visit. I provided the source that says how much a physician gets paid by medicare for an established outpatient visit. An outpatient visit for a new patient (99203) is 1.42 wRVU + 1.48 facility RVU + 0.13 malpractice RVU = 2.14 RVUs = $109 for Medicare. A complex new visit (99205) is 3.17 wRVU + 2.40 facility RVU + 0.28 malpractice RVU = 5.85*36.06 = 210 dollars. The facility RVU is the amount given to pay for staff, rent, and other overhead. In general, if a physician is employed, they are getting just the wRVU for the visit.

For outpatient visits, this source says medicare pays 92% of what private insurance pays for established outpatient visits, and 80% overall https://money.cnn.com/2014/04/21/news/economy/medicare-docto... .

I am a US citizen who used to be a software engineer who now attends a US MD Medical school and I have student health insurance.

For the heart attack patient, it isn't the physician who is charging the huge amount. It's the hospital. The physician is only going to get a certain factor (somewhere between 1x - maybe 3x on the extreme end) of that $440 for the wRVUs.

And like I said, billing for normal patients isn't determined on medicare/medicaid rates and those are widely noted to be far lower than break-even let alone private billing rates.

> The researchers found the gap between the prices Medicare and private insurers pay hospitals increased from 2015 to 2017. Specifically, the researchers found private insurers in 2015 on average paid 236% of Medicare rates, and by 2017 that grew to 241% of Medicare rates.

https://www.advisory.com/daily-briefing/2019/05/13/hospital-...

Again, I just provided you an example of me getting billed $250 for 15 minutes of physician time during an office literally this month. Right now. Just paid it today. Will seeing the bill solve this discussion for you?

> For the heart attack patient, it isn't the physician who is charging the huge amount. It's the hospital. The physician is only going to get a certain factor (somewhere between 1x - maybe 3x on the extreme end) of that $440 for the wRVUs.

That's not what we were discussing, you're changing the topic from an office visit to a heart attack. A doctor's office visit is mostly doctor time, there's no surgical ampitheatre necessary for an office visit. No recovery time in a hospital bed. Completely different situation.

$1000 an hour net billing rate for a specialist office visit sounds about right. That's what I just got billed.

And yes, student insurance is unusually generous and usually subsidized by the university in terms of provider reimbursement as well as direct rates. You are not paying the full freight there.

Furthermore, you are far, far off the reservation suggesting the normal billing for a heart attack is $3200. You are underneath the Dunning-Kruger curve here, you don't even know what you don't know and you think you are informed for it.

> Heart attack hospitalizations cost a median $53,384 and strokes cost $31,218, according to the study. The resulting catastrophic costs make it difficult for uninsured patients to keep up with basic living expenses such as transportation and housing, according to researchers.

https://newsarchive.heart.org/uninsured-patients-faced-devas...

Feel free to tell the American Heart Association that they're wrong by a factor of 15. Let me know when they update the article. You're wrong, it's no longer worth continuing the debate with you.

Again, like I said, I mean this in the gentlest possible way: if you think an average heart attack billing (not just for the doctor, the whole thing) is $3200, you're too privileged to have been exposed to the realities of the American system. You are more incorrect than you have the worldview to even grasp. Even the doctors' association themselves think you are wrong.

I get that a heart attack hospitalization is expensive, $55k on average. The physician is not pocketing all of that $55k. They aren't the ones charging that, that is the hospital. The physician will get ~$1k of that (look below for the calculation). Please try to be charitable in your evaluation of my ability to reason here.

I'm not trying to change the topic from office visit to heart attack. I provided the RVU calculation for the outpatient visits. That is how much the physicians are getting paid. You said that physicians are making a couple hundred bucks of each outpatient visit, which I don't believe is accurate, and I provided the calculation of why I don't think that is accurate. The total cost of the visit can be $250, but the physician is not getting anywhere near that.

I don't think it's accurate to say that they will be able clear $1000/hr. There is additional time needed to document each patient (often equal to the amount of time seeing the patient). I think seeing 3 visits in that time is plausible, but the physician is not getting that whole $250 (which is the point I'm trying to make). The clinic revenue may be $750 for that hour, but that needs to cover all of the overhead, and the physician will get whatever is left.

Make sure you are looking for sources that compare how much the private insurance pays physicians compared to medicare in particular vs how much they pay hospitals compared to medicare. The numbers will be different.

The $53,384 is what the hospital charges for the heart attack. The physician only gets the wRVUs for the services they provide in the hospital (if they're employed), so the 12.56 wRVU for the cardiac revascularization + the admission history and physical (2.61 wRVU CPT 99222) however many days of progress notes (2.00 wRV 1x each day - CPT 99233) in the hospital and the discharge summary (1.28 wRVU - CPT 99238) they write for the patient. So if a patient got revascularized and were in the hospital for 4 days before being discharged that's 12.56 + 2.61 (admission day) + 2 * 2.00 (2 inpatient days) + 1.28 (discharge day) = 20.45 wRVUs for the admission = $737 for the physician for that hospitalization.

I'm trying to make the distinction here between how much the hospital gets paid vs. the physician who provided the care. It's not accurate to say the physician is making $53,384 for the heart attack hospitalization, that is what the hospital is charging. The physician may make ~$1000 for an admission like that. If the physician is self-employed or in a group, they will charge for the facility RVUs and malpractice RVUs as well, because they need to cover the overhead of having a clinic to see the patient after the hospitalization.

If your bill breaks down the overhead for the clinic separate from the physician charge, then I'll agree that the physician made the $250 straight cash, but I don't think that is in any way the average amount any kind of doctor will make off an outpatient visit. Look at what you're suggesting, that a physician makes $1000/hr * 2080 workable hours in a year (not likely a physician only works 40hrs a week..) = $2+ million a year.

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