Throwaway05
6mo ago
I mean I didn't realize it was premiums and not profits that's a my b, but there has to be some explanation for why their behavior is so much more obnoxious than providers and way their denial rate and so on is so different (30% more I think?)
Throwaway05
6mo ago
The dynamics today are largely the same.
Negative, the AMA has spent the last few decades arguing for an expansion of supply not a restriction, nearly ten percent of residency slots are unfilled every year, and alternate funding for residency spots has been a part of the landscape for a long time.
This meme hasn't been accurate for ages but is very pervasive.
Throwaway05
6mo ago
Hmmmm, what's the explanation/incentive for their wildly shittier business practices then? They must be making money somewhere off of the sky high denial rates, no?
Throwaway05
6mo ago
price transparency really doesn't exist to your average patient.
I mean price transparency doesn't really exist for most things.
Two major problems:
-
Physician's are employed now and are therefore generally not in charge of anything when it comes to billing. This adds an extra layer of abstraction and problems. You correctly identify useless clueless staff as part of the problem and as the doc I generally have other stuff I need to be focusing on.
-
Most of the total types of costs are unreasonable or impossible to have useful price transparency on. The average patient may almost entirely interact through the medical system (just off the top of my head) through the window of just drug prices, professional fees, and lab tests/imaging. That's certainly plenty but it might just be 3/100 total things we deal with, and those three are a lower percentage of my actual workload than you might think. Two of the three are totally reasonable and many places will actually have better price transparency if you ask for it but if you try and pass legislation and include the other 97 it becomes an exploding fucking mess.
Meds (well, outpatient ones) and testing (well...outpatient again) are generally reasonably self-contained and it would be sensible to try and get it done at a cheaper place. Hospital based care? Procedures outside of very careful ASCs? Useless. Lots of things get sneaky though - the ultrasound is cheap, but who is going to read it? Is it going to get done automatically and a hidden professional charge or not covered by your insurance charge? Easy to mislead patients if you are unethical or by accident. Then people get mad and demand legislation which makes it even more complicated and confusing.
Professional fees also get super weird. I'm going to give a made up number for opsec reasons. If you come to see me and offer to cash pay my employer may or may not be okay with that. If they are it's going to be be a fairly reasonable number. Let's say 100 dollars for an hour long initial appointment (psychiatry shut the fuck up and stay out of this). If you are paying with insurance there is no number. None. It doesn't translate to anything directly, and if I have no cash fee schedule you can't even squint and go "it's 100 right?" No, it's a billing code, it doesn't relate to what's "fair" or what is "cost" it is all negotiation. State Medicaid pays me 20 bucks an hour for that billing code. We still take state medicaid even though that's less than the cost to run the front desk because my hospital gets a grant from the state government. Private insurance pays me between 40 and 140 dollars for that billing code depending on the insurance. If they decide to cover it. They may decide that on Tuesdays I must include the word "sneeze" in my note, and since I didn't no money for me (well, for my employer). Medicare pays 40 dollars and doesn't ask any questions normally but a few times a year they show up in my office and decide that half the charts need to include the word "mega-ultra-sneeze" since I didn't they are going to take back all of the money they paid me and fine the shit out of everyone.
That's just one way this is done, the more famous one is that my professional fees are 100 dollars but my employer charges 1,000 dollars and puts that on the bill and then the insurer pays between 15 and 200 dollars.
Sidebar: I don't recommend ordering yourself lab tests without physician involvement, it's easy to fall afoul of pretest probability and sensitivity/specificity issues. A big one I see right now is college age people will order themselves STD testing because they don't want to ask their doctor cause awk. Eh kinda harmless. Except these places will add on HSV, which you are not supposed to do (per AAFP) because a positive test result causes a ton of misery but only has a 50% change of being a true positive and there isn't any option for follow-up confirmation testing.
Throwaway05
6mo ago
I know you hate that argument so I very specifically didn't make it this time.
Based off your historical unwillingness to update your understanding of anesthesia compensation and work duties I don't think we are going to have a fruitful discussion on the doctor skills/role and work alternatives side of things.
