More doctors are charging fees to respond to patient messages
wsj.com
wsj.com
10 appointments a day, 30 mins each.
You have to write /everything/ down the patient tells you. You often have to go over the 30mins because some patients need it. You need to follow up to order extra tests, you need to occasionally google something.
You skip lunch often. You need to find time to reply to messages from previous patients. Nurses will mess up something or a patient will show up late. Want to see patients past 5? The nurses have left and you can't legally 'bill' or code the appointment without the nurses.
day is over and you review tomorrow's patients. You read through their histories. Now you check the messages. There's between 5-45 a day. You see a lot of patients.
Then you're told that your department isn't bringing in enough money. They want you to see 11 patients a day. The reason? They didn't bill people correctly. For the past year.
A lot of doctors quit.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
https://www.openhealthpolicy.com/p/medical-residency-slots-c...
But don't know how much is talk versus walk. It is not clear to me why only the US Federal Congress can fund residencies. Surely, with how much doctors can earn, a private underwriter would be willing to finance a residency.
https://www.washingtonian.com/2020/04/13/were-short-on-healt...
Anyone can fund residencies. If a wealthy donor has enough money to spare, a teaching hospital would probably be willing to create an endowed residency slot in their name. And there is already some private funding, although it is a tiny fraction of Medicare funding. Commercial payers (medical insurers) also indirectly subsidize residencies by reimbursing teaching hospitals at higher rates than other facilities for the same procedures. None of the other major healthcare industry players have a direct incentive to fund residencies.
https://www.chcf.org/wp-content/uploads/2018/08/GuideGraduat...
1) Insurance companies - extract profit from the usual insurance model applied to healthcare.
2) Drug/Device companies - extract maximum profit from patent monopolies, FDA regulatory capture, and marketing.
3) Malpractice lawyers - use regressive law precedent to maximize individual payout and lawyer billing to the detriment of everyone else
4) AMA/Providers - restrict supply, and maximize billing for services
Really, none of these pigs have the interests of overall public health in mind:
- Insurance companies are incentivized to maximize the cost of insurance and deny coverage as much as possible, like any insurance company vertical. Obviously this results in denial of care. However, an insurance company is motivated to reduce provider costs and possibly to incentivize preventative care. Insurance companies are also vertically integrating into owning provider facilities to solidify local monopolies (so people HAVE to use their insurance if they live in an area) and to be able to impose cost cuts to actual providers.
- Drug/Device companies are incentivized to maximize the profits from 20 years of provided patent monopolies, often exploiting desperate people looking for relief from maladies, but the cost is usually beyond the ability of individuals to afford. Lawyers are incentivized to bill/get percentages of settlements and maximize awards of "damages" regardless of the overall impact to health services costs and the implicit denial of care that involves. However, these orgs, while generally not doing the core science of new treatment modalities (universities do that), they do help usher treatments through safety review.
- Trial lawyers are incentivized to maximize their patient damages and billing, which obviously is transferred to higher costs for all. Lawyers are one of the few hammers to get insurance companies to properly pay out, keep hospitals from devolving into managerial corruption, and keep Drug/Device companies from fudging the numbers.
- And the AMA/Providers are incentivized to maximize the billing for their services, overbill for often superfluous services, resist any intermediate level profession (Nurse Practitioners, etc) from devaluing their law-enforced professional monopoly, and incentivized to not address general health of patients but rather bill with expensive specialist care rather than help patients maintain wellness that averts serious illness. In my experience no provider ever cared about how much their services cost the patient, until it became apparent the patient could no longer pay. Then their economic awareness of the cost of care become VERY APPARENT. The AMA is criminally complicit in restricting supply of doctors, which it very well knows raises the cost of medical services and of course denies care to people on the aggregate.
Each of the four pigs simply points to other pigs as someone to blame and lobbies with maximum force to prevent any threat to their gravy train.
To address US healthcare costs will generally require all four pigs: a public insurance option (at a minimum). Reduce patent length or invalidate patents, and with cases like unpatented production that has been monopolized (epipen, insulin) enforce antitrust. Fix prices if necessary. Obviously trial lawyers awards should be capped. Finally, nurse practitioners and AI expert systems used to decrease costs, and supply of doctors increased vastly. Overall, government needs to address the total lack of preventative care.
Are you aware of the lack of standards in NP education and training? The American public has no idea how raw of a deal they are getting. This is shrinkflation in healthcare, whereas you might have expected to see a doctor before, now you have to see a PA/NP, where the barrier to entry is extremely low and the training standards are loosely enforced, if at all.
In a perfect world, healthcare services would be well-matched to the level of care needed. Standards would be laid out and followed, and effectively priced care delivered.
And then, please don't laugh, if lower cost healthcare was delivered, then premiums would go down. No, no, don't laugh. Okay, you're right, there's no incentive for a local monopoly health insurer that owns the hospitals to pass the money to the consumer. YOU DON'T HAVE A REAL CHOICE. So if you are in buttshit Indiana, you basically get to use Anthem. And they have no incentive to deliver cost savings to the insured.
So of the four pigs, they are all opposed to each other to some degree:
Doctors: hate insurers (who want to lower their salaries/fees/billing) and trial lawyers (who cost them in malpractice insurance).
Drug/Device: hate insurers (who want then to pay less than bloated retail price) and trial lawyers (who sue them in massive class action lawsuits)
Insurers: hate everyone (because they own the money that comes into the system, they attempt to let it go to anyone else, be it drug company, doctor, lawyer, or claim)
Lawyers: hate insurers
BUT, the one shadow incentive they all have is to increase spending on healthcare. So even though the pigs oppose each other on details, they all want people and the government to pay more money for healthcare.
I can tell you that more than 75% of my medical school class was not in it for the money, for what it’s worth.
