How Outdated Data Distorts Doctors' Pay

Hugh Pickens DOT Com writes "Peter Whoriskey and Dan Keating report at the Washington Post that Medicare annually pays $69.6 billion for physician services according to an arcane and little-known price list, known as the Relative Value Update over which doctors themselves exercise considerable and less-than-totally-transparent influence. A 31-member committee of the American Medical Association (AMA) recommends what Medicare should pay for some 10,000 procedures — with the fees based in part on how long it takes to complete each one. But this time-and-motion study often fails to take full account of changing technology and other factors affecting physician productivity, so anomalies result. For example, if the AMA time estimates are correct, then 41 percent of gastroenterologists were typically performing 12 hours or more of procedures in a day, which is longer than the typical outpatient surgery center is open and and one gastroenterologist in the Post story would have to work 26 hours, according to the committee time estimates, to accomplish what he gets done in a typical workday. Here's how it works: Medicare pays for a 15-minute colonoscopy as if it took 75 minutes resulting in a median salary for a gastroenterologist of $481,000. It is possible that in 1992, critics allow, when the price list was first developed, a colonoscopy actually took something close to 75 minute when doctors had to hunch over an eyepiece similar to that of a microscope for a look. But technology has advanced and now the images are processed and displayed on a large screen in high-definition video. Responding to criticism that the nation's method of valuing medical procedures misprices payments, a bipartisan group of legislators has drafted a bill that would reshape the way the nation pays doctors. The bill would require Medicare officials to collect data such as how much time doctors spend doing procedures and reducing the doctor payment for overvalued services. 'What started as an advisory group has taken on a life of its own,' says Tom Scully, who was Medicare chief during the George W. Bush Administration. 'The idea that $100 billion in federal spending is based on fixed prices that go through an industry trade association in a process that is not open to the public is pretty wild.'"

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[smittyoneeach]

Praise legacy data
Sad, racist H8ah
Or sweep it from chin
For cleanshaven win!
Burma Shave

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[MichaelDelving]

Get out the pitchforks and torches, antisocialists.

What is interesting to me is that private hospitals negotiate rates with medicare and insurers, but basically set their own rates for the uninsured. My limited knowledge on the topic is merely based upon the few articles that have achieved my attention, but medicare rates are apparently the most reality-based, since the federal government gets to collect and analyze more of the pertinent data than anyone else. The private insurers have some strength in numbers/volume, and have their own data, and get to negotiate a bit. The uninsured are basically screwed, and are asked to pay many times what is charged to the insured or medicaid patients.

Google chargemaster, if you are interested.

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[NatasRevol]

You don't need to google anything. Just talk to someone who doesn't have any or good health insurance.

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[bkaul01]

While it's true that doctors and hospitals set their own prices for the uninsured, that doesn't mean the uninsured are being screwed. In practice, it's often just the opposite: if you're paying directly, they'll give you a significant discount to not have to deal with the insurer. However, if they submit a claim to your insurer on your behalf, they can't give you that discount. I know a number of people who have encountered cash prices less than half what the insurer would be billed, from both dentists and doctors.

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[Gr8Apes]

The answer is "posted rates" much like car repair shops. All service providers have to post their rates, and that's the price for all. I know that puts a huge dent in insurers who like to negotiate back door deals, but it levels the playing field for all. Insurance and providers shouldn't mingle anyways, it an inherent conflict of interest.

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[ebno-10db]

I know a number of people who have encountered cash prices less than half what the insurer would be billed

Irrelevant, since what the insurer gets billed and what they pay have little to do with each other. People who think they're getting a great deal may still be paying more than the insurer would.

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[Anonymous Coward]

I guarantee you that you can negotiate with the hospital as a private individual. I have direct knowledge of talking a $65,000 bill into a $1,400 bill. Seeing such a thing happen with relative ease made me question what my own insurance coverage is really paying for. Should the same bill have come to me and my insurer, I'd have paid enormously more than $1400.

There are other problems with this issue though, and that's that the entire system basically forces billing to be done at ridiculous rates because it is the right move from a business perspective. If a hospital knows that an insurer is going to come back with a 'most favored nation' type argument -- ie that hospital X billed lower for the same procedure, or even the same hospital had billed lower for another patient -- the only reliable defense is to simply continue to increase the amount billed time over time.

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[sycodon]

And they should be hourly rates, set according to the education and certification of the Dr. Also, equipment should be charged at an hourly rate.

The opacity of actual costs is probably the most significant driver of increased costs.

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[jittles]

Get out the pitchforks and torches, antisocialists.

What is interesting to me is that private hospitals negotiate rates with medicare and insurers, but basically set their own rates for the uninsured. My limited knowledge on the topic is merely based upon the few articles that have achieved my attention, but medicare rates are apparently the most reality-based, since the federal government gets to collect and analyze more of the pertinent data than anyone else. The private insurers have some strength in numbers/volume, and have their own data, and get to negotiate a bit. The uninsured are basically screwed, and are asked to pay many times what is charged to the insured or medicaid patients.

Google chargemaster, if you are interested.

My understanding is that the doctors have no choice but to jack the rates up on the uninsured. The insurance companies force it. They want a discount over what uninsured patients pay. If they do not get the discount they want, they do not add the provider to their network. My source for this information? A doctor I see on a routine basis. I needed a piece of medical equipment that my doctor carried. My co-pay, with insurance, was over $500. When the doctor saw the co-pay, he sold it to me for his cost ($100). I've known this doctor for a number of years, know the names of his kids, his wife, etc. So when I asked him what the deal was with that, he was pretty straightforward with me.

I suspect that providers like hospitals often charge significantly higher rates to try and compensate for uninsured people who never pay their bills. But I could be wrong about that.

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[__aaltlg1547]

That's pretty much correct. It's generally acknowledged that Medicare and Medicaid pay the least, private insurers pay more and individual patients pay the most. But now the other shoe drops and it appears that Medicare and Medicaid are being cheated, private insurers are being cheated much more and individual patients are being robbed at scalpel-point.

This is LONG overdue and the data should definitely be shared with private insurers and everybody else.

We also need price transparency. Hospitals and doctors should have to reveal what they pay Medicare and other insurance for services, at least on average, to both individual consumers and insurers, on lists available to the public, and except in emergencies, they should be required to disclose all charges to the patient or the patient's representative before the services are rendered.

As long as we have private insurers and uninsured people, that's the only way we'll get a handle on medical costs.

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[__aaltlg1547]

And you don't see being billed $65,000 for $1400 worth of services as blatant fraud?

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[quantumghost]

The actual situation is very complex and is actually somewhat rooted in the free market system....

Some of the factors involved:

1. anti-trust laws and specific legislation prevent hospitals and doctors for sharing price information (aka Sherman Anti Trust Act)

2. The government demands a discount from hospitals for services.

3. The insurance companies, not to be outdone by Uncle Sam, also demand discounts. (8th paragraph )

4. Different geographic locations have different pricing indexes.

5. Local competition, despite #1 above, can influence prices

6. Different patients have wildly varying medical histories and co-morbidities.

7. Most complex cases (esp surgery and other procedural based care) fall into a class of billing called the DRG (diagnostic related group), which is kind of a set rate for a package of care....so if I take out your gallbladder and you leave in 1 day or 3, the hospital gets paid the same (see side note below)

Taken all together, the hospital is basically free to charge what ever they want....not that they ever get it.

Most insurance companies pay a "regionally adjusted payment", and that's what gets paid....with a few exceptions. Those without insurance, usually get some kind of compassionate coverage from Medicaid (state funded, not Medicare). Those who do not are often eligible for charity care where part or all of the bill is reduced. So why not just bill the uninsured a lower upfront cost? Rule #2. Uncle Sammy wants his discount

The interesting side story....patients who have an exceptionally difficult problem can fall into a group called the outliers (imaginative name, but better I suppose than the untouchables....). These are pts who fall outside of the DRG....as such the hospital may submit a bill for outlier payment. This is typically $0.10 on the dollar of hospital billing. Well that sucks for the hospital....but a less-than-scrupulous Mega-Health-Care-Corp came up with the idea of inflating their outlier billing to be 10x what they had been billing.....the end result is $ for $ reimbursement. This was all well and good for them, for a couple of years....then Uncle Sammy caught on.....10 years later and they still haven't gotten rid of the shit smell after the government came down on them and beat the living shit out of them financially and punitively.

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[Svenia]

As a student with no health insurance I know all too well the inflated costs of medical care for the uninsured. I'd love if I could get my wisdom teeth removed, but until I manage to scrape up enough pennies I'll just keep swallowing bottles of ibuprofen.

Regardless, it made me think of this article I saw a long time ago on the news. I dug it up, because it interested me at the time. I'm not sure how overblown it is, but in my experience with numerous doctors across the board (hospital or not) it really wouldn't surprise me at all if it was accurate. I understand some items are a bit sensationalized (I understand the hospital being at risk if they reused certain items as it states, but things like the up-pricing on gauze? Really?)

http://sandiegofreepress.org/2013/03/how-hospitals-mark-up-the-cost-of-over-the-counter-supplies-like-aspirin-and-q-tips-as-much-as-1000/

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[Svenia]

The lower cash price might also be due to the fact that the hospital knows if they charge average Bob who makes $13k a year at his minimum wage job $30k for a surgery they'll never see a dime. Charge him $1.3k and they'll see it eventually.

At least I suppose that would be their logic in that situation, since healthcare bills don't affect his credit (So they say, maybe a misconception? A common one I'm sure average Bob would believe even if it is) so he would have no incentive to care about an astronomical (to him) bill.

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[smittyoneeach]

Then talk to them after ObamaCare is fully inserted, and they lack any/good health insurance AND lack whatever cash they had!