Throwaway05
6mo ago
This is no longer the case (your citation is from 1965) and is a non-sequitur anyway.
If you cut doctor salaries in half and double the number of doctors, you have improved physician lifestyle at the expense of compensation but not changed costs at all.
Throwaway05
6mo ago
OH LET ME TELL YOU ABOUT WELLNESS MODULES.
Problem: Our resident physicians keep killing themselves.
Solution: Make them come in at 6am on their day off to spend 2 hours filling out un-skippable e-learning trainings reminding them that they should sleep. The person who worked a 24 hour shift over night and is being prevented from going home starts screaming incoherently. Then the hospital hires a "chief wellness officer" at executive pay scale who comes up with more wellness modules. If you are lucky they throw the residents a pizza party while they are working and the nurses eat their pizza.
Sorry one of the other comments made me think about wellness modules.
Throwaway05
6mo ago
This article has been litigated elsewhere so I won't belabor the point, but it's very easy to use loop holes for this sort of stuff. Non-profits do it all the time. Oh yes we didn't make any profit, but all the executives and their nephews have massive salaries...weird that.
(the insurance companies can likely be run a lot more lean).
Throwaway05
6mo ago
Some even argue that most anesthesiology could be done by a non-MD.
Jesus Christ please no haha.
The rest of your comment.
Physician ownership is dead in most specialties, nearly everybody is employed now. There are some people who still own things now but the majority of people get paid salary with some element of bonus that is RVU based (eat what you kill type stuff). It did not use to be this way, and I won't argue that era had some excess, but it is dead now.
Procedural work does pay more and there are problems with that, but it is generally much harder (on an hours worked basis if nothing else) and as a result we have much less of a problem with rationing of surgery than most countries.
There's also a lot less of these people - there's 35 times as many (Family Med/IM/EM/Peds) doctors as dermatologists.
Skim 100k-200k off of the dermatologist and you do fuck all for total healthcare costs.
Decrease doctor salaries and increase doctor supply and you'll have doctors refuse to do out of title work and demand to work a normal day. If you half doctor salary and double the number of doctors you haven't done much. Every doc is doing 2-3 people worth of work and they do it because the money is good, money stops being good and then they stop...
I'm burnt out on the price transparency issues because of other conversations on this board but keep in mind that a lot of this already exists. Check out GoodRX.com Most doctors will use these tools nowadays when they can (lots of EMRs automatically tell you the drug cost for instance) but if given the choice of a drug that costs X or 10X they are going to choose 10X 10/10 times if they think its going to reduce the risk of a lawsuit.
Throwaway05
6mo ago
The physician pipeline is a whole separate problem that is infested with culture war (DEI and AA) and pre-culture war (autists bad, I want better customer service and English speakers!!!) bullshit.
If you throw out the customer service angle, then to some extent you want psychopathic hard workers AND autists. The supply of people who are both is limited.
Walking back all of the box checking side of things is also hard. These days autists get furious at mandatory wellness modules and other asinine useless horseshit and burn out. Banning that stuff is hard and box checkers are much better at dealing with it.
Throwaway05
6mo ago
If your trucking company goes out of business because they can't eat the loss then another firm will open and fill the economic hole.
We've had issues with hospitals going out of business lately due to COVID and other factors, and nobody replaces them. The patients go elsewhere (sometimes 50 miles elsewhere) and stress another system. It's a slow motion domino effect. The expense and risk is too much and the reward is too low.
Not directly related but we've seen issues with generic meds - generic medication has profit margins that are very thin, so manufacturers just don't make them. Then a drug is missing. That's not good.
That's usually downstream of regulatory oversight making the production cost aggressively high, which I'm not sure I mind (because safety is important), but we do often have shortages of stuff for that reason.
Throwaway05
6mo ago
Sure people talking about increasing the supply of physicians and therefore driving costs down, but that only matters if reducing physician salaries does anything useful. It's not a large enough slice of the pie.
