Doctors Are Fed Up with Being Turned into Debt Collectors
bloomberg.com
bloomberg.com
So patients must agree to a procedure -- yet only afterward find out how much it costs. That price can be shocking, and the patient never agreed to pay it. No wonder it becomes hard to collect from them.
In the rest of the economy, we agree on a price beforehand. That makes customers more likely to pay.
The medical system, however, has given up on disclosing prices to patients, because everything is paid by insurance. And now we have Doctors who say:
> “It's harder to collect from the patient than it is from the insurance,” said Amy Derick, a doctor who heads a dermatology practice outside Chicago.
If you want people to pay, then make an agreement with them before you perform the service!
"Sorry, the anesthesiologist was out of network, though everyone else in the hospital is in network"
After that I went to Kaiser because I'm not sure its possible to go out of network at least like that.
On particular phone call stands out. We got our insurance on a 3-way call with my SO and the hospital billing. For a urology test they charged us ~$800 for the test strip (just a single one!), which the hospital tried to claim was not covered (nothing, it seems, is ever 'covered'). Even the insurance person on the phone was aghast at the hospital: "Wait, so you are telling us that even urological tests, like a basic pH strip, at the specific office for urology, is $3000? What is our client even paying for, like, what is it exactly, that a urologist does? How much does a smile cost?"
US Medical billing makes Kafka blush.
https://www.tdi.texas.gov/news/2018/tdi10082018.html
> The problem meant consumers couldn’t get in-network anesthesia services at more than 20 hospitals and surgical centers in three of the state’s largest metro areas.
https://www.vox.com/2018/5/23/17353284/emergency-room-doctor...
> Except he wasn’t: While the emergency room where Kohan was seen was in his insurance network, the oral surgeon who worked in that ER was not. That’s how Kohan ended up with a $7,924 bill from the oral surgeon that his health plan declined.
> Separate data from the Center for Public Policy Priorities, an Austin-based think tank, finds that a staggering number of Texas emergency rooms have zero in-network emergency physicians — meaning that patients are guaranteed to see a doctor who does not accept their health insurance.
Someone up thread made a claim and the burden of proof was on them. Now multiple reliable sources have been provided to satisfy that proof.
You claim an unspecified law prohibit this and that this prohibition actually works. So now the burden of proof falls on you to actually cite the law and provide reliable sources of this law actually working.
Texas got mad here because there were no in-network anesthesia services. Having some out-of-network providers is depressingly common, and hard to guard against:
https://www.modernhealthcare.com/article/20180917/NEWS/18091...
> About 25% of patient visits to hospitals in their insurance network result in balance billing from care by out-of-network physicians.
Also, from the Vox article:
> The problem with that law, Pogue argues, is that it requires patients to contact the state — and patients often aren’t aware of the option. Kohan, for example, didn’t know he had these rights until I told him. Pogue’s research suggests this is really common: Only 3,824 Texas patients have used the law to resolve their surprise bills since 2009. CPPP estimates that this is a tiny fraction of the 250,000 surprise medical bills sent out in the same time frame.
This is just Texas, too. Plenty of states don't have their 2009 state law to work with.
https://www.cnbc.com/2016/11/16/many-get-hit-with-surprise-o...
This occurs in auto repair as well (though maybe less than it used to). Those repairs, in my opinion, have been quite stressful as well. Are there other industries where we bill afterward?
Home renovation. You'll get a quote, but the final price can be way higher. Any service when you are dealing with unknowns, the price is going to have to be flexible.
For a doctor, the unknown includes many possible things like drugs administered, blood administered, emergency care, hospital costs, etc. It's not as simple as an hourly rate estimate, unfortunately.
Hence my mechanic has my phone number and will call me if there is an issue, and we can agree to fix it (or not, which includes taking it to another shop).
Sounds like they put the MRI machine on the wrong setting.
Whatever happened to efficient markets? And why doesn't this kind of behaviour get fixed by the courts, it sounds like a lot of the players are in collusion to keep the prices high.
I'm not sure how this would apply to emergency care, but for non-urgent procedures I don't see why a quote isn't provided. It feels like a failure of the care providers to me.
People don't become debtors simply because they don't want to pay their bills, they become debtors because they can't afford to pay their bills. The number one cause of bankruptcies in the US is medical debt, and no amount of "price transparency" is going to fix that.
You'd think that for such an expensive test, the doctor or his staff would have a policy of getting our specific sign-off on the cost.
Even my vet gives an estimate before treatment -- with a "low", "typical" and "high" estimates. I have to sign off on it before they'll provide treatment.
Why can't hospitals do the same for non-emergency care?
No wonder they now have a "problem" having to chase non-paying people. It's like charging $10K for a handshake and then sponsoring an article on Bloomberg about being unable to collect it.
I've been a military dependent my entire life first under my father, then under my husband. I've essentially never dealt with American medical insurance. The military system is basically a different medical system.
There are probably other Americans who don't really know how it works either.
The military needs its own medical assets so it can treat soldiers in times of war. For security purposes, it needs medical facilities and medical personnel under its own control. It isn't sufficient for there to be sufficient civilian facilities.
Military dependents get free medical care in part to keep doctors busy with real cases during peace time.