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[Bengie]

The uninsured are basically screwed, and are asked to pay many times what is charged to the insured or medicaid patients.

There are ways around not having insurance. I was talking to an ER nurse who had been working in the ER for over 20 years. He said he sees people who come into the ER once per year, claiming to have a slew of issues. The ER is required by law to check them out, insurance or not.

The ER is also several times more expensive than someone scheduling a regular appointment. The nurse said so much money could be saved if these people could get a regular appointment than going through the ER, but because of no insurance, it's the only way.

Since these people don't have much money, the hospital eats the costs because they know they can't squeeze blood from a rock, and they raise the rates for everyone else who can pay.

Luckily our hospital system is one of the best in the nation/world, so people come from out of state or country to stop in for special treatments. The hospitals charge out-of-state people more than in-state, by quite a bit. This helps subsidize many of these in-state losses.

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[james_shoemaker]

oddly enough auto glass repair seems to be the opposite, I had to get some windows replaced and the cheapest quote I got was when I said I only had liability and was self-pay.

James

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[IronOxen]

Unfortunately, if the insurance companies find out about that, they may no longer pay claims for the insured patients of those doctors. According to the doctors I know, they are not allowed to discount the bills for the uninsured. The insurance company enjoys a discounted rate and never pays the billed price yet they contractually bind Doctors to have to make more money treating an uninsured patient with the ability to pay than an insured one. Billing at a discount for an uninsured patient is considered breach of contract with the insurance companies. They won't need to do that much any more, our government just handed them exactly what they wanted. Everyone now has to pay insurance companies and they have control over everyone's care. Insurance companies are absolutely the only ones that will be getting any good out of Obamacare in the long run. It was a bad idea when republicans brought it up and just because insurance companies now endorse democratic candidates it is still a bad idea. I have exceptional insurance but I choose to pay $30k to see a specialist my insurance company didn't think I needed. I would pay 10 times that for what I have gotten. Being free to make my own health care decisions and allowing the doctors to treat as they see best for this particular situation rather than try to make everything fit into a billing code has ended up giving me much better outcome at a far cheaper price than the insurance company would have paid in the end. Insurance was making me suffer needlessly by tying the hands of good doctors. When I said i would pay cash, I got help in 6 months for something that has been maintained at a "good enough" level for which my insurance was billed over $200,000 just in prescription drugs since 2000. Yet, me putting $30k up front fixed the problem. I understand many people don't have the luxury of being able to afford to fix their own problems and they need a solution too but not one that makes us all get "good enough" care. I wasn't making it living paycheck to paycheck just 3 years ago myself but I worked very hard in spite of my illness to be able to afford treatment that didn't fit neatly on an insurance form.

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[pr0fessor]

My wife with insurance had a back injury. The easiest way to get me wound up and angry is to talk about sub par health care at ridiculous prices, 30k for a herniated disc after insurance not to mention therapy costs and the worthless injection treatments 5k each before they decided to do the surgery.

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[Sentrion]

I had a facility bill my insurance for over $30k for a procedure that took less than one hour. Insurance paid about $600.00. The facility tried to get me to pay the balance, offered me a "deal" to pay just 1/3, alleging that I owed the amount because while the physician was in-network they were not. I didn't pay them anything and now the statute of limitations has expired to collect on the bill. The system is designed to screw over anyone who is accustomed to paying full retail price, religious people who presume they should always pay their "debts" regardless of how they were incurred, for people who don't have access to information to help them decide what the fair market value should be, people who are afraid of tarnishing their credit reports, people who are afraid of debt collectors, and people who don't have time or money to fight, haggle, negotiate, or go to court. Naturally the system hits honest, hard working American families the hardest.

To argue that we have a free market for health care makes no sense when such a massive portion of spending is channeled through government programs. When the government is paying your bill then you don't act like a cash conscious consumer at a grocery store. Instead, you get what you need from whoever is providing it with no regard to cost. Such a system artificially skews what is perceived as fair market value.

If you want a free market for health care, then you have to eliminate the non-free market participants. If healthcare providers could only be paid what their patients could afford then you wouldn't have a system like we have today - a system where a patient walks into a hospital and leaves behind his life savings. Even the so-called "charity" hospitals won't perform services for your child until your 401k has evaporated. Yet people keep donating to charity hospitals and feel good about themselves when they are only lining the pockets of physicians and managers. If you really want to be charitable, donate directly to patients. They aren't hard to find.

As for the free market, as long as patients can come up with data to show what the "usual, customary, and reasonable" charges are for a common procedure, they could argue effectively in court that they are being overbilled. Since the median income for most families is near $50k for many parts of the country, no clinic or hospital could effectively argue that their medical procedures should cost a patient $40k for a year's worth of services (say for treatment of diabetes, heart disease, cancer, etc.).

Of course the natural outcome is that those with below median incomes might be left with inadequate healthcare, free market forces being what they are, and expensive conditions, like cancer, might not be successfully treated except for those with substantial assets to pay for them. In the end, everyone loses, except physicians, hospital administrators, medical debt collectors, and pharmaceutical execs. Medical care would function much like dental care does in this country. Oddly enough, this is where we are today, in spite of the millions of dollars raised for private medical charities, private for-profit insurance companies, and programs like medicaid, medicare, VA benefits, and other state and federal welfare and disability programs. The problem is this patchwork of half-fixes leaves wide open gaps to exploit. Every day there is a clinic shut down after a physician and his staff were caught fraudulently billing medicare, medicaid, or even private insurance, but there are rarely any convictions of doctors who have been fraudulently billing their patients directly. There are physicians who target individuals that they suspect of having deep pockets and try all sorts of scams to tramp them into a situation where they are receiving servies out-of-network, because once a patient is receiving services without the protection of their insurance contracts they can be billed at rates several orders of magnitude over what insurance or medicare will pay.

When insurance and medicare a

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[GodfatherofSoul]

Hello? 2009 called, it wants to tell you this was all discussed during the run-up to Obamacare.

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[Sentrion]

Except that they wrap the equipment and all related supplies into "kits". Once a kit is opened, often in anticipation of possible need but not actually used, the kit is now no longer "new" and cannot just be repackaged. Instead it is often sold to a recycler who will sterilize and repackage the kit, often for export to other countries. This is just one reason why a few hours in the ER can be billed for several thousand dollars. "Charity" hospitals are granted non-profit status when they take the lost revenue from unpaid bills and add it to your bill.

Now, if by law hospitals could only charge a fixed maximum price for each hour a patient is treated, then I guarantee they will find a reason why they do not need to continue the practice of "kitting" their medical supplies in this manner.

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[unitron]

I see it as the hospital trying to cover some of the bills on which they never collect.

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[Sentrion]

Problem is that such negotiations are highly dependent on the inviduals on the other end of the line and the policies set in place by their management. Hospitals, along with any other creditor of any debt, have the right to pursue whoever they wish for payment. They can choose to let one bill slide and pursue payment for a different bill from a patient who is known to own substantial assets that can be seized by a turn-over order in court if they don't pay willingly. There are also factors working behind the scenes. If the hospital or clinic is operating in the black with steadily increasing profits, they may not be as aggressive with debt collection. But if they are running into cash flow problems, they can be very aggressive, down to the point of suing patients who might otherwise qualify for charity care. Such abuses in medical billing and debt collection are well documented and frequently reported in news stories.

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[DexterIsADog]

No, "posted rates" may lower dollar expenditure, but will worsen patient care. What we really need is a rational, universal system of payment based on outcomes. Doctors, hospitals, other care facilities all do better when their patients do better.

In the places where this has been tried, it works quite well.

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[Spy Handler]

Get out the pitchforks and torches, antisocialists.

It's not even that socialism is at fault here. Socialized medicine where the gov't pays for everything exists in most of Europe, Japan and S. Korea, and their healthcare is vastly more efficient than ours in pretty much all categories except wait time. Their medical care costs less and is better (surgical success rates, screw-up percentage, median longevity, etc).

Our problem is that gov't decided to meddle in healthcare but not take complete responsibility for it, and at the same time the gov't is directed by special interests wanting to make most money for their groups (big Pharma, doctors' groups etc).

Before the government started meddling in healthcare (prior to WW2), there is no evidence that healthcare in the U.S. was any more expensive than other countries. In fact it was quite affordable. Read books written in this period, such as Tom Sawyer... healthcare was not a huge deal, ordinary people could pay for doctors visits out of their own pocket. Doctors made house calls when your kid got sick, and it wasn't just rich people doing it either.

We need a single-payer system if we're ever gonna have any kind of sane pricing for healthcare, and having the consumer of healthcare pay for it is the most logical choice because that brings market forces into play. And free market is the most efficient distribution of goods and services known to man. However in the current political climate (read: dominated by LIBERALS) this is impossible. So the second best alternative is socialized medicine where the gov't pays for everything. It's gonna be inefficient compared to a free market, but still better than the insanity we have currently. And who can honestly say Sweden has worse healthcare than U.S.?

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[superdave80]

What is interesting to me is that private hospitals negotiate rates with medicare and insurers, but basically set their own rates for the uninsured.

Which is why the first thing we SHOULD have done to reform health care is require every hospital and medical office to list the cost for every procedure that they offer and rates for stays. Then insurance can say they will pay up to X amount for a procedure or visit, and the patient can decide to go to a hospital that is at or below that amount, or chose to go to a higher quality hospital and pay the difference (if they are able).

Let's at least try to get the consumer somewhat involved in the pricing and cost of health care. As it stands right now, NOBODY knows how much anything costs...