That's what the "restricted supply" bit is about.
Even the worst, most harmful doctors I've come across are making more than everyone else I know.
The specialists, the two I know probably make 700k and up, are superficially in it to "help people" but it is apparent they love the money. Radiology, Cardiology, and AssDocs.
US specialists make far too much money, especially considering that GPs barely make 100k sometimes, but for two extra years you get 6-7x the salary? Come on.
I worked at a drug/device company. It started out in a garage and was originally a "morally run company". But it had long devolved into an MBA enshittified acquisition-deal company.
I worked at a major insurance company. They can't for public reasons show TOO much of a profit, which is PERFECT for the MBAs running that company, because they hoover up all the excess in a bloated executive structure and embarrassingly huge bonuses.
Never worked for a law firm. I generally assume them to be the smallest pig, the runt, which is useful for the other pigs to bully and blame for everything.
But gp is where you do preventative care to avoid the specialists.
Nonsense if you read the SEC filings and compare health insurance executive compensation to other business' executives that lead similar number of employees and revenue.
Try to make sense for why people getting paid in equity would want to lower their own compensation by hiding profit. Across the entire industry, at least 7 publicly listed businesses (UNH/Elevance/CVS/Cigna/Humana/Centene/Molina). That would be a very impressive collusion scheme, if they can pull that off maybe they deserve it.
Insurance company profurs are in the 5-15% range. Drug/device can be in the 50-100% range depending on what patent monopoly they are riding.
But the health insurance companies operate regional monopolies or duopolies, which they achieve with vertical integration with hospital networks.
Health insurance knows they are riding a delicate balancing act. The entire first world besides the us has social health care. They all have better outcomes and vastly reduced costs. They are pure corruption.
So they can't show the drug device profit margins. They have to look like the hood guys who push down costs from the evil drug companies and those know it all doctors/ama.
One of the problems is that regulations require MD oversight but not necesssrily performing all operations. That’s a good thing but forces them into a role where they hover for a few minutes then get rushed to the next supervision activity.
So there are lots of dials to play with in addition to supply.
That's an understatement. It is blatant and deliberate.
We (the AMA?) regulate where a doctor gets their education in order to become a doctor. This gives schools a lot of power. It also gives hospitals a lot of power when those doctors work insane shifts during their rotations.
https://www.ama-assn.org/education/gme-funding/save-graduate...
It was obviously meant to be provocative and tongue in cheek. But all medical boards are exclusively run by doctors, so you have to assign blame to the profession for doctor NIMBYism.
Imo, it's another case of : "you can't get someone to understand something, if their wealth depends on them not understanding it."
You can see a lot more patients when you have less busywork. You can also be more caring and thoughtful when you’re focused on the patient and not the chart. A lot of patients give misleading answers (I don’t eat much! How are you 50lbs+ since last visit?)
More doctors will help. But management runs the hospitals so poorly they can’t run more resident spots!
And after each appointment they need to document everything in the chart. If you aren't charting in the room, you will be there for hours after your last patient catching up. But if you do chart in the room, your patients get mad at you because you are on the computer the whole visit.
Then you have to prechart at the end of the day on all of your patients tomorrow and get ready to do it all again.
1. https://www.advisory.com/daily-briefing/2013/08/27/the-secre...
I honestly hate this sort of stuff though. When I pay my toll on the highway, I expect it to pay for maintaining the road I used, not for unrelated things. Anyhow, may be a similar kind of thing going on here, or you know... just flat out profiteering.
This is a great example. You expect to pay for the "maintenance of the road", but what about the ongoing opportunity cost of the road and all the externalities of the road? What about all the roads that do not have tolls on them? The toll road does not exist in a vacuum, and life is not so simple so as to be able to sequester all costs into separate line items.
In fact, one of the main uses for tolls is not for the maintenance of the toll, it is for managing congestion of the road, since the road has a carrying capacity. After a certain number of vehicles, the road becomes less and less useful, so a variable rate toll can ensure a limited number of vehicles operate on the road at peak congestion.
It is simply not feasible to tie revenue to expenses 1 to 1, and specific taxes (like tolls) legislated to do that for government expenses hamstrings leaders because it removes flexibility needed to move resources around (which obviously could be used for bad, but also good, as you demonstrated your business's example).
What? I've never heard this requirement and I cannot think of why it would be the case (I'm a PCP). The rest of your comment is pretty much the issue as PCP though. I have at least 30 minutes a day of "out of visit" requests (reviewing documents from outside hospital/consults, labs, imaging, other results, extra nurse patient triages) in addition to anywhere from 30 minutes to 2 hours of completing my notes each night.
The payment methods for primary care do not work.
It's also ridiculous that I have to promise to pay any bills that my insurance won't cover. If some care can't be justified as medically necessary, there should be a specific contract for that when it comes up, not a blanket rider prior to accessing treatment.
Forcing the two sophisticated entities to have a workable agreement where they can't dump costs off on the individual patient would at least improve perceptions of care.
https://www.cms.gov/newsroom/fact-sheets/no-surprises-unders...
Responding to messages can also just be very difficult and time consuming. Maybe you ask concise, clear, pertinent messages to your doctor (or think you do!), but most do not. It's similar to problems HN readers might be more familiar with: user-created support tickets, and comment moderation. Medical office staff help with this triage and moderation, but it has become a big problem to manage with how easy it now is for bored/sick/scared patients to send messages.
My biggest gripe here is that if the doctor answers me outside office hours, an additional "emergency / inconvenience fee" is added. Like, I can't control when you answer, and I didn't choose it. If I send in something during daytime and you didn't get to it, answer me the next day, then. Or make it a choice that I want a prioritized answer so at least I decide. It's just bonkers.
