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
4mo ago
Two case studies in government waste:
As you can likely imagine right now a lot of people in medicine are sharing tales and taking sides in the great DOGE debate. Two that popped up on my radar and stuck out to me:
- One of my medical school classmates is a psychiatrist at redacted city hospital. He has been informed that the state Medicaid will no longer pay for psychiatric emergency room visits if the patients do not go to their aftercare appointments within 30 days. They have been informed that they could lose their government funding if enough patients fail to do this.
Some problems: -As an emergency room most of their patients have no insurance or Medicare or Medicaid, meaning the facility often get paid less than cost. They only stay open at all because of their state grants.
-Many of the patients are drug addicts or malingering (because of homelessness for example). Every day you’ll hear something like “you’ve been here every day for the last three weeks” or “have you considered stopping using PCP? You always seem to fight with the police when you do” and “here’s your follow-up appointment, will you go? No? Fuck me? Okay thank you have a nice day.”
-Many of the patients who do actually have mental illness are in denial about it, or have some sort of limitation that prevents them from attending aftercare appointments.
-The “best” solution is probably to violate patient rights and involuntarily commit them to make someone else be on the hook for making sure they go to their aftercare.
-In the meantime, the hospital has hired several additional staff to manage some of the administrative complexities associated with this change (for example hammer calling the patients to remind them to come to the appointment). They have also hired night staff whose job is to sit in an office overnight purely to schedule appointments with an outpatient program (otherwise no patient could be discharged overnight because they wouldn’t have an appointment to go to…).
- One of the residents I mentor is about to do a rotation at the VA. This is pretty common for residents. His rotation starts in a few weeks. A few months ago, he got an email that included the instructions “it is imperative that you start your onboarding process for the VA right now otherwise your onboarding may not be finished by the time of your rotation” and “it is important that you not start your onboarding right now as it is too early to start onboarding and your onboarding may not be valid if you complete it too early.” This is not a joke or an exaggeration.
Anyway, he dutifully completed his requirements in a timely fashion (which were all pointless! Ex: what is the motto of the VA???). So, months later his rotation is starting soon. He begins the process of emailing the education team once every 2-4 business days. You have to email them multiple times before they respond. The conversation goes something like this over the course of multiple weeks, “I think I’ve completed my onboarding do I have to do anything else?” “no” “okay is my onboarding done” “no” “okay when can I pick up my ID card” “when your onboarding is done” “I thought my onboarding was done” “yes” “okay what I am waiting on” “nothing.” I have seen the emails; it really looks like this.
At this point his program tells him to CC the chief of medicine at the VA hospital, at which point the person responds with “okay we put in a ticket for this a month ago, your training is complete but your training is marked as incomplete.” A screenshot has been attached that shows the request and an automatic response that says something about high ticket volume and that they will get to it at some point. The chief of medicine replies “….does the trainee need to do anything?” (we are here).
The resident will be able to rotate but will not be able to do any work without computer access.
It’s worth noting that the VA is paying for this resident to be there, despite the fact he will in fact not be able to do anything. At his last VA rotation (yes they go through this for every resident every time) he was six weeks into an eight week rotation before he got access.
Throwaway05
8mo ago
Trump's interview with Joe Rogan is out. I think it should be mandatory viewing, as someone who has read a lot about both of them but never heard either speak at length I had some interesting surprises.
I spotted a few major pieces of culture war fodder.
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Joe apparently didn't want to do this because he was worried it would end up being fluff or making Trump look good.
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I do think it makes Trump look good. It's the beer test, implemented, and for all to see. Many people have the instant opposite visceral opinion. As with everything about this, that's interesting.
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Most here have concerns about legacy media, I think this adroitly makes the case against legacy media - as does Joe himself explicitly multiple times during the interview.
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I've polled some Kamala supporters and they all think she'd have done just as well, but I highly doubt that.
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Trump gets asked about election stealing...and some of his answer kinda matches some of the "best" answers we see here (complaining about procedural changes and so on).
At time of this posting it's at 18 million views in the same number of hours.