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[sociocapitalist]

While it's true that doctors and hospitals set their own prices for the uninsured, that doesn't mean the uninsured are being screwed. In practice, it's often just the opposite: if you're paying directly, they'll give you a significant discount to not have to deal with the insurer. However, if they submit a claim to your insurer on your behalf, they can't give you that discount. I know a number of people who have encountered cash prices less than half what the insurer would be billed, from both dentists and doctors.

I remember reading an article (which I can't find at the moment) that there are three categories of prices for any given medical cost in the US:
  - the least expensive being what the US government pays (ie title 19)
  - the next least expensive being what the large insurers / MMOs pay after negotiations with the medical providers
  - the most expensive being the uninsured who are charged whatever the medical providers want to charge

The last being much more expensive than either of the first two.

I do note the word 'cash' in your statement - were there any records of the services provided or was this really under the table?

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[h4rr4r]

Be careful of that, infection can kill.

I would suggest you call dental schools in your area. A simple extraction can be done there pretty cheaply.

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[Dorianny]

Often it is the most successful monetary operations that have the most aggressive bill collection tactics. It stems from a management team full of MBA's that runs the hospital as if it were any other business and completely ignores that its primary mission should be peoples welfare rather than maximizing profits.

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[bluefoxlucid]

That's one takeaway.

The other is that we've gone from a $2 lens and a 75 minute procedure to an overpriced $3,000,000 machine and a 15 minute procedure and said, "it takes you 1/5 as much time so why aren't you charging 1/5 as much?" Ignoring the cost of equipment, of maintenance of equipment, and of the office time required to file and analyze collected information is going to be the next problem--i.e. when they cut the payments to match the time of performing the procedure as if that's the only expense that's changed, or at least as if other expenses haven't experienced a net-increase. Then people will cry that medicare is paying even less and private individuals are paying even more.

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[Svenia]

Been there, done that. I had it get very infected (it's amazing how quickly it occurs) and went to my dentist, he flushed it out and gave me a rinse for an ungodly amount of money. Since then they've fully erupted so for now they're not as likely to get an infection as far as I know, however they are still trying to adjust space wise and I'm severely concerned they'll crack my other teeth. Plus wisdom teeth are so much more likely to just rot especially when they're harder to reach in terms of how they're placed (mine are at the most bizarre angles).

Though the closest dental school to me is quite a ways away, it might be worth a phone call and a weekend stay at a hotel. Definitely good advice, thanks. =)

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[bluefoxlucid]

medicare rates are apparently the most reality-based, since the federal government gets to collect and analyze more of the pertinent data than anyone else.

Translation: "Socialism works, you capitalist pigs! Ha-HA! *raises sickle*"

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[AlphaWolf_HK]

I have a friend who runs a pediatric urgent care who tells me that his standard billing for insurance is $200 (or something close to that) and if he gets a patient who has no insurance they ask for the same price, but if the patient says they can't afford it (or balks at it) then they'll usually just easily negotiate down to $100 or something, and he says its no big deal to do so.

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[AlphaWolf_HK]

My dad had to get picked up by an ambulance once, and they were going to bill us $5,000 just for the ride. When it came down to collecting payment, they asked how much we could afford, and we had nothing at the time. They didn't even try to setup a payment plan, they basically just called it off - no report to a credit bureau or bill collections or anything.

It's entirely possible that in situations like that, trying to collect will cost more than actually collecting anything. The high cost is probably as a result of so many people not paying, so the ones who do pay (e.g. insurance companies, governments) have to subsidize.

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[__aaltlg1547]

That's one takeaway.

The other is that we've gone from a $2 lens and a 75 minute procedure to an overpriced $3,000,000 machine and a 15 minute procedure and said, "it takes you 1/5 as much time so why aren't you charging 1/5 as much?" Ignoring the cost of equipment, of maintenance of equipment, and of the office time required to file and analyze collected information is going to be the next problem--i.e. when they cut the payments to match the time of performing the procedure as if that's the only expense that's changed, or at least as if other expenses haven't experienced a net-increase. Then people will cry that medicare is paying even less and private individuals are paying even more.

An Olympus complete system costs $25,900.00. http://www.endoscope.com/End_List.asp?sub=Complete_G.I._Video_Systems

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[__aaltlg1547]

Would you see it that way if you took your car to the shop for a brake job and they did the work and then told you it cost $9000? Are you willing to pay $1,000,000 per year for tuition at a private college, that they only tell you about after your first term? Because some students, you know, are on scholarship or otherwise don't pay.

How about $125 for a hamburger?

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[__aaltlg1547]

It wouldn't hold up if I was on the jury unless the patient were not effectively under duress at the time they signed any paperwork and all of the charges were explicitly authorized in advance. No patient's initials by each charge == no evidence that the patient agreed to your rates. The jury I'm on will be setting the rates at something like the average amount *paid* by insurance, and if the hospital won't disclose that to the court, it's all free.

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[Gr8Apes]

just like car repair shops offer worse repairs? Or is it that the "worse" ones offer lower rates? My point is that Dr K charge you and me both the same posted rate, regardless of who we are or have as insurance. No more "in / out network" crap. That allows insurance companies to go the same route as car insurance for a whole host of issues/procedures. They will have to handle emergencies much as they do now. That levels the playing field for all. Surgeries will be the same - much as car repairs are the same. If hospital 'A' chooses gold plated tools, well, that's something you'll have to pay for, for non-emergency care, much like the dealer's body shop vs Bob's corner body and paint.

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[Gr8Apes]

That an assertion, not a fact. Right now, if you're not in network - you're getting charged double anyways, so what's your point?

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[vivian]

I don't think $451,000 is unreasonable pay for someone who has to look up diseased arses all day to help prevent their owners dying a horrible death - with the prospect of being sued into oblivion if you make a mistake? Sure it's s lot of money, and definitely on the high side, but I think I'd still rather be a programmer earning less than 1/4 of that compared to doing that job. You thik the goatse guy is bad? I reckon a day in the office looking over a proctologist's shoulder would make it look like kittens.

The tens of millions paid for company executives in charge of companies that take a nose dive and have to be bailed out by taxes? Now that's unreasonable.

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[bluefoxlucid]

Nice. That's about as much as it costs for scorpion sting medication that sells for $200 over the counter in Mexico.

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[unitron]

But if the brake shop was in the same situation as the hospitals, asking for $9000 wouldn't necessarily mean getting all of it, and they wouldn't be able to slap a mechanic's lien on the car to keep you from driving away, either.

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[DexterIsADog]

No, I think you missed my point. I don't care if Dr. K. charges the same for procedures A, B, C, D for me as he does for you, if he fails to address my actual problem, and improve my quality of life following treatment. If Dr. K. is instead paid on how well I do, he is then motivated to treat me for a better outcome, not for the procedures he can get away with billing, regardless of what he charges.

The whole point is that instead of doing procedures A, B, C, D for two patients, the doctor instead treats them as individuals and does procedures A, B, D for patient one, and A, B, C for patient two, and also orders a nurse to follow up patient one for meds compliance, because that patient is at risk.

We are not cars. We need the medical industry to stop treating us like we are.

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[HereIAmJH]

We need a single-payer system if we're ever gonna have any kind of sane pricing for healthcare, and having the consumer of healthcare pay for it is the most logical choice because that brings market forces into play. And free market is the most efficient distribution of goods and services known to man.

You seem to be confused by the terminology 'single-payer' and 'free market'. The only practical single payer is the federal government. Unless you're saying we set up a private company in a monopoly as the single payer. But that wouldn't be free market either and possibly the most idiotic solution.

And a free market isn't the most efficient method of distributing goods. It's efficiency is in profit margins. Example; suppose I open an ethanol processing plant and pay a premium to Nebraska corn farmers. The farmers choices are to sell at market prices to food manufacturers or at a premium to me, even if that means people starve. That is profit efficiency, not distribution efficiency.

Re: Praise Legacy Data

[gzuckier]

Not only that; if you have insurance you get the discount even if the insurance isn't paying and you are paying out of pocket.

Re: Praise Legacy Data

[gzuckier]

Post the rates, heck; if they are part of a group or based in a hospital, they likely don't have the faintest idea what is being charged for their services.

Re:Praise Legacy Data

[Gr8Apes]

That would follow - why would he give you a colonoscopy for a sinus infection? The point again, that you're diverting from is if we both have sinus infections, give the same description and have the same symptoms, then the treatment cost should be the same (ie, same procedures). If you instead have IBS, well, you have better have a different procedure than I, but it should cost the same as any other colonoscopy given to any other IBS sufferer. That's one thing that posted rates do. Another is to let you know what you're going to owe before going through the process.

Re:Praise Legacy Data

[Smokeybehr]

When I was in between insurance plans (and jobs) I paid cash for a doctor's appointment, and got a 25% discount, plus they changed what was done to a cheaper "procedure", so I paid even less. If the Federal Government got out of the business of providing healthcare, the overall quality would go up, and the cost would go down.

Re:Praise Legacy Data

[__aaltlg1547]

Does the hospital fail to collect 90% of its bills?

If the percentage is any less than that, then on that justification it's grossly overcharging.

If the percentage truly is that high, then obviously you'd be a chump to pay anything at all, since clearly you're not actually expected to.

Apparently not:
HCA made $1.69 billion last quarter on $8.5 of business. http://finance.yahoo.com/news/hca-reports-second-quarter-2013-121600685.html

And some of them always don't deal straight up:
http://finance.yahoo.com/news/whistleblower-suit-hospitals-defrauded-medicaid-005148370.html;_ylt=A2KJ3CdtGPtRKlQAjIWTmYlQ

Re:Praise Legacy Data

[DexterIsADog]

Colonoscopy for a sinus infection is a silly and frivolous example. A better example would be, two patients with sinus-related problems, but one is an infection and the other is some chronic condition. Whether the physician gets paid the same for the same procedures/tests on both patients is NOT incenting them to produce the BEST OUTCOME for each patient. Paying them based on how quickly and completely each case is resolved, and the wellness of the patient does improve outcomes.