Throwaway05
6mo ago
It is pretty astounding to hear that health spending occupies an increasingly larger share of GDP yet doctor compensation is worsening.
I think this should be pretty intuitive if you think about government and academic spending. More administrators and more middle managers are rampant everywhere and drive up costs. Market activity is somewhat protective against this, but healthcare has too much going on that doesn't resemble a market.
...faster you think on your feet the more good you can do...
One of the remaining perks that hasn't eroded is that you bring in the revenue for the hospital. Even an IM doc brings in 4-5 times their salary in revenue to the hospital. This gives some independence, should we choose to use it (we often don't because residency beats that out of us). You want me to fill out a yearly HIPAA training. Fuck off, fire me if you want. You won't.
This patient is having an emotional breakdown and really needs it? I'm skipping my mandatory meeting and spending time with the patient and their family.
Moments like that matter a lot.
Also, if you are smart and motivated you can discover entire new ways of helping people, stay on the bleeding edge, redefine what the standard of care is...and so on.
Even bad patients can be rewarding when you finally help them to the ah-ha moment.
Good stuff is out there.
Throwaway05
6mo ago
I think one of the common problems is that intuitions from other fields die in medicine. Your HVAC contractor fucks up and it costs 2-5 times more. If it's bad somebody goes out of business.
If something has 50x or 100x times cost overruns like idk the F-35 it becomes a national scandal.
In medicine that's just Tuesday.
You have a bad reaction to anesthesia during a routine case, die on the table, they revive you and dump you in the ICU for three weeks before you can think again and then end up in rehab for six months and it's going to cost millions of dollars for what was supposed to be 4.5k.
That's an extreme example but that kind of stuff happens, and lesser versions all the time.
The hospital can't go out of business, society says no. And we can't let you die. Society says no. I'm fine with both of those but they balloon expense.
Throwaway05
6mo ago
All the doctors like that are DINCs, from a prior time (aka the 90s), or from one of the well paying specialties. 300k a year starting in your 30s with 500k in debt isn't enough to make you rich until late in the game if you intend to put 2-3 kids through college and so on, if ever. Sure you can push state school or not pay but if you went through it you want to protect your kids from dealing with it.
These days the doctors are on the receiving end of class rage though, everyone is mad at us on both the left and the right, thinks our job is easy and easily automated, and wants us to make less money. Thus my long ass rant.
That said I do it because I want to help people and I like teaching. It's also interesting as hell. Medicine is hard because it is much poorer define than most knowledge work which means there is a lot of room to learn and research and for your job to stay interesting over the course of your career.
Throwaway05
6mo ago
A bunch of it is going to insurers. Profit margins are thin but if expenses are high from inflated salaries and the gross amount of money is hundreds of billions of dollars that adds up.
Clinical staff add value, most of the other salaries involved are siphoning value. Hospital and healthcare admin staff has ballooned. Practice managers. Billing staff. HIM staff. Midlevel mangers etc etc.
The system has a lot of room to be more lean but as with academia it's just expanded into an inefficient mess.
Many of the people who get paid unnecessarily essentially have the job of fighting other people who get paid unnecessarily (ex: hospital billing staff warring with insurance).
Throwaway05
6mo ago
Super super common "you said left-right, we want you to say right-left." Hospitals and practices have full time employee's whose job it is to comb over notes and have the doc rewrite them to satisfy a constantly changing set of requirements.
"Doc we need you to put that the patient is obese in the assessment and plan for this note" "well I didn't really do much for that to be honest and now that the patient's can read the notes they may not like that" "yes but if you write that you encouraged them to exercise we can get an extra five cents from the insurance company" "I did, in the section of my note when I wrote down what we talked about" "no, no it has to be in the assessment and plan as a specific problem"
Throwaway05
6mo ago
I've never seen it broken out in a way that granular but I expect a bunch of it would be line items like "secretary to assistant infection control nurse" and you'd be like "who the fuck is that and what do they do" to which my response would be "well I don't know who that person is, but I know the infection control nurse is the person who goes around cancelling all of our tests that will show that the patient got a hospital acquired infection" (through nobody's fault) because the government doesn't like when we have those.