Throwaway05
6mo ago
Why is it the physicians job to know what things cost? A hospital will literally have hundreds of employees whose full-time job it is to figure out what things cost and deal with insurance companies, who are always changing things constantly. Even a small practice will usually have 2-3 employees minimum who spend most of their day figuring that stuff out.
It's entirely orthogonal to providing good medical care.
We do cost benefit analysis all the time, but it is in terms of the risks and benefits of a given intervention, wouldn't you rather us be focusing on that?
Throwaway05
6mo ago
There are multiple parallel problems here.
The cost is fundamentally unknown. It is reasonable to determine what the average cost of a thing is, but that is not helpful information because when we leave the average the costs can become profoundly immense. More people are upset with an estimate that is off by multiple orders of magnitude than by no estimate at all, and that will happen.
To torture your mechanic analogy, it's like if you go to buy a car and ask for a Corolla, but 5% of the time you get a Bentley whether you want it or not.
The average cost is not necessarily known to your doctor. If I'm your surgeon I know what my professional fees are and how long my average case takes. I probably know the billing codes used, if I'm business minded I may know something about the average cost of supplies, instruments, and equipment. However a run of the mill routine surgery requires a team of 40+ people between the office visit, PAT, pre-op, intra-op, PACU, and post-op. It is unbelievable how many hands are involved and it is incredibly difficult to keep track. You immediately start running into problems like "cleaning staff are a critical part of the OR and are a cost to the hospital but are not usually considered a part of the surgery, is that a cost or is it not a cost?" or "does this facility charge by the minute for anesthetic gases or use a flat fee" both options are viable, your anesthesiologist probably knows, your surgeon probably doesn't. Keep track of "costs" is a full time job with an entire department just for the OR. Your surgeon might be able to say "your surgery probably costs 10k" because they asked someone in a billing meeting what all the averages on the spreadsheets said, but nobody wants to have a 20 minute conversation about how much of an oversimplification that is.
Additionally that is fundamentally not the surgeons job and does nothing to improve the surgeons provision of medical care. We evaluate whether to perform a case or not based off of the medical risks and benefits, not the cost. This is part of why healthcare is expensive in the U.S. but most people prefer that to the alternative.
Doctors wear a lot of hats. Things like increased regulatory burden and the dance with insurance below mean that you have of multiple departments involved in figuring out how to deal with the above. We already do a lot of things like that slow us down and prevent us from actually spending time with patients. Making it worse is not desirable to us or our patients.
The cost is irrelevant, which disincentivizes processes involved in streamlining all these things and makes it useless for your doctor to know and be able to relay to you. Almost all procedures are paid for by insurance or involuntary charity care by the hospital, with a small rarity of actual self-pay. Getting insurance to pay for something involves complicated negotiations where they try and pay you less than "cost" so you exaggerate cost as much as possible in hopes you don't actually lose money. It is not uncommon for the payment mix to end up being something like medicaid reimbursing 80% of cost, medicare 85% and private insurance 110%. If you mostly care for medicare and medicaid patients you go out of business (which has happened a lot lately) or require government bailouts. This is why the sticker price is so insane, and hospitals will almost always drop 90% of the bill if you end up being cash pay. You have to negotiate with the insurance company and that involves the "official cost" of a gallbladder removal being 100k instead of 5k or whatever.
A surgery has more in common with a government procurement and bidding process than getting a car repaired.
Even more simple things like an office visit are a pain in the ass to figure out. Unless you are doing very specific types of PCP practice or outpatient cash Psychiatry you are taking insurance. Therefore I don't know what the visit costs. I know what my billing team will try and charge for my time, they'll use the specific office visit billing code, I'm told to make sure to put X and Y thing in my note so they actually cover the work I did, but then I know that even the insurance company is supposed to pay for that code they'll make a big stink about it and require hours of the billing teams time going back and forth to make sure that its not worth it to actually get paid for that, even though the other insurance company always takes it if I put in X and Y, so my office staff will adjust the coding and bill you for the down coded visit even though that's not what I did and that's somewhat illegal, and your sister will get billed the actual billing code because she has "better" insurance.