In the US, a regular doctor's visit can cost hundreds of dollars.
The cost for this e-visit message would range from $65 if it took less than 10 minutes to $438 if it took more than 25 minutes.
With absolute zero accountability on how this time was spent.
Lawyers are way more transparent than medical billers
Now a days what happens is I send a message with photos or many details, and some poor nurse who is assigned message triage is going through many and responds with generic pointless text for my issue.
Then I get charged $15.
You owe me $3.99
If it was three minutes of "these are your lab results; you should/shouldn't come in for a follow-up," I'd agree that it should be a phone call that's covered under the cost of the original appointment. But given that vet friend is constantly pressed for time and doesn't get to bill separately for those callbacks, I can't imagine why my primary doctor would want to do the same.
I don't want medical professionals responsible for my care to squeeze things in when they have time. Insurance is likely to be even more of a pain in the ass, and cramming in tasks because they're unpaid means lower quality of care.
We're not even making money yet due to student loans. Sucks.
I wonder if charging for these messages will make doctors more likely to respond. I wouldn't mind a modest copay for these. But if I pay $30 for an appointment, a quick message should be under $15. There would also have to be some sort of SLA, or the ability for a patient to specify that a question/email has expired and no longer requires an answer.
I've had situations where I waited for a doctor's callback so long that I ended up calling a friend who was a physician assistant, watching a youtube video about how to fix the problem, and taking care of it myself. The only way that process could be any worse is if I got a reply after I had fixed it — and a bill for the message.
Edit: In no way am I saying "American healthcare is just fine!" only that I actually have had a really good experience using messaging to communicate with my care teams.
That said--hospital management, driven by the insurance world, tries to wring as much uncompensated labor out of the medical workforce as possible. Doctors (including my MD colleagues) do not get together to limit the number of doctors available. That's baseless conspiratorial thinking that doesn't withstand a moment's scrutiny when you understand the incentives at work in American healthcare.
There are limited slots each year at the accredited schools you must attend in order to acquire your role.
Nobody's accusing you of doing it - but the number of doctors is limited
Ultimately, the number of training slots in the current system is limited by MHA and MBA administrators who see training and instruction as subservient to profits, not the doctors who make up the departments and training faculty. Or, more broadly, they are limited by the healthcare operations not being legislated in a saner way. I was just clarifying.
How long until administration figures out that they can juice revenue by shitting up the emails to increase back-and-forth traffic?
Sometimes I have questions that don’t need the provider’s time, but there is no way to get ahold of anyone else in the office (the practice is part of a large hospital system and calls are answered by a call center that knows nothing)
Why do you think someone else's 'effort' should be free?
No-one's saying it takes zero literal effort. Just "Should I be billed by the practice $25-30 for an MA to get my email and say "I have forwarded your question to the provider"?", and then a subsequent $100+ for the provider's response to my question.
Why should that not be part of the intrinsic baseline officework and not a billable service?
Especially when it's a 100% artificial roadblock inserted by the practice? After all, the communication portal in MyChart is "Message My Provider", not "Message An MA To Message My Provider".
That is semantics, could be changed to "Message the office" but that isn't going to be the most clear title for the majority of people to understand what it is doing. It's the same as calling the office, 99.9% of offices (basically all outside of concierge/direct care) are going to be triaged by an MA/nurse first.
As far as the payment requirements I've heard of, I have never seen anyone bill just for the MA reply.
My comment on this was in response to a comment positing the potential for exactly this:
> How long until administration figures out that they can juice revenue by shitting up the emails to increase back-and-forth traffic?
And then, the reply I got was basically "Well, why shouldn't they be able to do that?"
Physicians won't see a dime of that money unless it's through RVUs and even then it's marginal at best. The real money is in procedures.
Why would it do that? If they get money for messages sent (rather than messages sent by doctors) then some flunky can send a message and you can still be billed. Given how this sounds like a profit center, and doctors are cost centers (imagine if they needed to send more messages... now they have to pay more doctors!), I figure physicians will be kept far away from any such system.
If we plot out perverse incentives as a space, I believe that our fate will be to trek through every possible point in that landscape such that we eventually see every single one. This means you will eventually get universal healthcare, most likely as the very last of those perverse incentives.
I think it’s much more likely that doctors will end up sending AI-autocompleted messages that take very little time to complete but seem like took much longer.
The standard will evolve to something like clinic staff sending the messages which will be overseen/supervised by a medical doctor (who won't be involved in composing the messages or spend any time looking at them before or after they are sent). We'll see trials where the doctor who was supposed to be keeping an eye on the messages wasn't, and some flunky kills a patient by suggesting that drinking used engine oil will cure the sniffles. Keep in mind that the messages can be sent from anywhere too, technically no need to keep that onshore. May eventually get legislation that would guarantee that, but only after a wild west period that lasts a few years.
Doctors should be compensated for the amount of time to send an email. Every other industry is capable of restructuring support to satisfy demand. It's up to the healthcare providers to manage this channel properly as any other would.
The real question is: what would it take for the healthcare industry to restructure itself to actually function?
I'd like to see the other usual suspects addressed too but it seems like the doctor shortage is a big part of the problem.
Not saying we don't need more doctors, but seems unrelated to to the problem being discussed.
Strike the words "over 65" from the medicare bill.
If you mean "universal single-payer", its worth noting that Medicare is very much not single payer and striking the population restriction for Medicare would not produce universal single payer (or even a single comprehensive plan for each individual, unless they are opting for privately-provided, publicly subsidized main insurance -- otherwise hospital [Part A], outpatient [Part B], and prescription drug [Part D] are separate insurance systems, and only the first two are public.)
Medicare is a particularly complicated implementation of partially publicly subsidized private insurance with an (incomplete) public option.
