Medical staffing companies cut doctors’ pay while spending millions on ads
propublica.org
propublica.org
It almost reads like a turf war over which industry subgroup has more right to the unusually high healthcare costs paid by Americans, driven by demand for profits from shareholders, which probably indirectly includes someone like me who has a 401k.
This fight has been going on for a very long time though. One reason (among many) that large medical provider groups started forming in the US more than a decade ago was to increase their leverage against insurance companies, who they felt were undercompensating them - small medical practices have little more leverage with insurance companies than consumers on the open insurance market. At some point these larger medical groups attracted the attention of private equity investors, who themselves demand a return on investment.
In the end it seems like the loser here is the healthcare consumer, who will pay the higher costs of this system, especially those without significant capital in for-profit healthcare related enterprises.
If everyone was forced to use healthcare.gov to purchase health insurance, then we could have a viable market similar to auto or home insurance, where consumers reward the insurance companies that negotiate lower healthcare costs by signing up for their lower premiums.
It is the obfuscation of costs by way of the tax advantage given to employers subsidizing healthcare that greatly reduces the insurability of the people on healthcare.gov since many healthy people are silo’d out into lower risk employer pools, and therefore reduces the amount of insurers that can exist and compete for business.
I also wonder what a world where we removed almost all medical regulation would look like.we would at least get true competitive market dynamics. Why do I know exactly what I’ll pay at mcdonalds, but not what I’ll pay for a medical procesure?
Instead we have just enough regulation to prevent healthy market dynamics, but not enough to have a single payer type system
this seems like a very concise summary of the problem. and insurance companies see the profits of this no-mans land
Along these lines, POST THE DAMN PRICES ON A MENU FOR EVERYONE TO LOOK AT AND MAKE CHOICES!
Right now, insurers typically reimburse higher for larger practices (due to volume), but smaller rural providers can have amazing leverage as well because they are the only game in town. Generally, the smaller providers would get reimbursed less.
If you force insurers to have only one "price", then they are going to set their reimbursement rates for the largest customers which would also apply to the smaller customers (so they'd get a bump).
Even if you attempted to make the costs of things more transparent to consumers, there's an inherent information asymmetry between a consumer and a insurer due to the economy of scale. There's also a lot of things a consumer can't know until it's too late.
I'm working on a site that will obtain attestation from Congressional reps as to their support for M4A, and for those who don't attest support, campaign funding will be funneled to competitors of said representatives who do.
https://www.congress.gov/bill/116th-congress/senate-bill/112... (S.1129 - Medicare for All Act of 2019)
Medicare might pay the least, but I assume they must still be a net profit center if healthcare providers accept them.
Clyburn, the congressman from South Carolina whose endorsement arguably delivered Joe Biden a landslide victory, has received millions of dollars from big pharma [0]
[0] https://khn.org/news/democrats-taking-key-leadership-jobs-ha...
The world is replete with examples of how to deal with this problem, but I suspect the issue isn't with lack of better approaches, but rather, in the US, what you refer to as inefficiency in healthcare is the industry's profits (as in, returns to shareholders/capital, dividends, etc, not as much wages paid to doctors, nurses, etc).
Ironically, this has only become an issue of interest in recent years because it has started to cause economic stress to the middle class - i.e. many who post to this board - due to rising healthcare costs coupled with wage growth not keeping pace with life's major costs (housing, education, and of course, healthcare). Poorer segments of the population have been facing this situation for much longer, but they don't have the same voice.
Hence, ads about how we are all in this together. It would be funny to watch as I do not even know how to satire this, but it is still upsetting that it likely will work on a subset of population.
That's only partially true. Yes, rising healthcare costs. No, it hits the poorest the most, well not exactly. Medicaid isn't horrible, but you really need to be at the bottom of the income stream. Once you hit a certain age you get Medicare, which itself covers quite a bit. The people most shafted are minimum wage workers and people who work retail jobs that don't provide healthcare. The working poor. And part of this is regional, too, it should be said. For example, this debt collector stuff where they can directly deduct from your paycheck or place liens or whatnot - that's not legal in all states. Where I live, a very large city, even a homeless person can go to a hospital and get healthcare. This is a law - you cannot be refused.
The middle class have for a long time been the ones to be shafted in the U.S. They don't have enough capital or income to avoid financial insecurity (one hospital bill, one accident away from tragedy). They don't have the right jobs where they can deduct huge amounts from their income (unlike self-employed / business owners), and they don't make their income through capital investments where they can pay a lower income tax (cap gains instead of ordinary income). They're trapped in their employer's healthcare choices, and if they lose their employer their only choice are a watered-down state-managed set of healthcare options that our executive branch helped drown.