All kinds of asinine shit like that happens for the most routine interaction with healthcare.
This is why psychiatrists are like "dude just pay me 100 an hour and we are good" and why there are now multiple forms of primary care that avoid working with insurance.
"What's my rate for a visit" is never a viable question because every insurance company pays me differently and its constantly changing year to year and I'm effectively only paid for by insurance.
Throwaway05
6mo ago
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"Your surgery will cost anything between 4,000 and 5 million dollars, as those are the minimum and maximum recorded prices we have charged in the last ten years." Is not a satisfactory answer. "The median price for the surgery is 5,000 dollars" is not viable either because patients will sue if it's wildly off that. Either way the cost doesn't matter, it's almost entirely removed from how much the hospital gets paid or collects.
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This like a governmental procurement process. The person who has knowledge of everything is the head of the OR or billing department, not the person who is on the ground doing the thing. You can't have the head of the FBI come down every time and explain what the cost of an investigation is, the individual agents sure as hell don't know, why would they need to?
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Healthcare systems (including doctors) are the victims here, victims of a predatory insurance industry and unhelpful overregulation that needs to be replaced with functional regulation or needs to be understood to be reducing the amount of and increasing the price of care. Don't blame us doctors and nurses are leaving the field and hospitals are shutting down because insurance companies are winning the battle. Blaming us helps them collapse the system faster.
Throwaway05
6mo ago
Healthcare is like aviation and nuclear in that bad outcomes are considered unacceptable, therefore there is a ton of regulation and complexity that does not exist in other industries, there is also more variation in health care than aviation and nuclear because people's bodies are variable and much of the more complicated stuff cannot easily be standardized.
It is its own entity not like other economic segments and intuitions brought in from elsewhere have a tendency to be incorrect. This is why companies like Amazon, Google, and Apple all tried to start healthcare projects and bailed out. This is why PE firms buy hospitals, crash them and then just sell the land. This is why Theranos happened. Healthcare doesn't work the same way as everyone else. Maybe it should but it doesn't.
Part of that, and something you really need to simply address is "who the fuck cares about the prices" the prices are made up, they don't matter, insurance pays and insurance NEVER actually pays the price. There is no value to you in knowing what the price is, and as given in an example in my last post sometimes the prices DOESN'T EXIST.
There is no cash value for my professional time if I don't see cash patients and what the insurance company will give me for my time is a big fat question mark.
You don't just get to declare that medicine is the same thing as everything else and call it done. Frankly I can't recall other industries telling me they were uniquely weird, my friends in most industries emphasize how similar they are to each other and go what the fuck when I explain how things go in medicine. "You get paid less for working in higher cost of living areas or for more prestigious jobs? What the fuck." "More years of training decreases your salary? What the fuck." "More complicated jobs pay less? What the fuck." "What do you mean a routine procedure could cost five thousand dollars or one million? What the fuck." "What do you mean you do 20+ hours of unpaid labor a week? What the fuck."
To emphasize: name another business that is forced to work for free and is prohibited by law from closing unprofitable businesses segments (example: the ED). Healthcare is prohibited by law from being more efficient and cost effective.
As previously mentioned we have a parade of outside actors coming into medicine in attempt to take care of low hanging fruit and apply general business knowledge because they assume everyone must be idiots. And then they catastrophically fail.
The complexity of medicine is higher than nearly every other field for a number of reasons including the fact that actual human lives are at stake. Bad outcomes are unacceptable so that makes things expensive in a way that does not apply to other industries. Voters have elected to avoid tort reform or rationing or a reduction in administrative and documentation burden and others things that might address the problems.
You are right of course that people will attempt to solve the problem by increasing regulations and doctor salaries will be likely cut. Well administrative costs are about a third of healthcare spending. Guess what is going to go up with increased regulation? Physician salaries are about 8%. Guess what's not going to move the needle if it is cut?
And of course price controls lead to shortages, which we already see quite a bit.