Focusing on the amount paid for a procedure, any procedure the physician happens to throw at the patient is, at best, incomplete and ineffective. I don't know why you resist the idea that this is important, but that's your business.

Since you don't seem to get it, let's not continue this, it's pointless.

Re:Praise Legacy Data

[Gr8Apes]

I don't know why you resist posted rates. The benefits are obvious. You're making the assumption that a Doc will then perform inadequately because of rates. Diagnostic office visits already have a relatively fixed cost, why not post them? As for tests, the doc can order appropriate tests for each patient, all at posted rates. Posted rates don't affect your treatment, they do affect what you pay versus patient X with different or no insurance.

It's apparent you've never seen the galactic sized joke of a modern US hospital bill, especially if you get hold of a bill for an uninsured person versus the actual bill. It'd be hilarious, if it weren't so flagrantly wrong. I have, and the numbers are ridiculous. a more than 7 fold difference for a specific insurance over none, about 5 fold for a second insurance, and they'd be good sports and settle cash for about 60% of the original bill, still 4 times the best insurance rate. why such massive differences, if the hospital can make a profit at the lowest price point, why charge others 7 times that amount? That's gouging under the best of circumstances, and it charges the uninsured for... perhaps subsidizing the insured?

Posted rates prevent that, and it's the same arguments used against body repair shops and the auto industry decades ago. The addition to law preventing insurance from deciding what provider to go to also separated their interests and overall seems to have made a more competitive market. Isn't it time to pull the health insurance industry at least into the the 1980s?

Re:Praise Legacy Data

[DexterIsADog]

Your assumption that I've never seen a hospital bill is wrong, just like your stubborn insistence that posted rates are the answer, to the extent that you haven't even addressed my point on payment based on outcomes in what, 4 replies?

You don't even know *why* those bills look like that. I, however, *do* know why, and the answer can be found in a comparison with the music industry, in which I have considerable experience, along with health insurance, including working for providers, insurers, and recovery audit contractors. I leave it to you to educate yourself with that hint about the music industry.

Since you're not making any progress in this discussion, please feel free to have the last word with another post that misses the mark. I won't bother to read it.

Re:Praise Legacy Data

[Gr8Apes]

Your comment was universal care (I agree, but we don't have this and at this point probably never will as they couldn't pass it with a super majority in both houses) and payment based on outcomes. What does that mean? Heart attack patient goes in - dies - no payment? Lives, the hospital gets $50K? You gave nothing to discuss.

Re:Can we have a real story

[geirlk]

Speak for yourself, I find this interesting.

On the other hand, if you _really_ would like to see other stories on /., feel free to submit stories yourself. After all, that is how /. works.

Thanks,
The other 99% of /.

Re:Can we have a real story

[Anonymous Coward]

It is a joke. The story had been posted to Slashdot three times already.

Technology costs?

[JaySSSS]

So, it appears the article only talks about the time spent by the physician. I'm curious if the costs of the tools/technologies of these procedures have gone up, and how the doctors get paid for those (potentially) increased costs?

Re:Technology costs?

[Shoten]

So, it appears the article only talks about the time spent by the physician. I'm curious if the costs of the tools/technologies of these procedures have gone up, and how the doctors get paid for those (potentially) increased costs?

Well, that's another part of the problem, I would say. If one cost isn't getting addressed/monitored, and the way to try and offset it is to have another cost kept arbitrarily high in a way that does not reflect reality, then you're going to lose visibility into the real economics of it all and get undesired effects. Add in the fact that a trade association representing the vendors (in this case) is a major driver in the price determination process and the lack of transparency, and you increase the likelihood of undesired effects even further, and practically guarantee that anyone who looks upon the result will question it.

Re:Technology costs?

[gandhi_2]

We all know that medical procedures require no setup, cleanup, assistance, explanation, or double checking, and of course are only done by one single doctor and no staff. Biling and coding, technology costs and training, facility costs.... those don't count either.

Clock in, surgery, clock out.

Re:Technology costs?

[MightyYar]

Even the AMA says the times are distorted, but they emphasize that the relative times are pretty good. Meaning, for the most part, a procedure that takes twice as long as another is accurately recorded as so in the data. Medicare is generally not covering providers' costs, to the point where most unsubsidized hospitals in poor areas have closed and doctors have to limit the number of Medicare patients they take. It's pretty clear that, in aggregate, doctors aren't fleecing the system. As such, the absolute numbers are pretty much meaningless and it's the relative numbers that count. If a certain type of doctor feels screwed out of some money because they don't think the ratios are correct, then let them take it up with the AMA - why would we want to get involved?

Full disclosure: my wife is a doc.

Re:Technology costs?

[thaylin]

The bill is usually itemized and accounts for these things. We are talking specifically about how much time the doctor is working on the case of the patient. They are billing at a rate for only being able to do one of these things a day, but are able to do 26, so their pay, at the cost the tax payer, has ballooned.

Re:Technology costs?

[SJHillman]

Have you ever been to a hospital for any sort of procedure? The bill is broken down into about a billion items (including a line item for stuff like over the counter grade ibuprofen that you would expect to be free). They also happily charge anything you say or is said to you as a "consultation". All of that stuff is accounted for in addition to the fee for the procedure itself.

Re:Technology costs?

[PopeRatzo]

I'm curious if the costs of the tools/technologies of these procedures have gone up, and how the doctors get paid for those (potentially) increased costs?

The same way you and I pay for the tools/technologies that we use. We write them off on our income taxes, amortize them over a period of time, etc.

I don't know if you're old enough to remember when doctors actually lived in the communities they service, solidly in the middle class. They might have lived in the nicest house in the neighborhood, but they lived in the neighborhood.

Only recently has medicine been seen as some sort of path to the top 1%.

You want to worry about someone who's income has shrunk? Look at the industrial worker who's making less than half of what they did 30 years ago (adjusted for inflation) and half of what they did in 1990 not adjusted for inflation. Maybe the worker who's handling your food and getting $7.50/hr. I'm not saying that a doctor should be paid the same as a person flipping burgers, or that they are equally important, mind, but the two have been in divergent directions for a long time now and it's starting to come apart at the seams.

And, if you look around your doctor's office, count the number of "technologies" that are so significantly different from what they were 20 years ago. The real significant increase has come at the hospital/diagnostic/lab location, where it is paid for the same way that all corporations pay for high-end equipment: by amortizing and tax write-offs. If you can justify the simplest blood tests approaching $1000, you'll have to be pretty creative. Or are you counting the doctor's new boat and mistress as part of the "new tools/technologies"?

Re:Technology costs?

[Rich0]

Medicare is generally not covering providers' costs.

Like the aforementioned gastroenterologist making $460k/yr?

The whole healthcare system is incredibly messed up. You get pockets of near-bankruptcy mixed with pockets of largesse.

Perhaps the solution is to just reduce reimbursements every year until the medical school acceptance rate is 90%?

Re:Technology costs?

[0100010001010011]

- $460k/yr

How much of that goes to malpractice?
How much of that goes to med school loans, undergraduate loans, etc? CHEAP Med school in the US starts at $250k without interest.

Disclosure: Fiance is a doc.

Re:Technology costs?

[MightyYar]

Only recently has medicine been seen as some sort of path to the top 1%.

I don't know where you get your data. A typical new family medicine doc gets a decent low $100,000s salary and has enormous debts and malpractice insurance to pay off. A pediatrician gets even less. True, there are specialties where they make a lot of money, but this is not typical. A $2500/month payment on student loans puts a pretty big dent in your take-home, and you enter the work force in your 30s, so everyone else has an 8 or 10 year head start. The hours suck, and unless you are in something like radiology or psychiatry, you have to cover weekends and evenings somehow. You need to take continuing education credits and you need to pass re-certification exams on an ongoing basis. I would never become a doctor - I'd bet that, per hour, they make less than a school teacher.

Men are increasingly abandoning medicine for more lucrative financial jobs.

Full disclosure: my wife is one of those docs with a well-paying specialty.

Re:Technology costs?

[gandhi_2]

But medicare and medicaid don't' take into account anything BUT the payment tables.

YOUR bill is itemized, the government's bill isn't.

Re:Technology costs?

[MightyYar]

Like the aforementioned gastroenterologist making $460k/yr?

You are cherry picking a specialty. The average family practice doc starts at $120k or so and might top out near $200k if they are lucky. Pediatricians make less than that. That GI doc took extra years of residency, probably a fellowship, and has higher liability insurance. You can offer them less, and watch as Medicare patients wait in huge queues to get a endoscopy. In Canada, they make about the same amount, and they have socialized health care.

Re:Technology costs?

[thaylin]

Irrelevant who gets the itemized bill. The issue people are having is with the part that "with the fees based in part on how long it takes to complete each one." That is the actual hourly wage for the doctor, not setup, cleanup, assistance, explanation and double checking. That is a different part of the tables

Re:Technology costs?

[sammy baby]

First of all - werd. To just about all of this.

Secondly I want to add that it's not as if there is some other definitive source that the government can use to determine the appropriate reimbursement rate for procedures. Hospitals have something called a "chargemaster list," but the prices on those lists vary wildly from hospital to hospital. And most hospitals, when quizzed as to why the prices seem so out of whack, argue that it doesn't matter because consumers "rarely" ever pay those prices.

Steven Brill had an amazing article on this subject in Time magazine, but it's now behind a paywall. You can find it here: http://www.time.com/time/magazine/article/0,9171,2136864,00.html.