I can't quote it precisely, but here's a gist from The Glass Bead Game:
> Intelligence can find its own way, the teacher's job is to address stupidity.
Overlooking the crudeness here, I think it's a good idea, and translates to medicine. Most of us are not qualified to define good care, but we know bad care when we see it.
One example of bad care is when you don't discover how expensive a treatment will be until 3 months after it has occurred.
Another might be cases where medical professionals are expected to work insane long shifts with insufficient sleep time in between.
Whatever the examples are, let's make a list of them. Build consensus around the worst offenders, and then start revoking counts-as-medical-insurance tax status from the insurers who fund the bad behavior. If you want pre-tax-medical-insurance dollars, you must:
- be able to turn a "what if" treatment scenario into a dollar amount in less than 10 minutes
- not have organizations be in-network which create unsustainable working conditions for medical personnel
- [other example of bad care goes here]
...and we add to that list over time. Markets don't do design, they do evolution. We have to kill off the ones we don't like if we want more of the ones we like.
Maybe we need to remove gatekeeping access to drugs from the primary care physician's job so that they can focus on the other parts.
If patients need lifestyle advice then going to a highly paid physician is a waste. Those patients should start with a (cheaper) therapist, personal trainer, dietician, or social worker. We can't reasonably put the entire burden on physicians; it's too much for one profession to handle.
I've had this experience once and my wife has had it thrice (different doctors, different injuries).
By asking primary care physicians to gatekeep drugs, we're introducing a bias where when you walk in the door they assume you're after drugs. I don't have a solution for how best to gatekeep drugs, I just wish I could find a doctor who was unencumbered by that task so they could focus on healthcare instead.
Certain health insurance plans may require a referral in order be reimbursed but that's not universal.
Every time you try to change a medical policy the threat is "you'll kill grandma". the fact is that grandma's care is awful and we need radical changes.
Breaking drugs out to pharmacies, Mexican style, would go a long way to interrupt this dependency.
I wonder if contacting your doctor directly is a US thing? Before this discussion I had never heard of such an option. I definitely don't have any way of directly contacting any medical staff, neither a nurse nor a doctor, it will have to be through an appointment.
This might finally explain why this "ask your doctor" is so often repeated online as a realistic option? You definitely won't ask your doctor about every minor thing if it's behind an appointment.
I bet there are a ton of consultants and lawyers (and maybe some accountants) on HN and most of them will charge you for time spent replying to emails.
Edit: inserted the word "all" before insurance to clarify my intent.
> Health plans covered the full cost of about 82% of claims, according to the Peterson-KFF analysis. Patients who shared the cost paid $25 on average.
I would be very curious to know if my insurance is paying for the useless messages that my doctor's office sends. I sure hope not — they are next to worthless!
Also, your TFA is kind of unnecessarily vulgar (You do know what the F in TFA is for?) here seeing as it doesn't change the point of my original comment. I did, however, add the word "all" incase someone took my comment to read that I didn't think any insurance covered it.
Thanks for the thought, but unfortunately our whole system (Stanford Health Care, FWIW) is like this. My doctor is better than my kids' doctor, and my wife's doctor. The incentives are just not there for them to engage, so mostly I get nurse messages that are useless. It appears to be a copy/paste from google (or some internal system), basically.
As for "TFA", I do know what it means and see it used here regularly [1] and without meaning anything harsh. It's not like some people say "TA" and some people say "TFA". It's just TFA. Regardless, I didn't meant to offend you or make it seem like I was demeaning you. I was just pointing out that the article addressed your complaint, and indicated that the vast majority of insurance plans don't leave the cost up to the patient. I nonetheless appreciate your feedback and will consider "TFA" more carefully in the future. If you have any equally pithy alternatives, I would welcome them!
I know a few primary care doctors and they are all overworked and overbooked. I can't imagine any of them going above an beyond unfortunately (not because they don't want to but because they don't have the time). But most of the one's I know hate the system too.
I appreciate the clarification on tone. As a dev I read TFA in the same time as RTFM (as in: why didn't you read the article you moron?). But I get your usage as well.
I would guess that fully covering patient emails would save insurance companies money in the long run, but why do that when you can boost short-term profits?
> Now, she says, patients are typically pleased that they are able to get a direct response from her through a portal message.
> “They’re thrilled when they get me directly,” she says.
Geez, this could make corporate PR people blush.
Yeah, it’s embarrassing. I am not “thrilled” to talk to a doctor directly. I pay for it, and when I do it’s because I have a reason to, which kind of limits the thrilling aspect. I expect it, and I need it, sure. But it’s not being able to talk to my doctor that elicits an emotional response, and it tends to be anger.
In Canada I had no such option.
In the Michigan Medicine system the 3 main message options are: refill a medication, ask a medical question, and ask a billing question. If you select "ask a medical question" the next and final choice is whether you're submitting a question in English or Spanish.
Most often I want to ask a scheduler (because each office/department schedules differently) or a nurse a question, but for that you have to call. Something as simple as scheduling a flu or covid shot can't be done via messaging.
Unless your lawyer is an equity partner, he's not getting much of that $150.
In the US, the median doctor makes almost 75% more than the median lawyer...
I’d venture to say that people with chronic illnesses that require ongoing intervention to sustain daily life are more likely.
If you just have a migraine out of the blue you’re gonna need a full appointment to provide context.
Trying to do simple things like:
- Setting or getting an appointment.
- Calling to sort out their office’s coding error that resulted in me getting an erroneous bill
- Trying to get access to their portal or getting results for tests transferred in a realiable manner to another doctor’s office.
I truly think that they would be mortified beyond words and wouldn’t believe their name is on the sign up front.