I'm not rich, but perhaps upper-income, and still a wage slave; the way I've dealt with the healthcare question is to live in the shadows of the rich (working in tech in financial services).
Once regular people have to actually start understanding the implications of the insurance they're buying, and are no longer bound by the whims of their employers with specialized employees who understand insurance jargon, I would expect massive consumer-driven simplification.
All corporations are driven by demand for profits from shareholders. If you're looking at outsized prices in the health care sector, look elsewhere for the reason.
Here's a helpful article about it:
https://www.theatlantic.com/magazine/archive/2009/09/how-ame...
I would be interested if any country has a system that reflects the ideas outlined by the writer, and if so what the results were. All the successful healthcare systems I am aware of our nationalize either at the hospital level, administration and financial level or some combination of the both.
The article points out that Lasik eye surgery is not covered by government programs or private insurance, and the price of it has declined dramatically over the years while the quality of it has improved.
You can't compare it to the type of non-elective or emergency procedures performed in other areas of health care, or treatments for severe chronic conditions. You can't even compare it to routine doctors' visits which are often put off by uninsured people due to the costs, allowing minor conditions to develop into more severe (expensive) ones.
They absolutely can be shopped around for best price and service.
Consider also that nearly all medical conditions have a variety of treatment options available, varying in effectiveness, time, pain, risk, and cost. For example, I recently had a tooth problem where the dentist laid out quite a range of options, all varying wildly in terms of efficacy, pain, time in the dental chair, risk, and yes, cost. It also had a year or so before it would become an emergency situation.
No, I don't have dental insurance. This is what a more of a free market approach would look like.
I've also had success negotiating the fees doctors charge for office visits, it's as simple as asking in advance what it will cost, and then just asking for a discount. That's all I do, and I often get a third off just for asking.
You bet you can negotiate. Doctors are not offended by this. The ones with their own practice are businessmen. If you don't ask/negotiate you get the sucker price, just as if you went to a car dealer and failed to ask the price and negotiate.
What you cannot negotiate with is Obamacare. I am forced by law to get health insurance at the price set by the state insurance commissioner.
Consider yourself lucky, you are an n of 1.
> This is what the vast bulk of medical care is. They absolutely can be shopped around for best price and service.
And it will have a little effect on the overall cost of medical care in this country. 5% of patients with extreme conditions account for 50% of healthcare spending.
https://www.newyorker.com/magazine/2011/01/24/the-hot-spotte...
> This is what a more of a free market approach would look like.
How would it look when you have a repeated anaphylactic reaction to an unknown allergen that puts you repeatedly in emergency care?
When you discover you have stage three cancer at age 50 and will die very soon unless you immediately start chemo?
When you are 34 and discover you have a degenerative condition in your hip which requires a hip reconstruction that only two surgeons in your metro area can perform, or leave you handicapped?
All of those have happened to people I know. Not sure how the free market would have helped in those situations. Insurance helped to varying degrees, but there were significant bills and co-pays.
Have you ever tried the magic words when you make an appointment:
1. how much will this cost?
2. that sounds high - can you discount it?
Don't say that's impossible until you try it a few times. I do, and it usually results in an immediate discount of 10-30%, with the condition that I pay in advance.
It's the same when I take my car in for service, book hotel rooms, or even when buying furniture.
I have a friend who regularly needs surgery for kidney stones. He calls hospitals one by one, utters the magic words, gets discounts, then picks a hospital. Sometimes, he gets the sucker bill anyway, then reminds them that they'd agreed to the lower price.
Don't knock it till ya try it.
Of course it has it's own issues, but the Singapore system works pretty well. If you're destitute, there is a government plan that provides healthcare. For everyone else, it's a forced savings plan that everyone has to contribute to. You can then make a choice as a consumer to either take the basic insurance (80% of costs covered for a basic ward where you have 6 patients to a room) or get your own private room that the gov't covers 50% of and you're responsible for the rest (typically though insurance).
So either totally government provided for the destitute, and a "forced savings plan" for most people, which is basically a tax/mandate.
> You can then make a choice as a consumer to either take the basic insurance > or get your own private room that the gov't covers 50% of and you're responsible for the rest
So the Singapore government is involved in subsidizing nearly all insurance choices all the way up to the high end, presumably funded by taxes. They also heavily regulate healthcare costs to keep them low instead of leaving it to the "free" market.