And the Washington Post has a brief discussion of the article here: http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/23/steven-brills-26000-word-health-care-story-in-one-sentence/

Re:Technology costs?

[Ded Bob]

Out of curiosity, what is the cost for malpractice insurance in Canada? The doctors may actually net more there. Sadly, the giant ACA had nothing, as far as I know, to reduce that cost to doctors which only gets passed to us.

Re:Technology costs?

[amram9999]

And this is why most US medical school students are going into Radiology, Anesthesiology, etc. and not Family Practice or Pediatrics. There's a shortage of primary care physicians, especially in rural areas. Seems as if it will keep getting worse.

Re:Technology costs?

[bzipitidoo]

It's pretty clear that, in aggregate, doctors aren't fleecing the system

I disagree. First, doctors are horrible at finance. Few trouble to manage their own money effectively. It's common for a doctor to be pulling down 6 figure pay, and yet be broke because he blows all his money on expensive cars, big houses, and trophy wives. They are even worse with their patients' money, going through that like the proverbial drunken sailor. They'll happily order unnecessary $2000 scans, "just in case", and to cover their asses and to get some use out of the really expensive equipment the practice should not have bought in the first place. They prescribe expensive brand name medication when a generic is available, and oft times is superior. An example is prescribing Crestor, instead of simvastatin or lovastatin. Even a generic may be the wrong approach, if patients have not tried other measures first, such as improving their diets and exercising. I realize there is a great deal of pressure on doctors from both Big Pharma and patients. We're really sold on the idea of magic pills that fix all our medical problems. Doesn't help that Big Pharma works the public over with all these ads. "Ask your doctor about ..." But rather than go with the flow, especially since it's more profitable, doctors have a duty to push back.

My own personal experience with this was thanks to an automobile accident. Had my parents with me, and they were both injured. My mother finished her hospitalization in a private place, where she had been sent for rehab. On the day they released her, they shoved a wheelchair at us, and shoved a form under her nose for her to sign. The form said that she promised to pay for the wheelchair herself should her insurance refuse. She didn't need the wheelchair, but at that time we were still just a little too credulous and inexperienced with medical profiteering. I protested that we could get a wheelchair from a friend who no longer needed his, but was ignored. I asked how much their wheelchair cost, and was told not to worry about it because insurance would cover it! I pointed out that the form they were insisting she sign suggested that there was a possibility insurance would not cover it, and so I ought to know what it cost. They replied that they didn't know but it was sure to be reasonable. Uh huh. Turned out that damned wheelchair cost $825, 4 to 6 times what it should have cost. That was hardly the only instance of profiteering.

You should read Bitter Pill (paywalled), and How Dentists Rip Us Off (pdf) if you are truly ignorant of the reckless and cavalier attitude the medical community has towards costs.

Re:Technology costs?

[MightyYar]

Yes, the salaries have finally started to rise, though, so it will probably correct itself.

Those specialties require more years in residency and fellowship, more board certifications, and have higher liability risk. Radiologists are petrified of being outsourced. Anesthesiologists are under constant battle with nursing unions to let nurses take on additional duties, and lawsuits are a big problem for them since they are involved in every surgery and almost all births. There are risks in most of these specialties that dissuade many.

Re:Technology costs?

[MightyYar]

My wife is a doc, so we've thought a lot about malpractice.

My opinion is that the doctors are at fault in large part. They could _easily_ band together and kill these lawsuits, but they have a very individualist spirit that harms them greatly. All it would take to kill the worst malpractice suits is for the AMA and local medical boards to start yanking licenses of docs found to be making unreasonable testimony. Many (most?) of the docs testifying are being paid by the plaintiff and do this as a substantial part of their living. Start reviewing expert testimony and punishing docs who are misleading juries. Set it all up to limit conflict-of-interest and keep it above board, and say bye-bye to most frivolous or false malpractice claims.

Honestly, they wouldn't even have to yank licenses... simply publish a hit list of docs that have been making misleading testimony and let the defendant use that as evidence to discredit the expert witness. They'd be constantly fending off defamation suits, but thems the breaks. Perhaps a little government help would work in that regard - pass a law that exempts the AMA from defamation in exchange for running such a program at no cost to the government and putting some kind of appeals process together.

As for Canadian malpractice, I only know that it is lower. I know that docs get reimbursed for their liability insurance to some degree, but I do not know if this is included in their salary figure. Certainly they pay a lot more in taxes than a US doc, so it's probably a wash.

Re:Technology costs?

[MightyYar]

I realize there is a great deal of pressure on doctors from both Big Pharma and patients

Most of the pressure they feel is time pressure and lawsuit pressure. Those extra tests are to cover their ass. We have the whole system set up to reward CYA and dissuade cost reduction, so it's hard to blame the doc for responding rationally to such incentives.

You should read Bitter Pill [time.com] (paywalled), and How Dentists Rip Us Off [go2dental.com] (pdf) if you are truly ignorant of the reckless and cavalier attitude the medical community has towards costs.

Again, this is the incentive system we have set up. If we only pay dentists a reasonable amount for x-rays, then we're going to get x-rays. And lots of 'em. They certainly aren't hard to justify, and the insurance company seems more than happy to pay for them. I have to assume that the insurance companies know about this, and that lots of x-rays are in fact cheaper than waiting for hidden cavities to cause a problem requiring anesthesia. I'm constantly fighting with my kids' dentist over x-rays. As for the piece you linked to, most of them were trying to sell him the Cadillac on the lot... not surprising given that he told them he had a blank check - again, incentives. For God's sake, don't tell someone you are buying from that you have an unlimited budget! Had he gone in there with the crappy dental HMO I have, they would have given him the $500 treatment.

Re:Technology costs?

[timeOday]

The average family practice doc starts at $120k or so and might top out near $200k if they are lucky.

Saw this on the local news a couple nights ago:

"A physician was hired in Roswell, a family physician, straight out of residency at a salary of $230,000 a year, which is sort of unheard of," said Montano.

That's Roswell, NM, where a nice 3-br home is $150K. Being a doctor seems to be the last "sure thing" in making big bucks, IF you get in. I think we need to focus on allowing/enabling more people to become doctors.

Re:Technology costs?

[MightyYar]

And fuck you if you think the AMA should get immunity for that. At that point, we'd damn well know it wasn't legitimate, but was a good reason to disband that corrupt organization as the criminal enterprise it really would be at that point.

Can we keep it civil? I clearly don't have all the answers, but I think my general idea is sound. You raise a good point - of course I agree that there is the potential for abuse here - which is why I think there should be some government involvement. An arbitration or appeal process is critical. Even without that, the AMA process would have to be transparent and above-board for this to work. Defamation suits from all of these crooked docs would be expensive, but just a fraction of what doctors currently pay in malpractice suits and settlements - so even without that immunity I think it would be a huge improvement.

Re:Technology costs?

[MightyYar]

Rural areas have to pay outsized salaries because, under normal circumstances, no one in their right mind would live in Roswell. The average starting salary is still around $120k, outliers included. In some crowded markets, pediatrics had dipped below $100k. I know a few docs that abandoned pediatrics in mid training because they weren't going to be able to make their loan payments after residency without stretching them to 20 years. At that point, why in the world are you wasting so much of your life on all this training?

Re:Technology costs?

[compro01]

Malpractice coverage is mostly provided by the Canadian Medical Protective Association. It's not really malpractice insurance like in the states, but they deal with providing legal services and paying settlements. Rather than premiums, they charge a annual membership fee, which is dependant on specialty and location (Doctors in Ontario and Quebec get different fees than the rest of Canada) and is massively variable. An office-practice family doctor in the RoC would pay $1,344/year, whereas an OB/GYN who does deliveries in Ontario is looking at $49,416/year.

You can look at their fee schedule here.

Re:Technology costs?

[bberens]

Sometimes you no one even says anything to you and it counts as a "consultation." Random doctor walks by and reads your chart in the hallway? Billable consultation. The best part about that Ibuprofen they charge for? Name brands like Tylenol give their products to the hospital for free as advertising. That's why they give you a Tylenol instead of Acetaminophen. There are associated costs to the hospital though: someone making sure there's no bad drug interactions for other stuff you're on and someone to carry it to you.

Re:Technology costs?

[geminidomino]

If you engage in a bunch of communist nonsense to devalue the work of doctors, people will stop becoming doctors for the money.

Fixed that for you. As a side effect, medical schools will have to decide between re-purposing themselves to underwater basket weaving or, just maybe, not costing a quarter of a mil.

This applies to anything. The cost of overhead doesn't pay itself.

I'm a miserable, cynical bastard at the best of times, but this ridiculous idea that money is the only reason anyone does anything is just sad.

All things aren't created equal. People who advocate that capitalism must apply to the care and ease of human suffering should be subject to having their organs harvested.

Re:Technology costs?

[bberens]

So if you had to live like you ONLY made $210k for the first year you could pay off your student loans in 1 year? Okay, okay, taxes.. 1 year and 4 months. Oh you went to a *good* school? Well then, it might take you 2, maybe even 3 years to pay off your student loans.

Re:Technology costs?

[bberens]

Most of the socialist countries I know of have a plethora of doctors while we here in the U.S. seem to be hurting for them in a lot of areas.

Re:Technology costs?

[dcw3]

So, what is the TCO of a colonoscopy. The WP argues "Medicare pays for a 15-minute colonoscopy as if it took 75 minutes". But they fail to account for all the costs of that visit. Mine (just last week) started with a 9:30 scheduled arrival, review of medical history, and checking to see that I followed the required preparation. I met with the Dr. at 10am, and was on the table about 15 mins later. I woke from the process around 11am, and was checked by the doctor again, and given the results, and out the door around 11:30. Was that 15 mins that the Post is complaining about fair? I don't think so.