Specialists make so much money they can hire a personal assistants to handle all the annoying things.
I know several pharmacists, one is highly intelligent and she is the only one who wants to get out of the field because healthcare in the US is toxic and profit driven.
That is why I have to be employed. I guarantee that after 22 years, office expenditures (rent, salaries, supplies, health insurance) would eat up the remaining $300. So taking care of Medicare patients would be charity. Medicare is 60% of my practice. Private insurance is 25%. Medicaid is 10% and unfunded is 5%.
I've been playing with the idea for a while that any time a company uses its name, it has to disclose its ownership (first the company at the top of the chain, then the ownership structure of that company). So like for example the company name "Gerber" would have to always be coupled with "owned by Nestle, a publicly traded company.", and "Dave Franklin, a Dentist in your Community You can Trust" would have to be coupled with "Owned by Private Equity Incorporated, mostly owned by pension funds".
This would make it easier to keep track of if the same company is just screwing you over and over again with different faces, while still allowing some value to remain to brands that are consistently good for customers.
My primary knows and gives me tips for navigating the administration of their own (as in, they own it) practice. I guarantee they hear quite a bit of griping and moaning from patients about phone tree and waiting room delays.
Retaining good admin staff in my area is very difficult, but doctors aren't going to close their practices because of it.
I've customized the hell out of my own hospital's Epic system (I'm an anesthesiologist) to make notes as easy as possible. 95% of the things I do are done the same way, every time. Back when we used paper, they had all of that in checkboxes on forms. Basically a way to say "yes, I did this legal and proper" very quickly. It was very useful because you knew that if you skipped over that and went straight to the written description on an old record, you'd actually get the important information.
Before billing criteria took over medical documents, doctors could do more because a board-certified pediatrician doing a well-baby visit could just write "18 mo WM, PMH NC, PE WNL, f/u 6 mo" (18 month old white male, past medical history noncontributory, physical exam within normal limits, follow up in six months). We had "skeletons" for reporting the most common labs in notes - just a graphic representation so you didn't have to write "Sodium 139, potassium 4.3, chloride 122, bicarb 24, BUN 9, creatinine 1.1, glucose 85".
139 | 122 | 9 /
--------------- 85
4.3 | 24 | 1.1 \
On the one hand I don't want doctors to charge for an email consultation every time I need a prescription refilled.
On the other hand, maybe insurance companies should encourage doctors to do this by paying them (and not charge a copay) because it will reduce the need for office visits which will probably be cheaper for them overall?
Maybe they put you on 5MG on amlodipine for your moderately-high blood pressure 18 months ago, but since then you have put on an extra 75lbs and now you have critically high blood pressure - lots of liability if they just keep re-prescribing a low-dose that doesn't match your current conditions.
Everyone wants the easy path to getting the pills they think they need - then there is a bad outcome and some greedy lawyer and client come along and want $10Million in damages for the poor care they got.
The only people actually winning in our health insurance system are the shareholders and the executives. Everyone else is being left worse off than they'd otherwise be.
TL;DR: The arguments against socialized healthcare make sense if you believe healthcare actually costs what American providers charge. It doesn't. They just know you have to, you know, not die and that they can charge whatever they want for that service. That's why it's fundamentally unethical for medicine to be a for-profit industry.
And still, drugs are too expensive in the USA, especially old drugs like insulin and albuterol (asthma inhalant) that seem to find new ways of being re-patented (e.g., through new delivery devices that are just novel enough to be granted a patent, but provide no significant improvement to the patient).
If drugs, pricey as they are in the USA, are only 10-15% of healthcare spending, that should frighten you as to how cost-inefficient our health care system is.
If the provider doesn't bill, problems from the patient's perspective:
1. Some patients are reluctant to message when they should, because they don't want to impose when they know the provider isn't set up to charge. Same "Should I send this?" problem.
2. Providers end up needing zealous triage/gatekeeping/diverting on messages, so more messages might end up handled with more generic responses.
3. Providers might have incentive to shift messages to billable nurse calls, just for fiscal sustainability, turning a message into phone tag and/or long hold times.
Personally, I'd prefer to pay for good message responses. (Initially I assumed I was, but the charges didn't seem to show up on the EOBs/bills.) Much like with a lawyer, but maybe priced lower than the effective rate for minutes with patient in an in-person appointment (since messages do have more async flexibility, and lower office overhead).
Huh? While I won't challenge these people actually exists, I cannot imagine they are statistically significant. I have never heard of anyone being worried about being charged too little by a health provider.
As things stand, I have to call. He doesn't take e-mails. If I have a quick question, I can schedule a virtual appointment. There is usually a 2-3 month wait. The appointment is scheduled for a day, not a time, and is limited to 15 minutes. They'll let me know the time about 30 minutes in advance, and it could be any time of day. If I miss or can't make the video call, it's usually another 2-3 months before he has availability again. There are no other doctors with the relevant specialty nearby, so this is what I get.
Around here, doctors have been mostly forced to work for hospitals now, because IMO doctor practices can't afford malpractice insurance, clerical staff to deal with all the insurance paperwork, computer systems, and computer software licenses. There are also huge groups of specialty doctors working together to avoid having to work for hospitals. Here it's urology, dermatology, and gastroenterology. In my experience these doctor group operations are run even worse than the hospitals: they have a monopoly on their specialty and know it.
I've been in meetings with healthcare providers about incorporating LLMs into text-based patient-physician messaging to improve triage and routing. It is just overwhelming for many providers. A large percentage are getting burnt out, and much of their time is uncompensated.
> If people had to pay, maybe they would _think_ before asking questions.
Be careful, a lot more people might be calling at 4am because they figure it’s okay because they’re paying for it. At least other contractors can give people a “fuck off” quote for work they don’t want to take, but might be difficult to implement that here.
https://www.msn.com/en-us/money/insurance/the-medical-bill-y...
