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Great post, although I think the word "salary" might be doing too much work.
I would argue that 250k-300k for a internal medicine doctor is very reasonable, as is the 1 million dollar a year that the top neurosurgeon gets.
But payments to doctors can be more than salaries. As we all know, seeing patients pays very poorly. But procedures and tests pay very well. The orthopedist who owns an MRI machine has a license to print money. He many only draw a "salary" of 200,000 while clearing over a million in profit.
Other specialties which involve procedures seem to pay an abnormally high amount as well, including anesthesiologists, radiologists, and dermatologists. The ease of these specialities compared with the outsize salaries make them some of the more competitive residencies. But is society better off having our most talented young people chasing these specialties? No, of course not. Some even argue that most anesthesiology could be done by a non-MD.
Rather than cut salaries, which I agree would be a bad idea, we need to fix the problem of outsized payments to doctors. We can do that in a market-based way.
Create more med schools and residency programs to increase the supply of doctors. If the AMA doesn't play ball, remove their involvement.
Reduce the regulation that leads MD's to do things that non-MD's can do.
Price transparency for procedures. I need to know exactly how much that ultrasound will cost, and I need to be able to shop around. Same for prescription drugs, which doctors often proscribe completely blind to how much they cost.
If you are a doctor making 250k a year seeing patients, no one is coming for your salary. At least I hope not. You deserve it. But doctors (in aggregate) do bear a large amount of responsibility for the cost explosion we are seeing.
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.
I don’t find the doctor to have any less price transparency than the mechanic?
The mechanic will have a plan for what he is going to do (e.g., "I'm going to replace your CV joint."). He will then assemble an estimate for how much that is likely to cost. He will probably even break down that estimate in terms of parts and labor. He might even provide you options for different brands of parts at different price points.
Everyone involved knows that there is some uncertainty in that estimate. They might get in there and discover that something else needs to be done, too. Usually, at that point, they will reformulate their plan, potentially with multiple options, assemble similar price estimates for those options, then contact the customer, try to explain the situation (knowing that there is an inherent knowledge gap), and ask which of the options the customer would like to take. I did this as a job long ago. There are some sketchy mechanics out there, for sure. But if you want to succeed, especially in a market where being sketchy will become 'known', you need to be very proactive in your communication with your customers, including on pricing information.
Doctors take the same exact sort of uncertainty in their work as a gospel truth that the price is "fundamentally unknowable"... and so, they just refuse to tell you. If you really press them, sometimes they'll do it, but sometimes, they just won't (and sometimes, they'll lie to you and make something up; there are sketchy mechanics everywhere). They certainly don't provide anything comparable to what the 25th percentile auto shop provides on a routine basis.
Perhaps you were thinking of a slightly different concept, that they're similar in that there is a significant information asymmetry. Customers don't necessarily know if the mechanic's plan is motivated by the car really needing whatever it is, whether it's barely justifiable and mostly a scam to increase billing, or whatever else. Similarly, patients don't always know that sort of thing with doctors; they could also be concerned that a doctor is practicing defensive medicine rather than thinking about the patient's pocketbook and giving them only what they really need. These questions are probably near impossible to estimate; I would like to believe that doctors are actually equal to or better than mechanics (the median doctor is almost certainly better than the 25th percentile mechanic if I had to guess, unlike with price transparency). In both cases, the most common solutions are to just diversify your sources of knowledge. I gave an example of how diverse those sources of knowledge can be here, but an extremely common suggestion in both domains is to just get a second opinion.
Again, I don't find it difficult to get healthcare providers to give me pricing information. I go to lower-rent(often bilingual) healthcare providers in a blue collar part of a red state, so maybe it's just different sorts of clinics.
I believe you said that you were paying up front in cash, and then getting reimbursed on your own. Probably the most likely places that are going to be top-tier in terms of price transparency are lower-rent places with cash-paying customers. They're way, way above the median. Especially when the vast majority of places get a whiff of it being insurance-involved on their side, they very quickly start with the whole "it's fundamentally unknowable" dance.
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