Re:Technology costs?

[dcw3]

I'll agree with your assessment of doctors and the 1%. As for industrial workers, I'm very familiar with those who were overpaid assembly line drones for the UAW. I can give numerous examples, but here's just one. Back around '74, my girlfriends brother hired in at $25k to do assembly line labor, right out of high school. According to the "Inflation Calculator", that's over $118k in todays dollars, and doesn't even account for any overtime, weekend, or holiday labor, which was extremely generous...potentially triple pay. So, the comparison is more and apples & oranges, than even up.

Re:Technology costs?

[Sentrion]

For the most part though, most patients don't end up with bank breaking bills from the family doc, unless that doc tricks them into getting a minor procedure at "his" facility, which you are informed the day of or evening before is not at the same location as his regular office. Though the doc is in-network, it turns out "his" facility is not, and you are billed directly $30k for a procedure that most other providers perform in their standard examination rooms for $600, which is usually paid by insurance.

As for the "increasing" cost of equipment, if the extra hardware adds to the total cost of services, then the physicians need to go back to the old way of doing things. If operating my laptop were to cost more than a typewriter without saving me any time, and if all I needed was a word processor, then the logical step would be to just use a typewriter and not splurge on the laptop. There was a time when computers did cost a lot more but were not as powerful, and at that time people still chose to use word processing typewriters for this very reason. If medical care is more expensive because the technology costs too much, and people aren't even allowed to access care because of the exhorbitant cost, then maybe we need a new class of physicians who are trained on the manual way of doing things. Or we could move to a European style healthcare system, which would make much more sense.

Re:Technology costs?

[MightyYar]

If medical care is more expensive because the technology costs too much, and people aren't even allowed to access care because of the exhorbitant cost, then maybe we need a new class of physicians who are trained on the manual way of doing things.

Until people are more connected with the actual cost of care, there is no pressure to keep costs down in this way. Right now we depend on the government and the insurance companies to provide the cost pressure, which takes choice away from the consumer. For instance, during end of life care, people want "everything possible" done for their terminal loved one. If they are responsible for the costs associated with that decision, it usually changes quite quickly. Maybe dying comfortably and with dignity isn't such a bad option after all...

Or we could move to a European style healthcare system, which would make much more sense.

Which European system? There is the British system, which is mostly government run like our VA system, the French model which most resembles Medicare, and the Swiss model which most resembles Obamacare. Each have advantages and disadvantages, and now we have all three! Yay for efficiency! :)

Re:Technology costs?

[DexterIsADog]

AC above is correct, the CMS bills are itemized. I worked at a CMS Recovery Audit Contractor, and we used any excuse, any at all, to deny as much of the payments as possible to the providers post-care, in order to get a ~5% commission on the recovery.

Our manager overlord often said, "Let them keep making the same mistakes, I just want the money."

Re:Technology costs?

[Rich0]

Even a generic may be the wrong approach, if patients have not tried other measures first, such as improving their diets and exercising.

While I tend to be a minimalist when it comes to pills, what you say is often not the case. Any modern pill on the market has demonstrated outcomes. You can argue whether the $5 pill is better than the 30 cent pill, but the 30 cent pill is almost always FAR superior to leaving a condition untreated.

By all means tell the patient to diet and exercise. However, for many conditions it is better to start treating the condition immediately than to play games for a year or two before taking care of the problem. By all means tell the patient to check their BP or do follow-up tests every six months and reduce medication if the patient manages to get things under control on their own.

I've talked to several diabetics now who report having had problems because doctors have taken their sweet time getting things under control. It should probably be considered malpractice to not request weekly appointments (phone, email, in-person, whatever) with any diabetic whose condition is not completely under control. Somebody I know required years to get things under control because they basically met with an endocrinologist quarterly who just tweaked their meds a little at a time while their A1Cs were >10 the whole time - they had a BUNCH of serious complications, and I can assure you that those complications cost FAR more to treat than office visits would.

I do think that diet/etc can be more effective, but it doesn't work out for everybody, and delaying effective treatment costs EVERYBODY more. I think drugs are too often viewed as a last resort.

Now, I say this mainly because your main example was a statin, which have pretty good outcome data. Blood pressure would be another area where weight has a big impact as do drugs. Diabetes is of course another which I brought up. I'll be the first to admit that not all drugs have such solid data backing them, and I'm not a fan of having people pay to basically be test subjects.

Re:Technology costs?

[PopeRatzo]

Remember, a beginning assembly-line worker today is working full time and is still below the poverty line.

Nobody who works full time at any job should be below the poverty line, especially when corporate profits are at all time highs and CEO salaries have gone up 40 just in the past 2 years.

At some point, the increasing concentration of wealth become unsustainable. We've probably already passed that point, which is why we're seeing the increased militarization of local police forces. They're well aware of what happens when the social contract breaks down.

Re:Technology costs?

[PopeRatzo]

Don't forget, almost all new workers are saddled with similar student debt, and they don't have the $120,000/yr average starting salary straight out of school.

And malpractice insurance is a cost of doing business. The premiums are high, but nowhere near a level that accounts for the high price of basic medical care. The average cost of malpractice insurance premiums for an internal medicine doctor is $4000/yr. I'll bet your average doctor has a dry-cleaning bill higher than that. His wristwatch probably cost more than that.

A surgeon has higher average malpractice insurance costs (about $10k/yr) but even so, that's about the same as his lease payment on his Mercedes S-Class.

The notion that malpractice costs are what's driving the price of health care is a canard. It's just not so.

Re:Technology costs?

[airdweller]

"If you engage in a bunch of communist nonsense to devalue the work of doctors, people will stop becoming doctors."

Just like nobody in those "communist" countries would become doctors? Please think before posting. Not everyone becomes a doctor just for the monetary profit. Not even in the US.

Re:Technology costs?

[MightyYar]

Don't forget, almost all new workers are saddled with similar student debt, and they don't have the $120,000/yr average starting salary straight out of school.

First of all, no they are not. The medical school debt positively dwarfs the undergrad debt, which still exists and has been accumulating interest as principal for 7 years or so. Second, the person who is fresh out of school has a 7 year head-start on earnings.

And malpractice insurance is a cost of doing business.

Malpractice varies a lot by location. In some places and some specialties, it can be a deal-breaker. Many OB programs are fleeing the state of PA, for instance. The cost for internal medicine is between $6k and $11k in PA. That is probably 5-10% of an entry-level salary! Some quick math:
$120k salary
- 10k malpractice insurance
- 35% tax rate
- $2500 student loan payment/month
-------
41,500 take home pay

Now don't get me wrong, lots of people would love to have that kind of take-home pay. And in 10 years the salary will be much higher and the student loans paid off. But if you are the typical young MD with a new family, much of that take-home will go away with child care costs, and you still need to live somewhere and drive something. You are also 10 years behind your peers on retirement savings, so you need to put some away for that. You are not starving, that is for sure, but you sure don't understand where people get off calling you rich, either.

The notion that malpractice costs are what's driving the price of health care is a canard. It's just not so.

While I certainly agree that the raw malpractice premiums are not a large fraction of health care costs, the cloud of malpractice makes doctors practice very, very conservative and defensive medicine. Thousands of dollars worth of tests are run to rule every possible thing out, all because the doctors are petrified of lawsuits.

Re:Technology costs?

[MightyYar]

You want to give the AMA immunity from defamation, but you can't stand a little salty language? Right.

I'm still chatting with you, aren't I? You seem hung up on my suggestion that immunity be granted. Honestly, it's not that important of a detail so forget about it if it bothers you.

Your idea isn't sound, it's utter nonsense, it's not a potential for abuse, it's an outright prescription for it.

I hate to break it to you, but doctors are self-regulating right now. I'm not introducing a radical new vector for abuse. I want to maintain the patient's right to sue while also cracking down on the lottery atmosphere of medical malpractice. Medicine is NOT an exact science, human error and mistakes happen. I think there needs to be a penalty for mistakes so that people should take pains not to make them, but it also shouldn't be a career ending experience. Doctors have gotten ridiculously conservative, and we all pay for it. You seem to think that there is no malpractice problem, in which case our disagreement lay way further down the tree.

I have another, much more government-heavy scheme as well, but you probably won't like that, either, because it would also put the "expert witness" scammers out of business.

Re:Technology costs?

[Anonymous Coward]

Were you charged a rate that would reflect a doctor hovering over you the entire time? That's one thing that I've noticed: you're charged the full doctor's rate for every minute that you sit in an examination room, even if you sit there for an hour and they spend three minutes with you.

Re:Technology costs?

[chihowa]

If you engage in a bunch of communist nonsense to devalue the work of doctors, people will stop becoming doctors for the money.

Yeah, my father is a professor at a medical school and he's been watching the decline of the quality of student for a while. While the students do well enough in the classes and are all extremely competitive, he says that he sees fewer students every year that have a real passion for medicine. The thing that really seems to pique their interest is any discussion of how much money they'll be making.

It seems to me that an interest in medicine, let alone a real passion for it, is not even remotely a qualification for becoming a doctor. In fact, many of the truly passionate applicants are previous nurses, EMTs, and the likes and they're often not competitive enough (on paper) to get in to med school.

Re:Technology costs?

[dcw3]

I don't know how they're doing today, though I would expect that unskilled labor would pay at or near minimum wage. What minimum wage should be is another topic, and should be related to local cost of living, and other factors.

As for full-time jobs at the poverty line, I'd argue that we should have at least two tiers of jobs. One would include kids who have summer jobs...remember when flipping burgers wasn't expected to pay a living wage?...now there's a strike on against McDonalds over this. And the other is where I'd generally be in agreement with your comment.