Military members and their dependents cannot file malpractice suits. There are people who are very unhappy with this fact. Mistakes do happen. When they happen, you don't have recourse to sue and this is a point of contention for some people.
They also have world class facilities. If something goes seriously wrong, you can get referred to one of their regional hospitals.
I'm alive in part because we happened to be stationed at a base with a regional hospital when things went badly sideways for me. It served military personnel in eight states. It was a teaching hospital with connections to UC-Davis Medical in Sacramento and, I think, Stanford in San Francisco. I had testing in both cities. I got a cutting edge diagnosis. That was a turning point in my life.
For the record, I think we need a single payer system in the US. The current civilian medical system is seriously broken.
What's the point of having access to world class facilities during combat, if you're just left to fend for yourself when you return home?
I'm not saying that means it didn't happen--things like this are incredibly common--but a reply suggesting you might not have described the full picture and it's possible there is no fraud is not completely out of line or an insult to your intelligence. (I upvoted your original comment, BTW.)
This isn't for lack of pricing data. Hospitals know what they've paid for procedures previously. Every patient and procedure is different but it's rarely very different.
If a hospital has to bill a patient without insurance, what they charge should be pegged to a historical average for the baseline procedure.
Forcing us to negotiate puts undue burden on the patient. It's bad enough I have to occasionally call to keep my prices the same for cable and phone services.
The worst was whenever we had our first child. I thought it would just be a single bill or something, but instead I received about 10.
One from the hospital, one from a surgeon, one from the OBGYN, and one from an anesthesiologist. We only met one pediatrician during our stay, but we received a bill from every pediatrician that did a rotation while we were there, so that added four more. One because a nurse working was an independent contractor, and one from the wet nurse who we talked to for like 5 minutes.
Two of them we never actually received bills for because they had an outdated address, so they were sent to collections. We discovered them a year later when we were trying to buy a house. It dinged my wife's credit so bad that we were recommended to not put her on our mortgage application.
This is it. This is the US medical scam crystallized. What you need to focus on as a US patient is the "Out-of-pocket maximum/limit." (a number) - which is the yearly maximum you pay as an insured person. Basically, once you enter into an ER you are going PAY this this number. This number is reset every January 1st. So If you have a child January 2nd -- you are in GOOD* shape -- since you will hit your yearly max ("Out-of-pocket maximum/limit.") early in the year -- all other medical is free.
My friends that had a child December 30th, are in bad shape. They pay for yearly "Out-of-pocket maximum/limit" two times: one for the current year and one for the next year.
I've been through this sort of thing, and it's ridiculous. Medical bills shouldn't be able to affect one's credit rating.
It ended up going to court and it was judged to be a legitimate bill that I had to pay. That's how bad the system is.
There is simply no end to the greed of the medical cartel hell bent on subverting market forces.
[1] https://www.the-alliance.org/uploadedfiles/Health_and_Wellne...
My wife was in a near-fatal traffic accident on 2015 (she was a pedestrian). She spent about a month in the hospital and a month in in-patient rehab. Extremely fortunate for us (and most importantly), she's made a 99% full recovery
She was insured, so that absorbed most of the $1M bill (though the insurance negotiated the bill from the hospital and rehab center to 400k somehow) associated with her care. Several months ago (i.e. 2 years later) we were informed that the insurance company had deemed my wife's last week in rehab "not medically necessary" and refused to pay the rehab center. So the rehab center responded by sending us a $26,000 bill. Due in 30 days lol.
The rehab center is the one who fixed her discharge date (we had no input) and it's not like we're in a position to determine when she's fit to facilitate her recovery on her own. The insurance company still refuses to pay after we called them.
So we're left with a) don't pay the bill and see what happens (credit score hit? Law suits?); b) hire attorneys that will likely cost about as much as the original bill; or c) pay?
Luckily my wife and I have the savings on hand to pay the bill without threatening our livelihood, but is there really no other options for us? How would the average American whose after-tax salary is ~30-40k deal with this?
Btw, if anyone has advice it would be much appreciated. We've talked to some attorneys about Option B but it's uncertain if the cost of retaining a lawyer would outweigh the size of the bill itself.
It's possible to also have added to the judgement in your favour, coverage for any fees you've had to pay to retain counsel to take care of this legal matter for you.
I'm not sure if by "talked to some attorneys" means a casual chat with a lawyer friend over lunch, or if it means "requested a consultation to determine whether retaining an attorney is the best path forward based on A, B, C".
Call your state's bar association. They can't recommend a particular attorney, but they can generally point you to organizations that can help find the right attorney for you, particularly if cost is a factor.
Will it cost money? Definitely, up front. Will you get it back? Quite possibly.
Conversely, when you make payments that you might encounter turbulence on, write a check (I know, gasp) or a USPS money order. Once it clears, save the front and back of the check images as proof of payment (for the money order, save a copy of the receipt and the entire check and receipt assembly prior to mailing or delivery). I've found this to be much more effective than a debit or credit card line item on a statement.
There are few weapons more powerful than a properly assembled paper trail, and the mere act of showing you're building one is usually enough to get action taken.
Tangentially, we've started to notice that doctor offices will often claim that procedures aren't covered and we have to pay out of pocket. However, we keep track of these out of pocket expenses since we're close to hitting out of pocket maxes. Turns out most of the time, the doctor's offices will still submit the claim to our health insurance company even though we paid, effectively double dipping.