You seem to think that everyone in healthcare is stupid and that nobody has tried to apply general business knowledge to these problems. Of course they have. Some well run places have managed to improve things slightly, but we don't have to speculate as to how hard this, just point to the parade of corpses that tried what you are suggesting.
And of course you have things like HCA which seem to be legitimately profitable! Great. Oh wait no they are grossly unethical and constantly under investigation for illegal business practices and nobody who works there wants any of their family members anywhere near those hospitals.
EDIT: Let me add one more - where else in modern America do you see costs kept down by using indentured servants? The closet thing to Residency is visa abuse in tech and that's not anywhere near the same level of insanity.
Throwaway05
6mo ago
Let's go back to basics. We can estimate the price of a given surgery prior to providing it but that estimate is misleading due to the frequency with which it is wrong, often to the degree of orders of magnitude. You might say "yes you can give me an average that's an estimate" another person might say "an estimate is only meaningful if it is reasonably correct."
In my experience people get pissed if they ask how much it is going to cost to renovate their kitchen and they get a bill for 3 million dollars instead of the initially stated 30,000.
So
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Estimates cannot be provided in the same way they can be in most other industries due to an intrinsic excess in variability secondary to the complications involved in human health.
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Giving estimates reduces bargaining power with insurance companies and is therefore disincentivized.
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Estimates have no value to patients because your insurance is going to be paying not you.
Please pick one or more of these you disagree with and explain why.
Throwaway05
3mo ago
So, I can often be found posting on here complaining about bias in medicine (although I disagree about some of the kinds of bias with quite a few posters here).
We do have something of an update to a long running story that’s worth sharing.
Meddit link for more discussion and detail: https://old.reddit.com/r/medicine/comments/1jotpzz/follow_up_on_the_study_showing_discrepancies_in/
Basically, awhile back there was a headline about how black babies received worse outcomes when care for by white doctors. Apparently, this went so far as to get cited in the supreme court.
Sometime later someone on Meddit (which is still quite pro-woke) noticed that they forgot to control for birth weight, which would likely completely kill the effect size (explanation: white physicians have more training and take care of sicker babies who have worse outcomes). At the time there was a significant amount of speculation essentially going “how do you miss this? That would be the first you would control for.”
Well, it turns out that someone filed a FOIA request and well, to quote Reddit:
“A reporter filed a FOIA request for correspondence between authors and reviewers of the article and found that the study did see a survival benefit with racial concordance between physician and patient, however it was only with white infants and physicians. They removed lines in the paper *stating that it does not fit the narrative that they sought to publish with the study.” *
While I often criticize medicine for being political, I’m often found here telling people to trust the experts when it comes to (certain aspects) of COVID or whatever, and well this kinda stuff makes it very very hard.
The initial findings were passed around very uncritically and sent up all the way to the supreme court.
How can people trust with this level of malfeasance? How do we get the trust back? How do we stop people from doing this kind of thing? I just don’t know.
Throwaway05
6mo ago
Dawg I have no idea what you are saying, I've been consistent in my messaging with you which is that this stuff is hard and complicated.
You don't seem to want to engage with any of the most important details here which include things like "medicine is not like other fields, maybe it could be but it is not allowed to be - and we have evidence of this!" and "the specific cost is not relevant in any practical sense."
Throwaway05
6mo ago
You have made this accusation multiple times, I have consistently maintained that it is fundamentally unknowable (because it is) if you loosen your definitions of knowable you can know some things about it. Additionally, it ultimately is not relevant and not our job, but we do know some things about it anyway.
If you think you "got me" in some way you will need to clarify.
This tack is not helpful, unlike last time I've tried to give examples of things you don't know and would need to know in order to understand the complexity at hand, but you need to actually engage with them. Every example I've given you about how healthcare is not like a car repair shop has been ignored.
Throwaway05
6mo ago
If you think you "got me" in some way you will need to clarify.
Yes. Please see above. Thank you.
Throwaway05
6mo ago
Yes.
Expected payout does not equal pay out.