Not gonna bite on the police comment...we could go on for a long time there.

Re:Technology costs?

[PopeRatzo]

Flipping burgers ain't a summer job any more. Neither is driving a cab, doing lawn work or picking strawberries.

They are jobs that are being done by people with families.

And I didn't say "at the poverty line", I said, "below the poverty line". If you work at a full-time, permanent job, you should be able to live without having to go on government assistance. Places like Wal-Mart expect their employees to go on food stamps, etc. They're using taxpayer money to supplement their payroll.

Re:Technology costs?

[PopeRatzo]

You find me a doctor that's actually paying a 35% tax rate on their $120,000 income and we can continue this.

Plus, the malpractice premiums are dedcutible.

Re:Technology costs?

[MightyYar]

I did the math with the malpractice subtracted out.

Doctors are not Wall Street types - they mostly take a salary, and it is taxable. They often hit the AMT as well. In any event, the tax rate isn't really important, is it? And I think it is close enough, depending on what state you are in. I'm using the tax rate my wife and I pay based on my state. I didn't include the local tax, or it would actually be higher.

The point is, a doctor is not a 1%er unless you start talking about the specialties. I know plenty of doctors - some of them live like kings, but most are simply comfortable and work CRAZY hours that probably put them below school teachers in per-hour compensation, especially school teachers that are 7-10 years into their pay scale. I'm not picking on school teachers, but I am pretty familiar with their compensation in our areas since my brother and sister in law are school teachers, and most people don't consider them over-compensated.

The medical occupation I would choose? Hands down, CRNA. Certified Registered Nurse Anesthetist. Really good salary - better than an internal medicine doctor - but much less effort to get there. You have to do a stint in the ICU, but that's no worse than residency and your pay will be better with much lower student loan payments.

Re:Technology costs?

[PopeRatzo]

But remember, doctors do get to write off that mortgage on a house or two, the car is a business expense, etc.

Even if after the school loans and the insurance and taxes that $120,000 comes to $60,000, it puts them in the upper tenth of all US workers.

And that $120,000/yr is just the average starting salary. Don't waste your time holding any fundraisers for doctors just yet, OK?

Re:Technology costs?

[Duhavid]

There is a good point there, but if doctors don't have to worry, some will act recklessly ( some already do, more will ), and patient's recourse will be removed.

Re:Technology costs?

[MightyYar]

Even if after the school loans and the insurance and taxes that $120,000 comes to $60,000, it puts them in the upper tenth of all US workers.

Well, I'm certainly glad to see I've talked you down by an order of magnitude.

Re:Technology costs?

[HereIAmJH]

How much of that goes to malpractice?

None of it? Wouldn't said doctor incorporate his practice so that he could deduct business expenses, such as insurance coverage, before paying his salary that will include tax obligations?

Re:Technology costs?

[Ded Bob]

Thank you. That is interesting. I did find something similar for New York (2007) that varied quite a bit depending upon location. https://www.univerahealthcare.com/download/files/med_malpractice_premiums.pdf

9k for 5 minutes

[Anonymous Coward]

A torn meniscus repair takes 5 minutes and costs $9000. Wish I made that kind of money. OK. So the cost was broken down into 3 ~$2500 procedures and the balance was assorted stuff like anaesthesia and bandaids. But still, 5 minutes of time for $7500 in doctor pay of which the assisting nurse will $3.50.

Re:9k for 5 minutes

[godrik]

There is indeed a ridiculous overcharge on all the medical profession. The number of times I went to the doctor and saw him/her for less than five minute, while still having me charged more than $100 is uncountable.

I really feel that doctors are running a nationwide blackmailing operations on the country.

Gak

[Impy the Impiuos Imp]

"Cut Medicare spending? Why do they want old people to die? Our seniors have earned this?"

Just wait for it.

It's only tens of billions of other peoples' dollars a year. Why bother checking up vs. what insurance companies pay, who have incentive to not be wasteful?

Re:Gak

[nitehawk214]

"Cut Medicare spending? Why do they want old people to die? Our seniors have earned this?"

Just wait for it.

It's only tens of billions of other peoples' dollars a year. Why bother checking up vs. what insurance companies pay, who have incentive to not be wasteful?

Not surprising. This is from the "keep the government out of my medicare" people. They rail at people that are on welfare, but staunchly defend medicare and social security. Maybe some social programs are wasteful, maybe some are necessary. But when you have an obvious bias in that one of the programs is giving you money; surely even people this stupid can see the hypocrisy here?

Re:Gak

[nitehawk214]

Replying to myself, but another thought: "Maybe some social programs are wasteful, maybe some are necessary." The issue here is that most of them are both. I don't know what the solution here is, but the polarizing nature of it means that no matter what we do, nobody is going to be happy about it.

Taking it up the colonoscopy

[Mike_Shane]

Sorry no information in this comment I'm just throwing out there that in my opinion since insurance companies are increasingly becoming the payors for services rather than individuals it seems stories like this are becoming more prevalent. I mean, and I stand to be corrected it seems that the medicare system now has a "watchdog/whistleblower" vis a vis the insurance companies. It appears to me insurance companies don't like to pay the costs it used to be OK for the average joe to mortgage their house/ruin their future for.

So what. Doctors SHOULD be paid more.

[blahbooboo]

You know I am sick and tired of everyone blaming doctors for the cost of healthcare in the US. When in fact, doctors salaries are a miniscule portion of US healthcare, especially compared to drugs and device costs and hospital CEO pay! Doctors should be paid MORE. Yes I said it, more! What other profession do you study at least 12 years before you make a decent salary, take on at least $250k in school loans, and work 12 hour days for your entire career?

Yes doctors make good money but it's far less than other folks in the US make who are far less deserving. How about addressing the seriously disgusting salaries on wall street? Should a computer nerd working in Morgan's computer risk group really be making $500k which is FAR more than the majority of doctors? What about the asshole investment bankers making millions at Goldman figuring out new ways to screw every US citizen out of a couple of pennies. Meanwhile the doctor is someone who makes you feel better and often will save your life.

p.s. I am not a doctor. I just work with a lot of them and see how hard a life they have nowadays.

Re:So what. Doctors SHOULD be paid more.

[Draknor]

I work in the healthcare IT field (formerly at an IT vendor). The reality is -- health care organizations are becoming IT shops. And that's expensive. Big iron servers, expensive SAN storage, workstations in every clinic office / nursing unit, and certified trained staff to run it all... It adds up.

There's definitely some research that suggests it results in better care -- warnings for med interactions, doing the right procedure on the right patient, etc. But it's really being driven in the name of compliance (and CYA). Document & audit trail EVERYTHING, so you can justify the charges if Medicare comes knocking for an audit. Or in case there's a lawsuit. It's complicated, and expensive. And Medicare (and the insurance companies) just make it more complicated & expensive by increasing complexity of the billing rules.

Re:So what. Doctors SHOULD be paid more.

[thaylin]

So what you are saying is we should allow doctors pay to continue growing exponentially, on the governments dime? If it wasnt for medicare/medicaide and other insurances doctors would not make what they do now.

Re:So what. Doctors SHOULD be paid more.

[lightknight]

Hey, hey, you, get back in line. We need you to express jealousy of another's wages as some form of moral righteousness, not try to reason why one person might be paid more than another. ;-)

You're arguing about how people value each other's work, and that's an entirely subjective phenomenon. And let's be honest, programmers are getting paid poorly these days, with other fields (doctors, lawyers, engineers, etc.) coming under the knife. They want the doctors to be replaced with nurses to cut costs...and the lawyers? Maybe some clerks or paralegals will do them in. Oh, but engineers? Well, it's hard to replace an engineer...so they're just outright attacking their wages / salaries. I tell you, gaze upon what has happened to programmers, and you will see what is coming down the pike for the others...

Re:So what. Doctors SHOULD be paid more.

[thaylin]

This is not subjective, and we are not talking about how someone values someone elses work. We are talking about specifically manipulating the data to make more money. IF you went to a mechanic and he told you he was going to charge you $70 a hour for work and it would take 8 hours to do the work, but then gave you the car back in 1 hour would you still be willing to pay for the 8 hours?

Re:So what. Doctors SHOULD be paid more.

[NicBenjamin]

Lawyers study as long as Doctors, get as many loans, and make less. Most Law School grads make under $50k. Vets are worse. It's harder to get into vet school then MedSchool, the coursework is harder (you have to know medical care for multiple organisms), the loans just as bad, and $50k is a really good salary for a Vet. Hell do you think ANY humanities PhD is ever gonna pay off his student loans?

I would have a lot more sympathy for American Doctors if their foreign counterparts didn't make do with a much less pay. Luxembourg is an incredibly expensive country to live in, yet their Doctors make 30% less then our doctors. Yeah we overpay our MBAs, and MPHs, but it's very hard for me to sympathize with a guy who does the exact same job as a Doctor from Winnipeg for $40,000 more and complains he isn't paid enough.

Re:So what. Doctors SHOULD be paid more.

[Anonymous Coward]

Nurses and primary care physicians should make more, specialists should make less. I've seen enough specialists work to know that they are not pulling 12 hour days. Although, I'm sure they did when they were training. Don't get me wrong, there should be a strong incentive. I expect them to make more than my engineering salary. But its out of balance, and we are the ones paying.

The Wall Street issue is a completely separate problem, and has nothing to do with this.

Re:So what. Doctors SHOULD be paid more.

[h4rr4r]

Bullshit. The simple fact is that tort reform does not lower costs, look at Texas to see this. What it does do is mean that you can be crippled by a doctor, forever unable to work and get less than he makes in a year out of it.