The sheer number of admin and regulatory compliance people who don't really do anything has massively ballooned.
It's very much like universities.
Throwaway05
6mo ago
I've never actually talked to a lawyer (well, one who knew about malpractice) about this so I welcome instruction if you think I'm off base.
My two primary thoughts are:
-
The problem isn't the expense of lawsuits and the verdicts, it is the impacts the threat of those have on patient care and physician decision making. Doctors are already (generally appropriately) very risk averse. Lawsuits are scary and we all know somebody who lost a lawsuit for bullshit reasons or went through ten years of suffering before winning. Even a dropped complaint makes licensing and other stuff a huge fucking pain in the ass. Therefore we do things like order unnecessary CTs and spend twice as long on note writing in order to hypothetically ward off the threat of malpractice. Most of the time it doesn't do shit but that doesn't stop it from making things more expensive, time consuming and increasing the risks on patients. Defensive medicine is problematic than actual malpractice is.
-
I figure one solution is to make the results more predictable. All of these posted cases where somebody didn't do anything wrong and the jury still dropped a hundred million dollar verdict are terrifying. Have a non-jury resolution somehow. Expert panel. Doesn't need to be just physicians, can be industry or legal experts or whatever, just anybody who knows what they are talking about so when the expert witness lies about what happened nobody believes it. Or empower licensing boards to take away the licenses of expert witnesses who sell a pile of shit. That's a dangerous power that I'm not super comfortable with but we gotta do something. And I do want to preserve the power of people to sue if someone actually does something wrong.
Ultimately the root of the problem is that awards and verdicts are independent of actual malfeasance and deviation from standard of care.
Throwaway05
6mo ago
On physician salaries:
This topic comes up from time to time and is more in the news now for obvious reasons.
Here I will point out that cutting physician salaries does little to address the healthcare cost crisis and also argue that the salaries are deserved.
Obviously yes, I am a physician and don’t want my salary to get cut, but nobody wants that to happen to them, how would you feel if people on the internet were saying you were over-compensated and demanding you take a 50% pay cut?
It’s also worth noting that everybody in the U.S. is compensated well (too well?). That includes within healthcare (see: nurses) but also outside of it. We make good money here; it’s one of the reasons so many of the successful elsewhere want to come to America.
-Okay how much of healthcare spending is doctor’s salaries?
About 8%. If you cut physician salaries by half you get 4% savings. That’s not a little but it is also not a lot.
-Can we do this?
Sure, you could, maybe, but you’ll introduce new problems, people will retire or leave the field, shortages will get even worse, and so on. Depending on how you did it, certain critical fields like surgery would vanish overnight. OB care would be financially impossible to provide (due to incredibly high malpractice burden (can be 150k per year). You can’t spend your entire salary on malpractice insurance and other expenses.
-Okay, but how are physician salaries trending, are you making more than you used to?
Doctors have been getting year after year real wage cuts for 20-30 years. Everyone else’s (in healthcare) salaries have been going up. Percentage of healthcare spending on physician salaries is going down. So, if you really want us to get paid less just wait. Our salary shrinks every year and the portion of the pie we are taking shrinks too.
-Alright, again. So, does cutting physician salaries help?
No not really, we aren’t a large enough slice of the pie and you’d cause a shit ton of new problems. We’ve already seen this a bit. More people are working part time, quitting, dropping out of residency, graduating from medical school and not doing medicine, not providing certain types of services or working in certain locations. That’s with a modest decline in salary and things like an increase in administrative burden and a decline in respect. This would shoot up if you dramatically cut salaries.
-Okay but let us just import a ton of foreign doctors.
Again, 8%. It’s not going to help that much. However, it’s worth keeping mind that a lot of what pisses people off about healthcare gets worse with foreign doctors. Yes, I believe that foreign doctors have worse training and experience than American doctors. People here seem to not like that argument, but we don’t need it. Foreign doctors are almost always coming from third world countries, not Western Europe. People hate when their doctor barely speaks English, spends little time with them, and acts like a cultural alien. All of those things are what cheaper foreign labor brings to the table. Patients in the 90s and 00s heavily pushed better customer service in medicine. It’s made things more expensive but has resulted in better customer service. Walk that back and make things cheaper if you are okay with worse customer service we can do that without breaking everything else.