Also, the amount of time spent following up with doctors, payments, procedures, claims, etc is mind boggling. At least 4-8 hrs a week. Getting an answer about what is and isn't covered also seems to be some kind of black art.
Let's not beat about the bush, this is _insurance fraud_, not "double dipping". The provider has to assert to the insurer that they have not been paid for that service rendered when they bill insurance.
Australia has bulk-billed doctors and there's no shortage of them. I can book an appointment online for tomorrow, wait for 10 minutes in a waiting room and see a GP for free. I can even choose which GP I want to see. And I'll likely get anything they prescribe me for free as well. Medicare refunds so much money I sometimes feel guilty because I know I can afford it.
My partner has a chronic health condition that resulted in her large intestine being removed and she requires thousands of dollars worth of medication a month, likely for the rest of her life. We've never paid for surgery or medication beyond admin or prescription fees.
I want this for everyone and I pay my taxes gladly. I would pay more for an even better system. You don't have shit if you don't have your health.
I returned to find that I couldn't enroll in health insurance until 2019 unless I joined a company as a fulltime employee, resulting in a terrifying 6-month coverage gap where the only option was BOTH paying the lack-of-coverage penalty AND paying for shit "no way they're reimbursing anything" temporary coverage from an agency that didn't even send an insurance card. Our system is undeniably and unjustifiably fucked.
We need single payer healthcare for all emergency and 'standard' care (government gets a bid on rates from practitioners in the area, and if it doesn't like the rate, supports patients via the military systems).
That includes vision and dental; being able to see and being able to consume food properly tend to be requirements for workforce productivity.
Cosmetic and luxury care (like cutting triage lines in non-emergencies) can be premium services.
Why should the military be involved?
There aren't enough military hospitals to meaningfully support civilians. There's not enough VA hospitals to do it either, but whatever.
Universal healthcare
There is a lot of money in private practice and insurance who are prepared to campaign against reform, however.
Look at the other things the government bids on. Are they getting a good deal?
The theory is that the government has a lot of purchasing power and can use it to get a discount, but that's not what happens in practice.
Suppose there are two providers of a service in the area. There are 800 patients and each provider has to capacity to serve 500. If one bids a dollar and the other bids a million dollars, what happens? Both bids have to be accepted, because the first provider can't serve all the patients. Of course, the first provider knows this too, so they both bid a million dollars to begin with.
Compare this with what happens to individuals if we had price transparency: Both providers would rather have 500 customers than fewer, so they try to underbid each other to be the one that gets to fill their capacity. Moreover, individual patients may decide that a significant discount is worth a two hour drive to a neighboring region, so you get inter-region price competition as well. The government can't exactly get away with telling you to drive to the next state or suffer any of the other inconveniences price sensitive customers may prefer over higher prices, so they have to suffer the high bids.
Using the VA healthcare system as an escape hatch is little help because it's just trading one set of problems for another, e.g. the system is very bureaucratic and it can take months to get an appointment. If the government carries through on the threat then the voters would be unhappy and both the government politicians and the providers know that, so it's an idle threat.
New Zealand has been under a lot of pressure to weaken Pharmac, the national drug purchasing agency, as part of the TPP agreement. It hasn’t happened yet and hopefully never will. The current system is far from perfect but we pay a lot less for funded drugs here in NZ due to Pharmacs bargaining power.
That's not bargaining power, it's price controls. You can have price controls even without single payer. But price controls are terrible -- if the price is too high you're paying too much, if it's too low you get shortages or providers have to cut corners to hit the price target.
In the pharmaceutical market this falls squarely on the side of shortages, which are then invisible because nobody is aware of the drugs that don't exist because the developer estimated that the government wouldn't allow a high enough price to recoup the R&D cost and then didn't do the R&D.
It's prisoners' dilemma at the national level -- if you defect by legislating drug prices, you pay less for drugs while other countries pay the higher rate required to fund their development. Then you say "look how great defecting is, why doesn't everybody defect?" Well, yes, that's the problem. Somebody has to pay somehow.
It also makes no sense to have drug patents but then regulate prices, because the whole point of the patent system is for the market to set the price of the drug at its value over the status quo during the term of the patent. If you're just going to regulate prices then you might as well instead just get rid of drug patents and replace them with X prizes. Then drugs would be much cheaper even without price controls because they would all be generics. The problem then being that then the government would have to be good at choosing what to pay prizes for, and they probably wouldn't be very efficient at it even before corruption set in.
I don’t see a downside for New Zealand, but acknowledge that money has to recouped somehow. I just don’t believe anyone would sell to us at below cost.
It's not free, the provider is getting paid out of taxes. But the price they get is chosen by the government. If they choose the wrong amount to pay they may overpay (and waste money) or underpay (and there will be less research).
> I just don’t believe anyone would sell to us at below cost.
Products have fixed costs (R&D) and unit costs (production). Suppose the R&D costs $10M, there are 20,000 patients world-wide and the unit production cost is only $1. Then the price per patient has to be $501 to break even, $1 to cover the production and $500 to cover the R&D. If one country says they'll only pay $100 per patient, they still make a $99 margin by selling there, but that country isn't covering their share of the R&D. And if every country was doing that, they wouldn't have done the research to begin with because they wouldn't expect to recoup the R&D cost.