In car repair your estimate may be off by a few hundred to a few thousand dollars. Maybe more than a few thousand dollars at maximum.
In healthcare your estimate can be off by hundreds of thousands of dollars or more.
This impacts the wisdom of giving estimates and the validity of the practical validity of those estimates.
And AGAIN you have yet to establish why cost matters. As previously stated repeatedly healthcare workers are often prohibited by law from making decisions based off of cost and often by necessary convention when not prohibited by law. Patients almost never pay cost and are rarely charged it. Why does it matter?
Engage with the substantive and relevant portions of the discussion.
Throwaway05
6mo ago
What information do you deliver to the patient. The maximum? The median? The average?
These are all wildly different, would potentially impact patient decisions, and do not matter because the patient isn't paying it.
What, if anything, a patient gets stuck paying after insurance has nothing to do with the cost or the charge.
Throwaway05
6mo ago
I mean patients ask sometime. We answer. Depending on the thing I can give hard numbers and explain that would be misleading, depending on the thing I cannot.
Ultimately it doesn't matter. What the thing costs, what the mark-up is, what the charge is, what the insurance pays, and what the patient ultimately pay are all different numbers.
You have to yet to explain what the relevance and importance of this number is, despite me repeatedly asking.
Throwaway05
5d ago
Thank you for sharing this!
I enjoyed that in a large part he seems to be sunk by the fact that he can't name his blood pressure medication.
This is vindicating to me, given the number of times I have asked a patient what life saving medicine they are on and gotten the response of "dunno."
Throwaway05
6mo ago
You refuse to answer the question.
But the question is the point. When patients ask "what does this cost" they usually mean "what does it cost me."
We don't know. Because who the fuck knows what your insurance company is going to do. Usually we ask in advance and the answer is supposed to be nothing but insurance companies do whatever they want and we don't lie to accidentally lie to you.
Price is not cost and you need to commit to what you are talking about.
If the question is "what does this thing truly cost the hospital" the answer is "it is not your business" and "we don't truly know." Patients are not entitled to what has the potential to be business critical information. Nor is it simple to explain how much things cost. What if the case goes late because the patient is obese and requires thousands of dollars in overtime? Does that count as part of the cost? Do the administrative staff count as part of the cost? Potentially hundreds of individual people are involved in a surgery in some way or another. Do we count these? I can check my professional fees and the supply etc cost easily but I don't necessarily know how the hospital business team handles the rest of this.
Hospitals have entire departments whose job it is to figure this stuff out and deal with insurance. We also bundle things frequently to simplify this, but if you are asking for the true financial cost to the hospital you have to unbundle!
I have asked repeatedly, why is this the physicians job and why do you need to know specifically the cost?
Throwaway05
6mo ago
The charge we submit to the insurance and the negotiated rate with the insurance are generally but not always completely made up numbers.
Sometimes the insurance neglects to the pay the negotiated rate. Sometimes that changes with phone calls and appears. Sometimes it doesn't.
The charge to the insurance for a roughly 5k dollar procedure might be 50k. The insurance might pay 5.5k. Medicare pays 4.5k. If you pay cash you get to pay 5k, assuming nothing goes wrong. If you have a cardiac event mid procedure and end up on ECMO the cost is suddenly 5 million dollars.
What number do you tell the patient? We've been arguing about this for literally days and you still don't seem to get it - am I supposed to go through all of this with a patient in my 15 minute appointment? Is the average person going to follow this? What if they are medically unwell?
You have to be exhaustingly specific about much of this. Yes I know what a prior authorization is. You can't always do them. The insurance company may authorize something and decline it later. Certain aspects of the care (like a consulted specialist who is the only person in the hospital for that thing) may not be covered. Etc. Etc.
Throwaway05
6mo ago
So you want to increase the shortages in healthcare by requiring every service to involve a 15-30 minute lecture in billing paradigms and want every physician to receive additional training in multiple other people's jobs so that they can talk about this in a maximally fluent fashion?