-Okay DW what’s the most histrionic thing you can say on this topic, just for fun.
If you cut MD salaries by half, I think healthcare costs would actually increase. You’d see a decline in certain types of care which is unexpensive, preventative, and annoying for us to do. Example: nearly every single endocrinologist would stop practicing and go back to doing hospital medicine (they already make less than hospitalists, often to the tune of 150k and have already completed the training for that). All those unmanaged conditions would end up costing more in the long run. You’d also see an increase in “well fuck you, I’m going to be shady now in order to make this worth it.” And you’d see a huge increase in low value – high expense defensive medicine since protecting your salary becomes even more important. A more modest boiling the frog approach is already in use, and involves far too little money to solve the problem.
Switching gears.
-Okay give me some numbers.
It’s hard to tell for a variety of reasons but the number going around right now is an average of 350k (it may actually closer to 300k and we are seeing a complicated post-COVID mirage). That’s a big number but this is a situation where the median and average diverge a lot. Pediatricians often make between 180k-200k. Family medicine makes more than that but not a lot more. Those are a huge percentage of the overall jobs. Yeah, neurosurgeons can make 5-10 times that, but there aren’t a lot of them, and they work close to 24/7, they still make the average weird. A lot of “rich” doctors are a small number of people in a complicated specialty working egregious hours and not really enjoying the money. At one point the neurosurgery divorce rate was over 120%. The median physician has much more reasonable compensation. They also used to make a lot more, the mental framing of this for some is anchored around 90s compensation which just isn’t true anyway. Doctors work a lot. People who run entire departments, manage millions of dollars in research grants, or own patents and other companies are sometimes presented in these numbers.
-That’s still too much.
Okay let us talk tradeoffs. Some things to keep in mind. Doctors don’t typically make money until after they turn 30. Up till that point physicians can often live in more or less in poverty (want to live next to your hospital in the nicest part of a major city on 60k? Good luck). Once you start making money you can start paying off your 500+ thousand dollars in loans. Delightful. Up until that point you have no flexibility. You can’t leave your job or your life is over. You can’t choose where you live. If you get fired your life is over. If your boss is abusive, you say nothing. Probably most importantly, you can’t get back time. Money and time are probably most useful in your 20s. Our peers are meeting partners, going on vacation, clubbing. We are working 24-hour shifts. That’s a huge cost.
-Boring. You chose this.
Fair. But if you want American to keep choosing this you have to be aware, otherwise it ends up like the other jobs that nobody in this country wants to do.
-Okay fine, like is it even that bad of a job though?
Yes. Consider that many doctors are functionally working 2-3 full time jobs worth of work.
-Okay hold up, yeah you work 80 hours in residency but not as an attending and certainly not 120 hours.
Okay, okay lemme explain. Yes, some people are working 80 hours a week (or a lot more) as an adult. However, you are more often doing things like working 60 hours a week, but that is including things like nights, weekends, and Holidays. How many jobs involve regularly working Christmas, or three weeks in a row without a day off, or 24+ hours in a row? Any job with hourly wage and overtime is going to add up to 2 times the base salary really quick under those conditions.
Also, unlike most blue-collar labor (which is laden with mandatory and very real breaks) or white-collar labor (which involves a lot of downtime), most doctors are working nearly 100% of the time while working.
That may sound unfathomable to you, and to some extent varies specialty by specialty but can be very close to literally true. On days when I’m in the hospital for three or meals I’m lucky if I sit down and eat for one of them. Usually if I’m lucky I’m just cramming a protein bar in my face. Trainees always go “what the fuck when do you eat. Or drink. Or pee.” We usually don’t. Surgeons are notorious for regularly giving themselves mild kidney injuries because of dehydration.