Additionally, you say that the government risks overpaying, yet we pay less than US patients pay. And why is paying a lot in a user pays system more desirable than paying little in a socialised system? Is it because paying our share is important? The drug companies are doing just fine and don’t seem to lack profits.
The population size has nothing to do with it. If the per-patient share of the fixed costs is $500, anyone paying less than $500/patient isn't paying their share (and someone else has to pay the difference or the research doesn't happen).
> There are insurers that operate in the US alone that have a customer base that is tens of times larger than the whole New Zealand population. Why can NZ demand a better price than them?
Because it isn't a free market in either case. On the one side you have a patent, and on the other side you have a monopsony government regulating prices.
The first situation is completely broken for insurance companies, because patients will scream bloody murder if the insurance doesn't cover a specific drug their doctor prescribed (even when there is a much cheaper one which is 90% as good), but when it's patented that means the seller can charge monopoly rents to a captive buyer.
The second situation is completely broken, because it's prisoners' dilemma again. Why not pay them below the amortized fixed cost? As long as nobody else does that it'll probably be fine, and if everybody else does then you're screwed anyway, so might as well defect. Until everybody does that.
The only one that works is to have the patient paying most of the money that goes to the pharmaceutical company, so they can decide whether the advantage over the prior art alternatives is worth the price they're charging.
> Additionally, you say that the government risks overpaying, yet we pay less than US patients pay.
The risk is of miscalculating the cost. If you're doing an honest evaluation to try to pay your share, there is a nontrivial risk of overestimating and paying too much (as well as underestimating and defunding valuable research), and doing the estimation is hard. For example, you have to account for all the promising but failed research attempts that went before the one that finally succeeded, without creating an incentive to do tons of garbage research that always fails.
Of course, that's before the perverse incentive to purposely defect and pay less than your share, which in practice causes socialized systems to err on the side of paying less and defunding research.
> The drug companies are doing just fine and don’t seem to lack profits.
It's not about total profits. The difference is at the margin. If you spent a million dollars and discover a drug that treats heart disease, you can make a mint, because tons of people have that. But there is some other, more promising treatment that requires you to spend ten billion dollars on research -- or a number of treatments that could each pan out but not unless you try them all to figure out which one. Then you're risking more, but it may still be worth it -- if you can save a million more people for $10,000 each in research costs, that's clearly a win, but it only happens if it's possible to charge $10,000/patient for the result.
The drug companies that still exist will still turn a profit, because they only do the lower cost lower reward research. The ones that can't turn a profit given the laws will cease to exist, or never exist to begin with because investors estimate the reward to be less than the risk at the outset.
Refusing to pay more than e.g. $500/patient is effectively setting the value of a human life at $500.
They say one good experiment is worth a 1000 theories. The experiments have been performed, we have the results and they are superior to what we have now.
Seems like a much better solution would be for the insurance to just pay it and then charge me the rest. At least that way I only have one entity to deal with and they probably support online payments. And they're in a much better position to exert leverage to get me to pay - if I'm too far behind on paying them they can suspend my insurance whereas a care provider that I'm unlikely to see for months or years really has no recourse other than sending me more dead trees begging for payment.
So I just wait 60 days and go with whatever the last bill is they sent me. I could do 30 days but I'm already pissed that they can't get their shit together (and at the state of health care) so they can stew for all I care.
> Now, instead of getting paid by insurance companies on a predictable schedule, health-care providers have to engage in an awkward dance. One moment they’re removing a pre-cancerous skin mole. The next, they’re haranguing patients to pay what’s become a growing portion of the total medical bill.
In a situation like that, why aren't they just taking the money upfront? It's not like a skin mole is ultra urgent.
HDHPs as I mentioned encourage people to bet against their own health, that they will never get in an accident, or their body won't decide to crap out on them and so forth. Additionally they defeat the entire purpose of insurance which is that the people at risk are subsidized by the healthier people; if you separate the two pools then the healthy pay marginally less while the unhealthy pay a lot more.
For example, would you consider HDHPs that don't cover vaccines to be a good or a bad thing? It's a routine checkup, yet we've established that in general it's of greater benefit to society if we do get those routine checkups done.
Does it discourage that? You still want to get preventative care, because if you don't, you'll have to pay more later. Secondly, people are still strongly disincentivized to become sick because of the way that being sick feels.
> HDHPs as I mentioned encourage people to bet against their own health, that they will never get in an accident, or their body won't decide to crap out on them and so forth. Additionally they defeat the entire purpose of insurance which is that the people at risk are subsidized by the healthier people; if you separate the two pools then the healthy pay marginally less while the unhealthy pay a lot more.
Who said anything about separating pools?
> For example, would you consider HDHPs that don't cover vaccines to be a good or a bad thing? It's a routine checkup, yet we've established that in general it's of greater benefit to society if we do get those routine checkups done.
Vaccines are cheap and plentiful. We already require kids to be vaccinated before they can attend school. I'm not sure why insuring them would increase or decrease their rates.
No, not everywhere does anymore.
"I'm not sure why insuring them would increase or decrease their rates."
Because some people are very poor. My friend didn't get her flu shot because she couldn't afford the extra $50 this month. And that's a cheap vaccine that doesn't also require a doctor visit to go with. Some people have to worry more about today than tomorrow or they don't have food and rent money this month.