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actually i understand that doctor said that you could film here today but
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unfortunately that's not going to be able to happen i know that he advocates for patients changing their diets but the
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hospital makes money off these surgeries and the reality is he does too so we can't do anything that's gonna
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negatively impact the hospital so unfortunately you're not gonna be able to film here today
I don't think I've ever seen a lower bar.
There's also quite a difference between the ethics of healthcare and legal services.
Most of the time if you need a legal answer from a lawyer who charges like that, it's because you know you'll net more money from having the answer than it will cost to get a reply.
With healthcare, you're not trying to make money you're just trying to live.
And usually I’m paying my lawyer to protect me from risks to my financial health, not because I think checking with them will make me money. My doctor helps protect me from health risks. It’s pretty similar. A mess-up in either area could easily mess up my life very badly.
You're correct that I'm in the privileged position of being able to afford my lawyer. (And my doctor and health insurance provider.) I'd just point out that not everything that involves a lawyer is about making money.
But you raise a fair point, and I apologize if my somewhat flip comment came across as insensitive.
No fixed fees. No per-visit charges. Just bill for the time spent (including pre- and post-visit paperwork) and the direct expenses actually incurred. Everything else is built into the hourly rate.
It will never happen, but it would be much better.
The problem is that without demonstrating somehow that they read it, they cannot prove they actually read that correspondence when they claim to have. This puts them in a difficult position because the client can plausibly claim that they did work they didn't actually do. Perhaps they don't need to send an explicit acknowledgment (even though it's the right thing to do), but if they don't even act like they received and read it, yet charge you for it, that's a real problem.
FWIW I've had little trouble getting my attorneys to credit me for activities I didn't ask them to do. Somewhat different situation, but most good attorneys aren't scumbags.
Having received many email tomes from clients, I wouldn't think twice to charge for reading their email. I would typically respond, but not necessarily if they weren't asking a question, or if we were going to be meeting soon to discuss.
I don't know any attorneys (note: all the attorneys I know are corporate attorneys, so may be less bill-sensitive) who would not bill for time spent reading emails. Lawyers spend tons of time reading emails!
> FWIW I've had little trouble getting my attorneys to credit me for activities I didn't ask them to do.
This makes sense, but is somewhat orthogonal to the email question. If a client sends his lawyer a long email, he is implicitly asking the lawyer to spend the time reading the email.
Not gonna get in the merit of saying if it is ok or not, but I believe some already have the capability of answering screening questions and even exams results.
The culmination of the American middle-man capitalism.
On the one hand, it’s frustrating to me that I can’t see my own data without first reaching out to my doctor.
On the other, it terrifies me that he’ll respond to any question I send him within minutes, because his workload is clearly unsustainable and I’m deeply concerned about burnout.
Would a charging me make me message him less? No, but my guilt and concern greatly restricts this and I can’t imagine that’s true of everyone.
• I needed refills for two prescriptions that I've been taking for years. This time, for opaque reasons, I needed to talk to a doctor first.
• Fine, but I couldn't accommodate an in-person check-in. I chose a "video visit" that, due to logistics, I had to do while away from home. Because they were a half-hour late, I was effectively forced to do this from the couch of a Costco floor display so I could still pick up my kid on time.
• The appointment was 8m, at an out-of-pocket cost of $160+. I was not warned that I'd be forced to pay $20/minute for the privilege of being blessed with refills.
Land of the fee, baby.
It's effectively a scam, don't give in to scammers.
Fucking. Ridiculous.
At no point did the ER staff ever talk to me. At no point was I in a room. Or in an ER bed, hallway or otherwise. Just ambulance, transport, and then to pre-op.
But, because the transfer physically happened in the ER, that second hospital tried to bill my insurance for an ER visit to the tune of $2,800 which I appealed (successfully, at least).
How did the determination that you needed urology, "oops, no urology available", and ambulance transport get arranged? It seems like some level of triage, routing, unable, re-routing had to have happened, right?
But yes, hospital two tried to charge me for an ER visit, as well as the surgical billing (which of course was reasonable).
Shock, horror, you actually need to read through the form and select the appropriate checkboxes (around ability to stand, need for oxygen, fall risk and hazard, danger to self or others, etc., etc.)
Too many of them literally fill out patient demographics and a signature and say "here you go".
We push back because our organization policy is that we will transport those patients, BUT we would also much rather bill Medicare than the patient (our billing staff and C-suite may disagree, but EMTs and paramedics wholeheartedly understand that routine privately paid ambulance transport is not a viable option for 99.998% of the elderly).
Now the doctor has to put an appeal to explain medical necessity, I'm at his mercy.
An MRI shouldn't cost $26k, even with contrast, and at a hospital.
If this was non-emergency, it should have been pre-cleared with insurance per their policy.
You could fly to New Zealand, have a scan on a state of the art machine, get a good report, have 3 weeks holiday and fly home. You’d have heaps of money left over.
The ambulance ride alone from the accident site to the hospital (like, 5 miles) was several thousand dollars.
Probably the biggest surprise there is that a doctor saw you at all instead of you being filtered out by a triage nurse and sent to urgent care.
It is fairly common for someone to be advised to seek emergency treatment out of precaution to ensure that a minor symptom is not indicative of a severe problem.
For example dizziness can be a completely nothing-burger inner ear problem treated with a bunch of motions from youtube, or it can be a stroke. The ER exists to make that distinction.
Part of all those logistics and resources should be used to shunt people to the correct treatment center, but liability suits and extreme profitability mean that the incentive is to treat them in the ER.