Sure doesn't sound like what proposals like voluntary HSAs and their ilk propose in the US. The proponents of those stridently oppose any government regulation of healthcare costs or measures to ensure universal coverage.
Instead, in the US, we consumers have plenty of skin in and the game, huge uncertainty and disproprortionate leverage put in the hands of our employers and health insurance companies, lack of universal coverage, and worse average outcomes.
Agree that implementing cost sharing without transparency into pricing is a bad approach.
Practices that are outlawed in other industries such as opaque rebates and kickbacks are explicitly allowed by law. Hell, there's even a law on the books that prevents medicare from negotiating drug prices. The bill's architect in congress went on to make $2 million a year as the head of a pharma lobbying firm.
As someone who works in a PE backed healthcare provider, I can assure you that we are not opposed to single payer. Some are, but they're mostly in spaces that provide out-of-network coverage or other services that are still "bill what you want and argue about it later" spaces that are rapidly disappearing. OON services are increasingly difficult and are generally covered by single-case-agreements which are negotiated either before service is rendered, or at the very beginning of the treatment process.
Single payer is welcomes by a wide swath of PE back healthcare because it would reduce our costs DRAMATICALLY and provide predictability that currently we do not have. It used to be there were small changes in what insurers would cover from year to year, but now the changes are potentially HUGE and we have to adjust much more quickly.
We pay gobs of money to departments filled with people who have to manually verify patient benefits, validity of insurance, continually monitor the patient progress to make sure we're fulfilling the various metrics each insurer sets that varies according to the patient's plan, audit each bill to make sure everything is coded correctly to avoid a typo getting an entire claim rejected (which then we have to resubmit), then once we bill it to the insurer there's the game of nagging them to pay claims they approved weeks ago.
Single payer would eliminate almost all of that. We'd know everyone was covered. We'd know what is reimbursable and not. We'd have one set of rules for all patients, one set of metrics to adhere to. One source to bill, and one source to track payments from. Literally 20% of my company's staff is just for those things. Not to mention how much time our medical staff would save by having a single set of rules to work under.
PE firms are in healthcare to try to leverage economies of scale to make the money side more efficient, and thus increase margins. A stable environment is good for any business. We work hard to make things as efficient as we can, and reducing the massive overhead attached to just making money would be a great efficiency. Single payer would be great news for the industry.
FWIW everything you're saying makes sense to me personally since I used to do medical billing more than 25 years ago, and I clearly remember how disastrously complex it was for seemingly no reason.
One of my first jobs was sitting in an office full of medical procedure face sheets, spending all day calling doctors offices to get billable diagnosis codes for procedures.
The question I have is whether the medical provider community is ready to stand up for single payer, if only on the rationale you explained. That would go a long way toward convincing segments of the public who do won't support it on human rights grounds alone, but might support it because it makes more business sense.
Some doctors are, but not most. Doctors are bad business men, as are lawyers. It's part of their training, they spend years learning how to avoid risks for their patients and clients. Business is risk management, not risk avoidance. So most doctors just try to struggle along as best they can with the current environment rather than rocking the boat. Don't get me wrong, they're not struggling to pay the rent, but running a health care provider is not easy.
[1] https://www.bloomberg.com/news/articles/2020-04-20/kkr-s-env...
Hate to say it, but the only signal that truly matters is leaving.
(The one other related signal is hires, or lack thereof, but it's far weaker.)
If I'm wrong about that, I'd be curious to hear the theory.
So, what's my employer to make of that? I might not be happy, but I'm still here. From a capitalist perspective, I'm being paid enough to hold me in position. So arguably my employer is getting my wage "just right", in that I'm close to not taking it, but not actually leaving. Kudos to them.
This does cause a lot of secondary problems, but most of those are relatively invisible to those making these decisions.
I don't have any good answers to this, but it does mean that many of the best minds of our generation end up working on elaborate advertising platforms and sometimes-dubious finance/trading applications.
I understand. It was academic to me until one of my close family members became a doctor.
I have no good answers here either. What you say is correct: from a capitalist perspective, the pay is just right. But it doesn't feel right, relative to everything else, and the result is that wages are roughly inversely correlated with actual utility a job has for the society. This situation seriously sucks.