Caught in the middle my arse. This is bigly shirking the responsibility and falsely playing the victim. Healthcare providers are extremely well versed in the billing rules and are playing dumb when they pretend not to know. There are literally manuals and seminars on how to bill (i.e. "code") one service as several, or code to a more profitable option when several options are possible, while hiding behind a veneer of respectable neutrality. Multiple large providers have been sued for essentially insurance fraud and go back to doing exactly the same.
It's a big business driven by quarterly numbers and providers don't hire expensive staff to lose at gaming the system. Do you as a patient have a full-time staff to go through billing arcana for you all day? It's impossible to even find a patient advocate. Then on top of that larger providers like hospitals aggressively sell bills to collections agencies on any dispute, abusing the power over the patient's credit as their first resort at price gouging. Thank god for the CFPB and the 2015 credit reporting rule change [1]. The day of reckoning is coming and doctors need a long look in the mirror for why they are in this line of work.
[1] https://ag.ny.gov/press-release/ag-schneiderman-announces-gr...
Higher the costs, more incentive (or mandatory) for users to buy insurance and also more profits to insurance companies.
Full article - https://theconversation.com/private-insurance-reliance-means...
My aunt went to the ER for a snakebite. They gave her the anti-venin and let her stay for 12 hours.
It cost 46,000 dollars. It was a rattle snake. They do this thing all the time in India for COBRA bites and it's not even close to being that expensive.
US Pharma would say because India doesn't care about medical patents and R&D cost. (Not saying I agree at all, but that's the excuse given)
Unsurprisingly, its mostly blatant money grabbing.
70% is pure markup that insurers don’t pay but uninsured do.
2% is the R&D cost. Probably for something we invented 100 years ago which makes you wonder just how the R&D continues to cost $100+ per dose decades after its basically perfected anyways.
[1] https://www.washingtonpost.com/news/wonk/wp/2015/09/09/the-c...
During a recent trip to the ER with my son, for abdominal pain, one of the pop in doctors told me that he reviewed the CAT scan and 'her ovaries look good' ... I'm now inclined to write down identifying information with timestamps and summary of interaction for anyone that comes past the curtain.
For bonus points, not all hospitals require their physicians to be in the same network as the facility, so you can get an "out of network" bill for the ER doc at an in network hospital.
Or, to get even more ridiculous, I went to a large chain urgent care. They had labs in house. I got a blood draw there as part of a physical from the PA-C. And an out of network bill. Lab ABC, owned by healthcare provider ABC, inside an ABC urgent care, was somehow out of network, in contrast to the facility and the provider. Cue a $600 bill...
My problem w/ the discourse here is people who treat this like some econ 101 practice problem, when there's no evidence that "price transparency" does anything to address healthcare costs [1].
[1]: https://www.nytimes.com/2016/12/19/upshot/price-transparency...
The cost of healthcare for those not under a group insurance plan or subsidized ACA plans is crazy expensive for a family regardless. To the point of what's more important your house payment or health ins payment? People are just barely scraping by so the intent to pay in the bill in full is just a dream, even if it's just a $100. They would rather face the consequences of bill collectors nagging them which they just ignore.
[1]: https://www.aclu.org/issues/smart-justice/mass-incarceration...
We pop the corruption bubble and all fights about insurance costs would just disappear because in reality the reason they are so high is because all of this is just a shakedown from the medical/pharma industry.
I'm so sick of this all being framed as a battle over single/multi provider obamacare insurance bullshit when it is really just misdirection and we are being wildly overcharged for services.
It's like we can only debate whether we pay 1000% markup using a credit card, paypal or cash, and not talk about the 1000% markup.
Is there any good source of hard data on the billing amounts and quantity by doctor, practice, or hospital?
Also doctors' pay does grow at super-inflationary rates according to data. That's at least part of the story.
The average debt is reportedly $190k for medical school graduates.
> The country should follow N.Y.U.’s lead in recognizing the damage wrought by crushing student debt. Making higher education free for all should not just be a pipe dream.
I don't know how I feel about this. I for one expect people who make over five times our target minimum wage[1] to contribute more through income taxes than they do now. While I agree people at higher levels should progressively pay dramatically more in taxes, if I were to run for political office today, I'd run on the platform of increased (federal) individual income tax for all and an eventual end to all tax credits, deductions, and any such incentives.
How will these high earners pay my demands for a higher income tax if they have trouble paying their loans? I understand that take home pay per month with $180k salary is about $9k per month[2]. Let us say your student loan payment is about $2k[3]. Let us say that your medical insurance and other career related expenses are about $1k. This still leaves you with about $6k per month. Assuming you save half your income (which I hope you do at this income level), you have about $3k a month to spend on rent, groceries, and transit. Assuming you don't have any children and don't have any plans to have any children, this is not a bad spot to be in. Sure, one is not wealthy or financially independent until you are like 65 if you started working at 30, but if one wanted to make money, why is one in the medical field? In my opinion, it is kind of absurd to get into medicine and expect to become wealthy.
[1] Target minimum wage of $15 an hour at two thousand hours a year is $30,000. Five times $30,000 is $150,000.