Almost nobody I know who isn’t a physician has worked a 24-hour shift. Most people I know have never worked 8 hours in a row for real with no breaks, certainly not for weeks and weeks in a row. Your year-end scramble or Go-Live or tax season is our baseline, and often we are doing it for 24+ hours at age 55.
Once you break this down to hourly wage the numbers get much more reasonable.
-Hold up you work 24 hours in a row with no breaks? Is that real? Isn’t that unsafe?
Yes, at around hour 18 you become disoriented to the point where it’s not safe to drive anymore. Yes, this schedule ends up actually making a lot of sense somehow. Yes we sometimes work more than that, at any given time in a hospital there’s probably someone working a single shift longer than some of the nurses whole work-week.
-Okay but like, outside of the sheer hours it is not that bad right?
Well lack of breaks is part of that. Plenty of other stuff though. Perks are non-existent these days. Most places got rid of the physician lounge and parking lots, which mostly exist to make us faster and more efficient so not the best move in the world. Keep in mind that the chair in my office is maybe older than I am, and most places I work my personal laptop screen is bigger than the screen I’m doing my work on. Most corporate jobs are comfortable. Medicine is not. Little things like that add up and are part of why a lot of us get lured into the general workforce. For some reason I pay for parking.
Also, the job is intrinsically hard. Treat us like kings and pay us millions of dollars a year…and you are still dealing with death and entitled and demanding people all day. You can get sued and lose all your money, your job, or more likely just be miserable for five to ten years while the case gets sorted out in your favor. Most jobs if you make an inattentive mistake, you say oh shit and fix it, or somebody loses some money. Doctor fucks up and somebody dies, and you make thousands of decisions each day where if you lose that focus…
Alcoholism, drug abuse, and depression rates are high. As are suicide rates.
Sidebar: most white-collar work does not involve dealing with the dregs of society. This occasionally makes useful for for instance talking about the practicalities of the criminal underclass but is absolutely stressful.
-Okay but like, not everything is clinical work, right?
Well yes, to some extent that is part of the problem. An increase in charting and administrative work has made healthcare more expensive and restricted supply and quality since I spend less time with and working on patients. Writing bullshit notes does not increase my job satisfaction.
However, there are good other parts – leadership roles, research, teaching. Most doctors are clinical care providers, mentors and educators, and team leaders and managers all at the same time. With the demands of all of those things.
-That’s a lot of shit, anything else you want to unload?
Yeah, there’s other stuff that makes being a doctor be expensive. Board examinations and licensing can cost tens of thousands of dollars. If you get caught smoking weed you could end up losing your job and have to pay hundreds of thousands to get it back for some god forsaken reason. Everyone wants to siphon off of us because they know where the money is. This is also why NPs don’t get sued despite having less training and more bad outcomes. Less money involved.
You constantly get expensive retraining, tests and learning for the rest of your career also. Medicine changes all the time and we are required to stay up to date.
-Okay but like if I’m in the hospital I don’t see you at all what the fuck are you doing?
Operating. Teaching. Calling the lab. Writing notes. Seeing other patients. In committee meetings. I swear we are working you just aren’t seeing it, and a lot of what we do isn’t direct clinical medicine.
-Thank you for coming to my TED talk.
Throwaway05
6mo ago
You can vent someone by hand with a bag, especially if they are sick enough to not require sedation. Horrifyingly we were doing this at times during the pandemic, and we do this all the time acutely to manage emergencies, start anesthesia and so on.
The machines automates the process and doesn't have the attention issues of a really person (or like physical exhaustion).
So yeah a huge chunk of it is personnel - the doctor (who needs to be caring for a smaller number of patients because ICU level care requires much more attention and closer eye), the nurses who need to have very tight patient to nurse ratios. Both of these need to be round the clock including weekends and holidays.
But more personnel are involved than you think - cleaning staff, people to bring up the medication and fluids, dietitians and respiratory therapists to focus in on those sides of things because they are cheaper, than having the doctor do it, unit clerks to manage angry family and paperwork, tons of mostly invisible people.