Put into other terms, if you were hospital admin incentivized on billing, and could bill someone $5k instead of $160 for a non-urgent issue, wouldn't you? The fixed costs are the same, the ER is running 24/7 with a trauma team, might as well make it profitable.
I feel fairly comfortable assuming that they were being seen for a minor-to-moderate burn.
Well, at least, a functioning health care system shouldn't penalize for that sort of thing. We don't really have that in the US.
I don't know either, but the broader point is that people are referred to the ED by medical professionals for seemingly minor issues all the time, and that the incentives are all lined up to treat stupid shit in the ER rather than have someone tell them to go somewhere that makes more sense.
Insurance did try to deny coverage, but fortunately I appealed and won.
What matters is who picks up a bill (or challenges hospital and negotiates). I see little protection in US between patients and healthcare corporations, but its true I look from afar.
That solution doesn't really scream "emergency" and seems like a waste of their time and resources...
Some ERs don't always provide the level of care that they should, some doctors/insurance companies require patients to go to the ER for anything they need after office hours, and sometimes there's a need to be seen for something because of perfectly reasonable and valid concerns that it might be more serious than it ultimately ends up being.
While it's possible that the commenter's visit to the ER was a "waste of time and resources" I don't think it's fair to assume that from what was said.
Personally I am not qualified to determine what a treatable and non-treatable burn looks like. Where I went to school they don't teach that.
My order of operations for medical treatment are:
1) Virtual consultation. Free through my insurance. If you need to pay full price, this about as expensive as option 2. Also worth skipping if you can tell that an in person visit will be needed anyway.
2) A clinic. I use CVS's minute clinic. Looking at their price list [0], a minor burn treatment will run you about $100-$150, which is about what I would expect for talking to a professional.
3) Urgent Care
4) Emergency Room
This is further exacerbated by the limited safety nets in the US–even people who would on principle deign to sue others who tried to help them in a time of bad luck may find that a lawsuit is the only way they'll be able to maintain a decent lifestyle after the loss of a partner, or with a newfound need for long-term care.
One more layer is the fact that doctors are so overbooked. Many people cannot reasonably get appointments with their family doctor (if they have one) on short notice, so some things that, in the past, might have been a "wait-til-morning then call the GP to drop in same-day" are now "GP is booked three months out, guess we're going to the hospital".
Or maybe the patient didn't know what was required.
[1]: https://laeger.dk/media/mjpbsm2a/honorartabel-2023-januar.pd...
They ask you to set a primary care doctor, but I have had more success with seeing a small group of their more available non-MD physicians.
Everything you're describing is screaming monopoly and artificial lack of competition.
If providers of class X are too busy to see you, then there's plenty of people who could, or you're just going to do it on your own. It needs to be more like that.
Obviously there are some limits, but educational pathways could be much more diverse, and there are many things that patients are capable of accessing on their own or through providers like pharmacists.
But I agree that for some appointments it obviously doesn't work because you can't examine the patient or take vitals the same way/at all.
Call me new-fashioned, but I don't want to spend a few hours of a workday several times per year to see a doctor for less than 5 minutes for prescription refill for a drug that I have been taking for years.
Why in the world would either of us need to see each-other in person when he can ask me the same 3 questions he always does over the phone?
For certain things, like common illnesses, it is pretty good.
But that being said, use caution. I had something minor turn into an ER visit because I used telemedicine instead of going to my GP. Telemedicine prescribed antibiotics, which was correct, but GP would have done a drain too. Lack of drainage caused uhh unpleasant problems down the road.
It should be noted their virtual visits are mostly performative. You're filling in a survey beforehand and the doctor is just there to read the survey and push a big green button.
I've only ever had doctors that worked that way so didn't even know that there were some that did not.
I now wonder which is more common, and if there is some way to tell beforehand when choosing a new doctor which kind they are?
It’s terrible and the only thing worse than the exorbitant fees is the complete and utter lack of consideration to the patient’s time.
The lack of regard for patient schedules is a direct result of how insanely packed the schedules of providers are. Fifteen minutes per patient is luxurious and my partner spends a lot of time after work entering notes for patients she saw that day (she "works" 32 hours / 4 days a week, which is really closer to 40-45 all told). My understanding is that the clinic does not have a high profit margin (serving medical / medicare patients + high overall costs), so every patient counts, and the admin staff will add people w/o permission. It's common for her to find patients scheduled over her breaks or for her to be scheduled after she should have left the building. Burnout has always been bad but it's reaching epidemic levels now in the wake of covid, which further restricts the supply of healthcare and makes people wait longer to be seen.
For a recent event, I got a whole nurse calling me from the "insurance" company, out of the blue, seemingly just to chat about the medical situation and how things are going. I haven't figured out what her KPIs are, but I doubt she remains so friendly when you bump up against them! And she obviously represents a severe misallocation of labor - the industry would be better off if someone with her education (and likely experience) was actually providing healthcare.
Worse the odds are good she was hired to help the insurance company prevent people from getting healthcare.
It's the same story every time. Something works relatively OK (US health care before 20 century big-gov), huge changes to incentive structure and overheads are introduced by statists ignoring higher order effects, everything goes downhill, statists blame capitalism.
Let me legally not have insurance, pay anyone in cash for my health care (no licensens and government enforced monopolies), and buy any medicine I'd like and opt out of this madness completely and let's compare with real capitalism.
If you try doing health care this way for long enough, you might even discover which incentives are poorly aligned without collective policy of some kind, but who knows, maybe not.
Then someone from outside the US says, "that would never happen in my country; here's how it works here..." and it's immediately assumed there's some sort of huge catch, that never, nowhere could a health care system work that well without some sort of major trade off or downside.