[2] https://screenshotscdn.firefoxusercontent.com/images/f645f47... https://screenshotscdn.firefoxusercontent.com/images/ecf9387... I initially made the calculation with semi-monthly pay checks which made me doubt my math a little. I have since corrected it to a monthly pay check.
[3] https://screenshotscdn.firefoxusercontent.com/images/61e426e... Interest rates vary but I am pushing for an aggressive twenty year loan which you should be able to refinance when times are good.
https://members.aamc.org/eweb/upload/Education%20Debt%20Mana...
https://www.nytimes.com/2018/08/20/opinion/medical-school-st...
Outline: https://outline.com/Cy2Pdp
Archive: https://archive.fo/dxmZG
A centralized system has a better way of tracking this. If everybody involved with the health care system is working for a government salary, and everybody who sells equipment is selling it to the government, then we know who is getting rich by exactly how much.
It isn't going to any specific place. The system is designed to destroy price sensitivity, so everything is overpriced and everyone is charged for things they don't actually need.
When there is a bill for $58000, it's not that the procedure costs $1000 and there is this one place receiving the remaining balance we could just cut out. It's that the procedure would cost $1000 only everything that should have cost $20 was charged for $200 and then 500% more steps were performed than were necessary.
Trying to play the blame game is pointless because everyone will come up with a reason to justify their high margin or unnecessary step and the truth is nobody is innocent. What's needed is to actually make purchasing decisions based on price. If one provider charges $58000 and the other charges $56000, the patient should know ahead of time that there is a $2000 price difference, and actually pay the entire $2000 less by choosing the less expensive one.
Do that and there is price competition, and the provider that does the work of eliminating unnecessary costs for you will be the one with the lowest price. And once you have someone offering to do a $1000 procedure for $1000, who is going to pay $58000?
This procedure costs $x because it is the oecd average cost and that is the end of the discussion. It is on them to fight over their slices of the pie with each other. They don't get to make their problems our problems.
Its not realistic to act like people have time to price compare for emergency medical services. It just isn't a normal free market so much as it is like a mugging. When you get mugged the question is how much will you trade for your life, and the answer is everything you have. We need to stop pretending like it is a free market and trying to apply free market solutions that do not apply.
When their costs are lower than the OECD average then you're still paying too much, but it's even worse when they're higher. Each country has different regulations, taxes and subsidies, real estate costs, medical licensing rules and supply of medical professionals, average income and cost of living which affects how much workers have to be paid etc.
When the OECD average price for a procedure is $5000 but the zero-profit cost of doing it in your country is $7000, nobody will do it. Or the provider who already owns the equipment as a sunk cost will do it, but the waiting list for the procedure will be 22 months. (Hopefully it's not related to an active pregnancy.)
> Its not realistic to act like people have time to price compare for emergency medical services.
It's not realistic to act like all medical services are emergencies. Most of them aren't, what's the excuse then?
And once you have a baseline for what a procedure costs in a competitive market on a non-emergent basis in your location, it becomes a lot easier to identify a 10,000% markup for no reason in an emergency situation as manifestly unreasonable.
Vet school costs a lot, almost as much as medical school. Yet the procedures are much, much cheaper. Probably because vets are paid half as much or less than doctors.
Salaries are supply and demand. If you lower salaries you get fewer doctors -- you have to convince people to go to medical school instead of law school or business school.
And the OECD average salary may be too low if the relevant city has a higher cost of living than the OECD average, requiring higher salaries to get people to practice there rather than somewhere their money goes further.
Because no one is going to haggle properly when they're in unimaginable pain, or when their options are the local far more expensive doctor vs another that's hundreds of miles away, or when the illness is time critical.
People need to stop thinking that somehow price transparency will solve problems that arise from mostly unpredictable circumstances.
The first are people who can't take any time off from work. 200 miles away means less time working or less time managing family. I can think of a few circumstances where people lost their job as a result of such an injury, so for them the priority is feeding their family and then dealing with the bills later. Because you can put off medical bills, you can't put off food on the table.
The second are people that are going to go bankrupt anyways. Why does it matter to them how much they're going to pay when they're losing literally everything anyways? Might as well go for the closer option since again, work and all.
And finally the third are people that literally don't have the option to drive 200 miles. When my mother had her stroke she didn't have the option to go anywhere but the closest possible hospital, and post-stroke recovery had to be done locally.
If you can't think of the dire circumstances people are in, then you've never been poor or have had to deal with seriously ill people. Think harder.
What about everybody else? Lowering the cost for everybody outside of three groups of people would still be pretty great. Especially since it would be hard for providers to justify specifically discriminating against your groups, so they would still benefit from competition lowering prices in general.
> The first are people who can't take any time off from work. 200 miles away means less time working or less time managing family. I can think of a few circumstances where people lost their job as a result of such an injury, so for them the priority is feeding their family and then dealing with the bills later. Because you can put off medical bills, you can't put off food on the table.
This feels pretty weak. You can't afford to take a day off work, but you can afford to pay an extra $40,000? Basically nobody is in that situation. If they incur the $40,000 debt, they'll not be paying it, so this is really just your second group.
> The second are people that are going to go bankrupt anyways. Why does it matter to them how much they're going to pay when they're losing literally everything anyways? Might as well go for the closer option since again, work and all.