I also have a feeling this is related to a more general problem: using prices to allocate scarce goods is an efficient mechanism. Those who care more are willing to pay more for access to a good/service. This works great when those prices are low relative to everyone's budget. It becomes an ongoing humanitarian disaster when you get people priced out of access to food, water, shelter or medical care - especially if the reason you're being priced out is because wealthier people who care a little will still pay more than you can when your life depends on it. It's like there's a "divided by all your wealth" factor missing on the market, like we're operating in absolutes where we should be using fractions.
Anyway, I hate that too.
That's insane. You can google symptoms, but you can't google context. Doctors are paid to interpret not to regurgitate. As an example, let's talk airline pilots as an example, Air France Flight 447, the crash of an A330 over the Atlantic. The computers were giving incorrect airspeed readings because of frozen pitot tubes. The pilots, reacting based on the computers, ended up stalling the airplane. The computer gave erroneous information, the pilots (trained to fly the "Airbus way" -- i.e. the airplane knows more than you do,) reacted exactly as the computers told them to react.
The "doctoring by computer" concept, while can be beneficial, can't replace the judgement of a human, just like highly automated flight decks, can't replace the skill of experienced pilots.
Google also is a search engine. It only surfaces results that "rank" -- not necessarily results that are correct. And certainly not results that are necessarily correct for the specific combination of circumstances.
You’d have to dangle a pretty big carrot to get me to do that. Otherwise, change the system so that you don’t have to sacrifice the best decade of your life and more.
Here is a chart for Australia: https://www.businessinsider.com.au/heres-how-much-money-aust... Hard to say how much they earn when working private as well. Anecdotes from the medicine subreddit suggest a lot.
Canada: https://www.cnbc.com/2018/03/06/canadian-doctor-protest-thei...
Medscape always sets the bar low when comparing US to other countries. I don't know why they do not include these ones. Here's the Medscape report that conveniently leaves these three countries off (wonder why): https://www.medscape.com/slideshow/2019-international-compen...
I'll try to find more sources for the other countries as I am interested as well.
220k is likely on the low side for PCP here. Offers coming in more around $250-270 range.
Do we? Please educate me then. I have a few guesses, the primary ones being artificially limited numbers of doctors, the artificially inflated cost of a medical degree, and the elite status that doctors hold.
A runner up guess is that Americans have the delusion that modern medicine has a near perfect solution for every problem, so doctors do not factor in cost when prescribing treatment, even when extreme costs are associated with marginally better outcomes. The funny thing about this is that because of the extremely high cost of modern medicine in practice, prescribing treatments that have the best health outcomes at the present can cause years, decades, or lifetimes of poor health and hardship due to the burdens of debt and stress. If I had to pay $10 grand for some stitches that I could do myself (which is a fairly common amount for say, 30 stitches), that cost would decrease both my life expectancy and my personal happiness.
You could suggest we replace the high paid physicians with nurse practitioners or physician assistants but that is ignoring the fact that they are paid in the exact same way (and soon to be amount - executive order signed to equalize Medicare payments b/w midlevels and physicians) as physicians! If an NP or PA sees 25 patients in a day, they will bill for the exact same amount as a physician would. Additionally, the midlevels would order more tests and imaging on average than physicians, driving healthcare costs ever higher. There's a reason hospitals love midlevels so much and are helping to push for their independent practice. Each unnecessary test or CT scan is extra $$$ to the hospital.
And someone with the intelligence and drive to become a doctor in the US can easily earn $100k per year for 40 hours per week in their 20s if not more, so the lost income alone is a minimum $500k, on top of hundreds of thousands in debt.
It all doesn’t make sense unless you come out making $200+ per hour.
There is no reason they need to be run through that gauntlet, other than to restrict supply and make them go through a hazing of sorts. Why can't they have work life balance? Why do they need so many years of schooling when other countries don't? Why are they paid minimum wage (if calculated per hour) during their residency years?
Other countries show that none of this is necessary to heal people who are sick.
People just have no idea what goes into training a physician. Even after 2 full years of studying medicine I feel like I don't know anything, the field is that huge. I assume some of the bad takes are due to most people on this site being young and only ever interfacing with the healthcare system whenever they get strep throat. Sure someone can Google that you need to treat strep throat with antibiotics (maybe they'll even pick the right one!), but make sure to warn them about post strep glomerulonephritis. Oh what's that, and why do I need to warn them about that and not rheumatic fever...
Side note: I hope your second year is going well. I know they've had a lot of changes for USMLE because of coronavirus. Stay safe, and feel free to reach out if you ever have questions about med school or just want to chat. :)