This is why healthcare is so expensive "great, tell me how much it costs or I get charged or whatever" starts off reasonable but turns into thousands of hours of unpaid administrative labor a year and hundreds of salaried employees who are required to manage what is ultimately unnecessary and adds minimal value while creating a tremendous amount of expense.
Nobody needs to be on a receiving end of a lecture that explains that their insurance is paying 110% of the number that medicare randomly decided is an appropriate amount to pay for their diagnosis and that that number has absolutely nothing to do with the actual amount of money that the hospital is paying to provide that service or is charging the insurance company for it or would ask the patient to pay if they were financially on the hook.
The solution to government regulation and insurance making healthcare expenditures stupidly complicated to understand is not to subject everyone to a lecture about it, and it's certainly not to increase the cost of healthcare by adding unnecessary complexity that adds zero value.
Since these numbers are all made up and mostly unrelated to each other and de-tethered from reality and changing on a frequent basis, would you just accept us creating a new category of pricing which is "whenever a patient asks how much we give this answer" and then we can just call it a million dollars and call it a day?
Let's say you passed a law that says "a patient is required to get a sheet of paper with the cost, price, insurance charge, and so on for the median procedure of that type, and if you don't provide this accurately you get fined." Do you have any idea how expensive that would be to do because of how frequently these things change? You'd have to hire an extra department which works 24/7 365 and has a multiple staff in the hospital at all times or hospitals would have to just eat the fine.
Throwaway05
6mo ago
The funny thing is, if this sort of law actually got passed, I'm pretty confident you'd figure it out pretty quick.
Actually no. A rule very much like this was passed a few years ago. Guess what happened? The information was inaccurate in the places that attempted to follow it and many hospitals chose to just be out of compliance and ignore it.
Throwaway05
6mo ago
Throwaway05
6mo ago
The government said "publish price transparency" and a third of hospitals just said "no." The remaining 2/3s published random nonsense. And there were penalties for this!
Because the price doesn't matter.
It's pure cost disease. Zero value.
Everyone has one or more ideas like this that don't do anything useful at all and increase costs and complexity.
And then they get mad when shit is expensive or the doctor can't spend time with you and explain things but they have tons of nonsensical administrative work.
If you are going to make things more expensive do it in a way that provides some value, but better yet don't make things more expensive for no reason especially if you are going to complain about costs.
This is (and you are proposing additional) regulation that adds nothing of value and increases the administrative burden that is already a third of healthcare spending.
Throwaway05
4d ago
I understand that drug names are not necessarily intuitive and while they have some tricks those will be impenetrable to patients.
That said, you need to know what you take, when, how, and why - otherwise you are at significant risk of increased bad outcome (although this obviously depends on what conditions you have).
What we usually recommend the elderly do is have a sheet with that information written out and store it in your wallet so it becomes easier to read out, can be retrieved if you are not arousable and so on.
This advice is good for anybody however.
With respect to this specific patient - we see a class of older men who have a large number of medical problems and put no effort into understanding what those are for, what they are doing about them, how to avoid making them worse and so on. While some of these people are stubborn or anti-medication most just have very low conscientiousness. Not ideal for a first time gun buyer at 80 something.
I now interrupt your regularly scheduled WWIII/Nothing Ever Happens to ask a question:
So, the Bike discussion down below generated a lot of angst and heat, so I'd like to poll The Motte on our driving habits a bit (in the CW thread because I do fear we are going to get some strong feelings).
How do we feel about the following:
You should turn on your turn signal every time you switch lanes or otherwise would be expected to use it, even if nobody is around.
Stop signs and red lights need to be fully stopped at, even if nobody is around and you know there isn't a red light camera.
Speed limits should be followed to the letter when possible.
The left lane is for passing only, and also, if you are in that lane and not passing and someone cuts you off or rides your bumper, that is fine.
If someone does not make room for you and you need to come over (and properly signaled) you can cut them off guilt free.
I can break some of these rules (or others) but other drivers should not.
Any other possible driving scissor statements?
If you'd like to be mad at me: Yes, Yes, No, Yes with qualification, Yes, No.
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