But then they're not actually paying it. When charging $50,000 only means that it selects exclusively for people who will file for bankruptcy, the provider who does that is headed for bankruptcy itself, to be replaced by someone who realizes it's better to get $10,000 90% of the time than $50,000 ~0% of the time.
> And finally the third are people that literally don't have the option to drive 200 miles. When my mother had her stroke she didn't have the option to go anywhere but the closest possible hospital, and post-stroke recovery had to be done locally.
Isn't this just emergency care again? Emergency care is different. It makes sense to have the locality provide it in the same way they provide fire departments, with the purpose to stabilize the situation to the point that you (or whoever is making your decisions) has a chance to assess things and make a reasoned choice how to proceed further. It's also a small proportion of overall medical costs.
And for recovery, we're just back to cost vs. convenience. If it was actually $40,000 more for each visit, it may still be worth driving 200 miles each time. If you had to drive 200 miles each way every day for ten years to save $40,000 once, well, that's another story. But the claim isn't that the further away place is always cheaper on net, it's that the fact that it sometimes can be would force the closer place to compete more on price.
> If you can't think of the dire circumstances people are in, then you've never been poor or have had to deal with seriously ill people. Think harder.
This kind of policy choice is literally a matter of life and death. Don't pretend you know the answer before you've had the debate. Being wrong is killing people one way or the other.
This reveals that you have an utterly fundamental misunderstanding of how things work in the US but I'll give it a shot at fixing the problem. For many people an extra X amount of debt means nothing to them. They're already knee-deep in debt paying back a lifetime of loans or medical issues. You're acting like people are paying the extra $40,000 upfront when in reality those costs are distributed out over the lifetime of a patient post-operation. Debt becomes more and more meaningless as you accept you can never afford to pay it back, so you focus on the immediate problems over the long terms.
In fact this is why hospitals have so many issues. They can't actually get any money (you know, blood from a stone and all that) from the poor, so they squeeze money from the middle class and up in order to keep on the lights. The result is higher prices across the board for ludicrous things.
>But then they're not actually paying it. When charging $50,000 only means that it selects exclusively for people who will file for bankruptcy, the provider who does that is headed for bankruptcy itself, to be replaced by someone who realizes it's better to get $10,000 90% of the time than $50,000 ~0% of the time.
If that was true, then the system wouldn't have the problems that it does, now does it? It's simple and I'm sad I have to break this down to you: They charge ludicrous amounts knowing that they'll either get the baseline from the poor people over time ($10,000), or they'll get the absurdly overpriced amount from people that can afford it. This is why doctors and hospitals become debt collectors.
>Isn't this just emergency care again? Emergency care is different. It makes sense to have the locality provide it in the same way they provide fire departments, with the purpose to stabilize the situation to the point that you (or whoever is making your decisions) has a chance to assess things and make a reasoned choice how to proceed further. It's also a small proportion of overall medical costs.
No, emergency care is not different. We have Americans using emergency care more and more often because the cost of regular care is through the roof. Even if prices were transparent, poor Americans that can't afford even basic preventative care will still end up further burdening emergency care because of how fucked up our system is.
>This kind of policy choice is literally a matter of life and death. Don't pretend you know the answer before you've had the debate. Being wrong is killing people one way or the other.
You're right it's a matter of life and death. Which is why I argue so vigorously against bullshit solutions that do nothing to solve the problems that are brought up by people that have never had to deal with the depths of poverty or the shit poor/rural people have to put up with. Price transparency is nothing more than a feel-good measure that slaps a band-aid on the problem for upper-middle class people while continuing to give a middle-finger to the poor. The market is broken much like how the ISP market is a sham and thinking that competition will magically pop up if we just implement one or two changes like this is folly.
I've seen and experienced what it can do to families.
But for those people it also means nothing to the hospital. The hospital can only benefit from charging higher prices if someone actually pays them.
> They charge ludicrous amounts knowing that they'll either get the baseline from the poor people over time ($10,000), or they'll get the absurdly overpriced amount from people that can afford it.
Which is what price transparency changes. The people who intend bankruptcy don't care, but the people who would actually pay the debt do. If it was known that another provider charged $10,000 rather than $50,000, those people would choose to pay $10,000 and the one charging $50,000 would be left with only people who will file bankruptcy. Instead of getting 20% of $50,000 as they do now, they would get nothing while the other provider actually gets the $10,000 most of the time.
> We have Americans using emergency care more and more often because the cost of regular care is through the roof.
The cost of regular care is through the roof because prices aren't transparent and everything has to be laundered through bureaucratic insurance companies with tons of paperwork and overhead. There is nothing about a normal doctor's visit that should command a price which is unaffordable to someone making minimum wage.
> The market is broken much like how the ISP market is a sham and thinking that competition will magically pop up if we just implement one or two changes like this is folly.
The ISP market is broken because it's a natural monopoly. The healthcare market is broken in an entirely different way -- there is no monopoly at all, there are tons of providers. The problem is political corruption resulting in bad regulations that inflate prices.
Nobody is arguing that the existing market works. It's a total farce and people are dying. But the primary problem isn't how people pay, it's what people pay. The cost is too high. It's no solution to just pay for it out of taxes -- that doesn't lower the cost if you're just funding the same corrupt system from a different pocket, and it's already bankrupting the country as it is. Something has to get the cost down. And once it's down to something people can actually afford, people can afford it on their own.