Everything in an ICU needs to be "safer"/cleaner/whatever because the patients will die at the drop of a hat.
Fundamentally its not like this could be done at 85% instead of 95%-100% for much much much cheaper, but nobody wants to get fined or sued so we spend twice as much money to go from 85-95.
Throwaway05
6mo ago
It can be pretty easy to go over lifetime limits - if you are a sick kid you burn through all of your insurance you can ever get by age 8, and what...nothing after that? Not even if you stay healthy for 60 years?
Certainly you can consider rationing for some things, but if you do all the right stuff, have good genetics, stay healthy, you can still get hit by a car and then be unable to get any care ever again?
This is magnified by the way that charges are inflated as part of the dance of getting insurance reimbursement since those numbers are basically made up and have minimal relationship with actually cost.
Something that costs 1 dollar might be billed as 30 dollars so the insurance pays 1 dollar five cents. But if they can they'll charge 30 dollars against your lifetime limit.
Rationing is exceedingly unpopular and hard to implement in a way which doesn't immediately run afoul of some angry interest group, and all it takes is one photogenic person who would have survived or not gone bankrupt...
Throwaway05
6mo ago
Random trauma like car crashes only happen to a small percentage of people every year, and so it's the kind of thing that insurance is good for.
It's a small percentage of total healthcare contact by number of events, but it's a huge percentage of total healthcare spending. Fundamentally seeing your doctor is at most, getting a lawyer consult expensive. The hourly rate could be high but it's reasonably throttled. Being hospitalized is buying a house expensive. It takes a lot of lawyer visits to add up to a house.
This is a choice we are making. We could just as easily dismiss such cases as frivolous and instead have people sue ambulances for taking them to an undesired hospital.
Tort reform would dramatically decrease the cost of care without upending all these other apple carts.
Another way is to just have a single price for the surgery that averages out complications. No, that is not general insurance.
This just isn't feasible with how badly things can go. If the "normal" price is 5k but the "Averaged" price is 35k we are absolutely screwing over people who have routine surgery. When stuff gets expensive it can get really, really, really expensive.
It's not quite clear to me that we should be spending millions of dollars to save a single person's life. Unless it's really simple/easy to do, in which case why does it cost millions of dollars?
Simple and easy is flexible. A lot of problems are managed by forcibly keeping someone alive while their body heals itself. This is what most hospital COVID treatment was. We can provide a short term external heart and lungs and the person's body will fix itself without our intervention then we can turn it off. We can put someone on a ventilator. A vent is "simple" - but it's not cheap.
Also, do not discount how much money each person would have in their HSA,
HSA type situations require real teeth, otherwise people will bet they won't get seriously sick and most of them will be right, but the ones who aren't will fuck the system. One bad episode of sepsis wipes away hundreds of thousands of dollars but is totally survivable.
In the U.S. we spend a lot of time and money keeping people alive we really shouldn't, but we also spent a lot of time and money keeping people alive and it works great but is reasonably expensive. A good amount of these are otherwise young and healthy and economically productive (to say nothing of the ethics). In resource strapped countries these people just die.
You also have things like heroic efforts to keep children alive, many of whom have healthy lives if they make it through whatever acute thing is happening. Might cost a few million to keep the kid alive but their parents will think its worth it and society may actually also.
Throwaway05
6mo ago
For anything the provider does for him it has to claw the money out of the insurer itself.
This actually already happens now. We spend a lot of time on the phone with insurance trying to get them to cover what they said they would that's for both us and the patient "no no you can't bill us for this office visit because you described the mass as spiculated" "that's a technically term" "we will only pay you if you describe it in your note as spiky" "wtf."
Hospitals have entire departments whose full-time job it is to assist with this.
It just doesn't involve the patient typically so they don't notice.
There is also an excess of medical students applying for spots each year (primarily driven by shitty Caribbean schools and foreign applicants). Even a small number U.S. MDs and DOs go unmatched each year.
We have an excess of supply in the form of medical students and residency spots but for both the excess is of insufficient quality.
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