No! Stop this! A health care system should work for patients, not against them! Injured or suddenly-sick people are not in the best head space to make rational, informed decisions as to what level of care they need in the moment. Even if they were, nearly all lack the specific medical training that would always allow them make that decision with a comfortable level of certainty.
And even if someone should have known better, I just don't get the ire. Why should we put people into tenuous financial situations just because they made a mistake in how they sought medical care? Medical care! What the hell is wrong with people?
The US health care system is awful, despite having so many great and talented doctors, nurses, and staff! Let's get that through our heads! We pay so much more than other developed countries, for so much less care. And the reason we don't have something better is because the right public policy is labeled "socialism". This is so exhausting.
The US healthcare system is completely broken. Hospital systems and doctors offices in general lost a shit ton of money last year. There has been massive layoffs throughout this sector. There will continue to be this year. This year they all are going to try to survive by recouping their prior losses. Get ready for more fees.
In addition - there is consolidation in the physicians groups. Mom and pop groups are almost unfeasible at this point. Look for venture capitalists to scoop in. Guess what - you won't have better care with after those changes - I can promise that.
Lastly, the pharmaceutical industry is out of control. They hike prices on any and all medications that they are able to. They recently hiked flovent to a cost that no insurance companies or hospital will pay for it. There are limited alternatives at least for kids. This is medications that that has been out since the mid 80s. It is a controlled market, with high barriers to entry - you can either permit a wide west time of pharmaceutical environment or you can understand the need for a regulated marketplace and meet with with equivalent regulation in terms of pricing.
Finally the insurance companies are the worst. I don't know anyone with a good experience...the only ones that have a positive experience are those that don't use it. I try not to hate any single group but I hate insurance companies.
The system needs to be burned to the ground. It is fragmented and burdensome for healthcare providers and for patients. It benefits no one at this point. It creates additional workload for providers hospitals and patients alike.
I am afraid of what will come in it's place but can't we worse that this shit.
Just went out and bought a bottle of Avamys (more modern version of Flovent) for $15 without any hassle. Shed a tear for poor Americans.
It costs 2-3x of healthcare in equivalent countries, with worse results. Where is that money going?
> In addition - there is consolidation in the physicians groups. Mom and pop groups are almost unfeasible at this point. Look for venture capitalists to scoop in.
Private equity already has, from what I've read.
I'd expect the same from a doctor. If I am asking a very occasional and non-urgent question with a quick answer (e.g., can I take my medicine and drink alcohol safely) then yeah, I'll be annoyed if I get a $25 fee. But typing out responses to question might take my doctor 30 minutes, so it's fair if they charge me, so long as I get a good answer in a reasonable timeframe.
Obviously there's exceptions. If it's a brain surgeon who just made $25,000 on a single procedure and I have a 15 minute followup question, it seems a little nervy to bill me $25 more, but not if I'm emailing my kid's pediatrician a picture of a rash.
1. The accountant will tell you that pricing up front, so you can make a decision before you send an email. No doctor in America will answer any question about pricing ahead of time.
2. The vast majority of Americans know precisely when they need to pay taxes and roughly how much work they will be, how many accounts they're dealing with, what types of questions might arise, etc. It is extremely rare for most people to ever have an urgent question for an accountant. Healthcare on the other hand is inherently unpredictable, and urgent questions are very common.
3. Most people don't have, and never will have, an accountant. Every single living human of any age needs at least one doctor, and often quite a few.
4. If you don't like your accountant's pricing, you can easily shop around for a different one. You can't do that with a doctor (see point 1). You can sort of do it with insurance, but that isn't the same thing, can only be done once a year, and the options are very limited for most people.
5. If you don't like dealing with an accountant at all, you can just get a normal job and never talk to one again. It's entirely within your control. If you don't like dealing with doctors, you're out of luck unless you want to die.
Well, it would be occasional for you to ask questions to your doctor, but your doctor wouldn't be just occasionally answering questions from their patients
> Non-urgent questions
Imagine everyone sending non-urgent questions... Isn't it even more irritating to be receiving non-urgent questions than urgent ones if you're a doctor? I guess the doctor could reply with a FAQ.
Honestly, this is where I think personal LLMs should come to the rescue. Just ask a doctor-sanctioned/fine-tuned LLM for trivial questions.
Doctors charge for identifying and telling you things non-doctors can't, with a high degree of non-harm-doing.
They've already put in the 10,000 hours to know which bolt to turn.
The same is true in law. Just because you have 10,000 hours of training doesn't mean you aren't billing by the hour.
This is why there are many many doctor and attorney millionaires and very few doctor/attorney billionaires.
I have no problem telling clients these days, if you don't want to pay me for my knowledge/skill/experience, I will go home and spend time with my family or doing something I enjoy. My time is not yours unless we both agree you will pay for it or I give it to you for free out of my own choice. You do not own my time and you do not own your medical professional's time either.
PS: To the person who said you can willingly go to the open market and find professional "X" somewhere in this thread. Good luck. CPAs, lawyers, any professional with experience is in such high demand its hilarious. We name our price and chose the clients we want to work with these days. I know people in my industry from a variety of locations across the US, same problem everywhere. If you don't want to pay for experience from any professional industry, go ask ChatGPT or spend half your day watching Tiktok or Youtube videos, good luck. Not saying it to be pompous, it's reality and has been for ~5 years.
careful what you wish for.
I’m making up numbers but if a private practice physician earns $250k/year for 2000 hours that’s $125/hr + taxes and benefits + rent/overhead + nursing and staff, you figure that cost is probably closer to $300/hr then you you assume they have to do ~30min of prep/admin for every patient hour that’s closer to $450/hr that’s ~$37.5 per 5 min of patient time (and none of that is factoring in reimbursement rates), people can disagree as to how those costs should be borne but let’s not kid ourselves as to what the cost of doctors time is…