Did you not see the audit from the pentagon that came out today???
https://www.reuters.com/article/us-usa-pentagon-audit/pentag...
Why would you think they will track things well when they clearly do not.
It also provide more control over wages, drug costs etc. For example, Canadian doctors make less than their US counterparts.
https://nationalpost.com/news/canada/canadian-doctors-still-...
If we do this we will have even less recourse and there will be even less accountability when regulatory capture happens and prices are driven up even higher because all the lobbying money can be focused like a laser now on this one board that we are going to create to manage everything.
The current system is totally fucked, but once the price concerns are made a tragedy of the commons through taxes the medical industry will be able to drive prices even higher just like how the government isn't allowed to negotiate drug prices for medicare right now. How can you not see the insane level of corruption already baked into the system when we have a policy currently where the government can't negotiate drug prices? How fucked up must the system be for that to have ever even gotten to the stage of being considered as a serious proposal, much less implemented?
Without attacking the corruption in the system I just don't think sweeping it under the rug and throwing it on the deficit is a reasonable plan.
I think you are making the case for single payer. The government has much more power to reign in the pharma/medical industry. See the linked article on Doctor salaries.
Look at the biggest industries in any free country and you can see it replay over and over again around the world.
Our problem unlike the rest of the world is that pharma and medical is our industry. That is the main reason our prices are crazy compared to everyone else.
We're being wildly overcharged for basic services because ultimately that's exactly how the market is designed to work.
It seems like we will have even less recourse and there will be even less accountability when regulatory capture happens and prices are driven up even higher because all the lobbying money can be focused like a laser now.
I also think the current system is totally fucked, but once the price concerns are made a tragedy of the commons through taxes the medical industry will drive prices even higher.
Without attacking the corruption in the system I just don't think sweeping it under the rug and throwing it on the deficit is a good long term plan.
Here's one way to solve this: single payer. The payer (government) sets the price and the doctors either accept it or stop treating patients. Maybe they'll bill 15% less a year, but they'll also never have to deal with this debt collecting bullshit, so they don't need as many staff.
Do any of those other countries have a policy that their government is not allowed to negotiate drug prices? Our medicare system has that rule.
We have a system so incredibly captured by the pharma industry that it could actually approve a proposal that the government shouldn't negotiate drug prices with our own tax dollars. Even though everyone knows Medicare is going bankrupt, somehow we can just keep overpaying for drugs.
The problem is that the biggest industries in any free country always take over politics and dictate the policies around their industry. That is why single payer will not be a panacea for us, it will be a feeding frenzy of government money being transferred to private industry.
Until we make moves to clear out the corruption, granting the government more power to transfer our taxes to the pharma companies is just going to be a blood bath.
The hospitals often pay less than private practices, but also come with fewer headaches, so many prefer them.
If medical billing was simpler, doctors could potentially make more money, with less concentration of medical services in large providers (eg large hospitals) and more competition.
This would likely benefit everyone except for large hospitals.
Because the demand for your life and health is infinite.
I broke my hand a little over a year ago during a gap without health insurance. Knowing the ER would start at $1000 for a 'hello' and that I might not have a competent specialist, I decided to take matters into my own hands (haha). First was a call to a friend in Montreal with a sister that's a surgeon. I assessed that while driving to Canada would be more cost effective than a US emergency room, the border might give me issues and followup visits would be troublesome.
So, I walked off the mountain and made a makeshift splint at a Rite Aid with medical tape and a plastic ruler for around $5 ( https://twitter.com/vvtgd/status/879360595526635520 ). When I got back home a few days later I went to a hand specialist, told them I'd pay upfront and had them set it. All in with followups it was around $800.
Initially the specialist's receptionist idiots couldn't figure out how to bill me in person. If you have staff that doesn't know how to invoice a client that pays in cash, you shouldn't be in business. Full stop. Why should a cash paid-in-full client pay more than any other insurance company is beyond me.
Another back on insurance anecdote: I needed an urgent visit not too long ago. PCP wasn't updated on my card, but I did it through health insurance website. Dr still wouldn't accept. Had to pay in person with my CC. Receptionist stole the CC details (it was the only place I used that card for magstripe transaction at in weeks). I needed to get a new card and manually submit the payment details. It's been two months and I still don't have the money back for the visit.
(I'm not going to repeat myself but many years back I also had a rabies vaccination story in which I received almost $20k in hospital bills)
What the above anecdote suggests is that the industry is broken and relies on fantasyland pricing because providers no longer have to compete due to insurance networks. The new hotness is VC's getting into running clinics because as universities can do, they can charge unlimited pricing and force the market to accept it. You don't have an option to barter with health providers, you can't sue them when they are scumbags (because professional protections, etc), and in most situations you don't have a choice whether you get sick/injured... it's just the risk of living.
What? It takes less than an hour and only two medical people (doctor doing the dirty work and a nurse observing the patient and double checking the video) plus a few minutes to finish the paperwork. The machinery involved is very cheap nowadays and anyway lasts for many thousands of procedures. The consumables are some lubricant, sterilising solutions, paper towels, and something to clear your bowel the night before. At least that's basically what it was like when I had one a few years ago in Norway.
How does that add up to two thousand dollars? Of course I don't know what mine cost because I only had to pay about NOK 250 (very roughly USD 30).