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Jesus Christ please no haha.
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.
Maybe you don't see it as an MD, but price transparency really doesn't exist to your average patient. You go in, you get your thing, and then you get a shocking, incomprehensible bill somewhere between 2 weeks to 2 years later. Sure, part of this is insurance. A lot of it isn't.
Providers will happily charge you $1000 for a routine test if you don't have insurance and then I guess you're supposed to like call them up and negotiate. In the real world, that's just not going to happen.
Yeah, savvy customers will find a way to reduce costs. You can ask the doctor what blood test they want, go on ultalabtests.com (highly recommend), get your tests results for incredibly cheap and without having to wait in line, then print them out and give them to your doctor (or, shudder, fax them in). Maybe the system will tolerate this. But they are not set up for it, and it will be a ridiculous burden on the patient, who will have to fight his doctor and clueless staff every step of the way.
Drugs are a little easier to save on, but face much of the same burden on the patient to proactively battle to save money. And since something like 80-90% of health care is paid for someone who is NOT the patient, there is little incentive anyway.
On a personal note, I don't think you should fear reform. As an average doctor making 250k, you have nothing to worry about. The system needs you more than you need it. And maybe we can even find a way to reduce the bullshit that doctors have to deal with. But not everything always has to be the way it is now forever. The $5 trillion we spend every year is clearly going somewhere. The people who take surplus profits from the system are not exactly going to stand up and advertise themselves.
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.
I just want to add, I mostly think your comment chain here is rad, even if I had a slight disagree, but there’s absolutely zero price transparency in medicine.
Zero.
I’m 40 and even tho I don’t go to the Dr a lot … there has never, ever been price transparency. In anything remotely close to medicine, for myself or anyone else I know.
That’s not your fault.
But not defaulting to the obviousness of a lack of price transparency is driving me up a wall.
Ultimately the lack of price transparency is not something that should be relevant to patients, you functionally need insurance in the US and every having to do with payment outside of your insurance fees is a total nonsense dance between various entities. If your ultrasound costs 300 dollars or 350 dollars shouldn't be relevant if you are paying 0, 5, or 20 for the thing.
It's certainly annoying not to know stuff if you are a curious person, but I'm not really sure it is ever relevant.
The problem is for example, me going for a colonoscopy, I contacted my insurance company to ask how much would be covered. They said if my doctor coded it as preventative (i.e. I was just being screened due to my age) it would be essentially entirely covered, however if it was because the doctor was trying to find a diagnosis it would be 50% co-pay. So I asked well how much would that be, and they said depends on your doctor and their facility but somewhere between 3 and 10,000 dollars, perhaps more.
Now the problem is I was having symptoms, which is why my GP referred me to a GE (the only GE I can get into see inside 3 months in the area as it happens) in the first place. So I ask the GE how they are going to code it and he says, no idea, you'll have to ask the front desk staff who do my billing. So I ask them and they say, depends on what the doctor puts in his notes. If he mentions pre-existing symptoms we'll code it as exploratory. So I ask how much that will cost and they say, we have no idea, so I ask how much does it usually cost OOP on average and they mumble around a lot and eventually say 2-4000 dollars.
So I get the colonoscopy because I am feeling pretty bad, and I get diagnosed with ulcerative colitis, they code it as exploratory and I end up having to pay about 4 and half grand out of pocket (most of which as it happened went to the facility and the anesthetist and the lab that analyzed the removed polyps and tissue, it appears). Now luckily I can afford that, because I am a responsible person with a decent paying job. But I asked my doctor what would have been different if it was just a routine screening and he said nothing at all. He would still have checked polyps in the lab, he would still have done everything he did, except I wouldn't have had to pay more than 50 bucks. And of course he is recommending I get a colonoscopy every 6 months because I am at elevated risk of bowel cancer. Now my GE doctor says he does 5 or 6 colonoscopies a day. It is essentially the main thing he does, and my insurance company is the biggest in the state. There has to be a better way than telling me, well it can be somewhere between zero and unknown but probably between zero and 10K, for a procedure which is pretty well defined.
Thank you for providing a good example, last pile on about this nobody gave me anything to work with. I'm assuming in this case that your plan is a high deductible one and once that runs out you no longer pay co-insurance right? (If not... I didn't think that was legal anymore?).
My mental model of the deductibles is that if anything remotely complicated happens you'll burn them instantly but it appears that isn't the expectation for most people. Probably because in hospital medicine if you so much as sniff a patient they've been charged an arm and a leg but our population on this board is mostly young people who aren't utilizing medicine too much with related expectations.
That said 25% your doctor is being lazy asshole for not trying to work with you, but 75% he's employed and not in charge which is pretty common these days. He can write his note however the hell he wants but the backend people are just going to do something else. He doesn't want to promise you anything because you'll take it at face value (because doctor!) but then somebody he never talks to in a building he's never been to changes some shit and you go form 0 to thousands of dollars.
Your story smells a little more lazy asshole doctor and I'm sorry that happened to you, during my training most of the attendings I worked with would try and save patients time and money, even when a little tiny bit fraud was involved to make that happen. I tried and remember that and encourage the people I train to remember that. I don't do any fraud though. Obviously.
Asking the doctor to know what somebody else is going to do (in this case, sometimes it's for knowledge he doesn't have) isn't super reasonable but that's a lot of this stuff at times.
The whole system is arranged around insurance plans where this kinda stuff never really applies but it hurts those in edge cases.
Also your plan sounds shitty.
Also also: shit. UC sucks. Follow the screening recs they give you. Seriously.
I'm not SSCReader, but for a different example:
I have the low-deductible buy-up plan. Deductible is 1500 per person or 4500 over the whole family, for in-network providers. This is not the same as an Out of Pocket Maximum. When the deductible is hit, insurance starts paying 50% of the costs until the Out of Pocket Maximum is hit. Individual Out of Pocket maximum is $6,850, over the whole family it is 12,000.
I had the ill fortune of reaching my family's Out of Pocket Maximum a couple years back. Three young kids hospitalized with complications from a bad combo of RSV and Parainfluenza. Two of the kids spend 2 days in the ICU, the third spent 9 days in the ICU. Each day in the ICU was $8,140.00 charged to insurance, and that is leaving out all other services that were provided while they were in the ICU. In the end, about $300,000 was billed to insurance and I paid only $12,000 of that. (That doesn't count the hundreds of dollars we spent on the Starbucks in the hospital over the three weeks we were swapping kids in and out, but you can only expect so much from insurance.)
Naturally, when I was sitting in the Emergency room with an unresponsive kid I had no way of knowing how much would get charged to insurance. I think by the time I was bringing my second child we assumed we were hitting our Maximum.
Also, my husband has annual colonoscopies and SSCReader's experience is also our own.
Thank you for sharing your experience.
I definitely did not realize that most people don't just view the deductible as a sunk cost with any significant utilization.
RSV sucks but kids bounce back thank god.
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