If you want to make that kind of money you have to be willing to take some risk. Tort reform is simply the doctors privatizing the profits and socializing the losses when they fuck up. This is because once those meager limited payouts runout we as a society have another person to pay for on disability.

Re:So what. Doctors SHOULD be paid more.

[thaylin]

Except that is itemized on lines other than the actual physicians time, which is the line item this is talking about.

Re:So what. Doctors SHOULD be paid more.

[SJHillman]

I'm also in IT in a healthcare facility. Our department has exploded in the last five years and IT staff has gone from one person ten years ago to nine people now. Likewise, our server rooms were getting packed to capacity before we started migrating everything possible to VMs within the past year. It's amazing the record keeping we're required to keep (by the state) for auditing... backup jobs, server updates, software updates, etc. I spend an average of five to ten hours each week just documenting crap that we might need for an audit. Working on getting some of that automated, but that takes back seat to other projects we need to do to stay in compliance.

And this is the same state that owes us six figures in back pay for medicare.

Re:So what. Doctors SHOULD be paid more.

[blahbooboo]

Lawyers study as long as Doctors, get as many loans, and make less. Most Law School grads make under $50k. Vets are worse. It's harder to get into vet school then MedSchool, the coursework is harder (you have to know medical care for multiple organisms), the loans just as bad, and $50k is a really good salary for a Vet. Hell do you think ANY humanities PhD is ever gonna pay off his student loans?

I would have a lot more sympathy for American Doctors if their foreign counterparts didn't make do with a much less pay. Luxembourg is an incredibly expensive country to live in, yet their Doctors make 30% less then our doctors. Yeah we overpay our MBAs, and MPHs, but it's very hard for me to sympathize with a guy who does the exact same job as a Doctor from Winnipeg for $40,000 more and complains he isn't paid enough.

I disagree as your facts appear to be incorrect.

1. Lawyers have 3 years of school and no residency. Doctors have 4 year schooling, 4 years of residency, and more residency if they specialize. Cardiologists often don't finish training until their mid-30s. I don't follow how you say they study "as long"? They aren't even close to similar.

2. You're not comparing properly. In Canada med schools are far less than the US ones. About 1/3 less according to the article. Thus, the society subsidizes some of the costs of their training. So they don't have large loans with interest to pay off which enables them to be paid less...
http://oncampus.macleans.ca/education/2011/06/01/should-med-school-be-free-in-canada/

Re:So what. Doctors SHOULD be paid more.

[stenvar]

You know I am sick and tired of everyone blaming doctors for the cost of healthcare in the US. When in fact, doctors salaries are a miniscule portion of US healthcare, especially compared to drugs and device costs and hospital CEO pay! Doctors should be paid MORE

Everybody makes these arguments: "we should be paying more for drugs, they save so much money on doctors", "we should be paying more for CEOs, they can save so much money", etc. The problem is: nobody knows how much any of these "should" be paid, and if you leave this to committees and planners to decide, costs spiral out of control. The only way to have people paid what they "should" be paid is to have a fairly free and unregulated market.

Re:So what. Doctors SHOULD be paid more.

[stenvar]

I work in the healthcare IT field (formerly at an IT vendor). The reality is -- health care organizations are becoming IT shops.

The reality is also that all that IT contributes little to day-to-day healthcare.

Re:So what. Doctors SHOULD be paid more.

[blahbooboo]

No, I do not. If you read my comment the first sentence addresses this...

Re:So what. Doctors SHOULD be paid more.

[SJHillman]

Specialist vs generalist is supply and demand. Specialists in any field cover a niche. If I have an issue with my Exchange server that no one on the IT team can figure out, I call in a specialist. He might charge twice what it would cost for the IT team to figure it out, but he can solve the problem much faster and give more confidence in his solution - which is exactly why he can charge more.

Re:So what. Doctors SHOULD be paid more.

[ebno-10db]

Doctors should be paid MORE. Yes I said it, more!

Depends on the doctor. Primaries aren't getting rich, but some specialists are. That explains why we have too many specialists and not enough primaries. I don't buy that most specialties are all that much more difficult than being a primary. As per the article median gastroenterologist income is $481k. IIRC that's 2.5x what a primary makes. Moreover, income often has little to do with the difficulty of a specialty. Radiologists are amongst the highest paid, not because it's so difficult, but because you can flip through scans pretty quickly and charge for each one. The actual scans are done by techs.

The ratio of specialist to primary pay is largely controlled by the AMA's "advisory" committee, so they are very much a part of this. The AMA has long had a pro-specialist bias.

How about addressing the seriously disgusting salaries on wall street?

Does getting ripped off by one group mean we shouldn't also worry about getting ripped off by another group?

Should a computer nerd working in Morgan's computer risk group really be making $500k which is FAR more than the majority of doctors?

It's not the computer nerds making $500k/yr.

Re:So what. Doctors SHOULD be paid more.

[SJHillman]

Then why do nurses and doctors bitch so much if the servers have so much as a hiccup? They spend more time on various software programs than they do with actual patients.

Re:So what. Doctors SHOULD be paid more.

[thaylin]

No, it assumes the tools, and use of the tools (even though in a doctors visit everything is itemized including the tool usage). I have worked for a garage, my mother still does. At $70 an hour the mechanic gets 20-35 (more or less) and the rest goes to the shop for the tools use, bay use and profit. If you are paying 8 hours work but getting 1 hour of actual work, you are being ripped off.

Re:So what. Doctors SHOULD be paid more.

[Rich0]

You know I am sick and tired of everyone blaming doctors for the cost of healthcare in the US. When in fact, doctors salaries are a miniscule portion of US healthcare, especially compared to drugs and device costs and hospital CEO pay!

Well, looking at this graph, which I'd say looks like most I've seen, for every dollar that gets spent on drugs, two dollars get spent on doctors. In most cases it is the drug that actually has the health benefit, and the doctor just figures out which one is the most appropriate one to prescribe. I'm not sure where this particular breakdown stuck devices - often they're treated as drugs (they're certainly regulated in a similar fashion).

Now, there are certainly plenty of ways to make drugs cheaper, but you can't really pick any part of the US healthcare system and say "hey, this one part is fine - just make everything else cheaper."

As far as schooling/etc goes - the cost of medical school certainly is higher, but that is simply because that is what the market will bear. No idiot is going to spend $250k to get a PhD in Biochemistry, because Biochemists get paid peanuts (despite the fact that they invent half of those drugs, devices, and procedures the doctors end up using).

The whole 12-hour-day thing is a culture thing - there is no need to have doctors working those kinds of hours. Just educate more of them, and have them work more reasonable shifts. If anything those hours probably chase off many who would otherwise want to work in the profession (something the AMA probably counts on). Medical school selects for workaholics and it shouldn't be surprising that workaholics like to work. It isn't some kind of virtue. There is certainly a need for continuity of care which isn't always conducive to a 9-5 M-F schedule, but if individual doctors took on fewer patients they could still give the ones they take better care while spending less time doing it.

Lots of people work hard. Few get paid the kinds of salaries doctors collect.

As far as investment bankers making $500k goes - that is nuts as well. However, you can't point to the 0.001% of workers who make such insane salaries as justification. How about looking at the average US salary of full-time PhD holders of $80k/yr?

Re:So what. Doctors SHOULD be paid more.

[c]

Doctors should be paid MORE. Yes I said it, more!

Whether they should make more or less isn't quite the issue at hand.

The real problem is that there's essentially no sane way to understand health care costs.

You say doctors work 12-hour days? Well, what if Medicare says some are billing for 26-hour days, and a hospital maybe says they're only spending 6 hours in surgery (that's a wild guess)? So, what's their hourly wage? How much of it goes to medicine, and how much of it is administrative busy-work? Can it be made more efficient? How?

If we haven't really got a clue how much doctors are being paid for the work they're actually doing (versus, say, the base costs needed to run their practices, hospitals, etc), then how in the hell can someone come up with a rational argument about whether or not they need to be paid more or less? And the same point applies to virtually every aspect of health care. Drugs, medical procedures, hospital costs versus billing, lab costs, technology costs, nursing staff, admin workers... you name it, and there's virtually no well-understood relationship between what it costs and how patients pay for it.

That's the real problem. Not how much doctors are paid, but the fact that health care is basically a big fucked up black box which nobody really understands how it works or how to make any part of it better.

Re:So what. Doctors SHOULD be paid more.

[ebno-10db]

ObamaCare fueled a huge wave of consolidation in the health care industry.

ObamaCare aka the Great Bogeyman. It's barely started to take effect and yet you're saying it "fueled a huge wave of consolidation in the health care industry" (note past tense). Next it'll be blamed for natural disasters.

Re:So what. Doctors SHOULD be paid more.

[fermion]

I know a lot of people who study 10-12 years and make, make 30-50K for years afterwords, and if they are luck they can get into 100-150K by the time they middle aged. I don't know that anyone deserves money more than anyone else, particularly doctors. After all most doctors haven't actually generated new knowledge or created an innovative solution. Yes, a few like Michael E Debakey are more than technicians, but if we are honest are just highly skilled technicians, not trained in high level skills o research, development, or engineering.

I would agree that we have a shortage in primary care physicians, so they should be paid more.

Yes, c-level executives are paid a lot, but I think they would argue, just like doctors, that the excessive pay is justified because they make sure that everyone else gets paid. The question is does the family of a person in the fast food industry deserve to poor just because they could not get accepted to medical school. Does a person who completes medical school automatically deserve to be in the top 1%?

From an objective economic perspective, most doctors make too much money because we have too many of them. As mentioned, GPs may make too little money because we have too few of them. It could also be that the system of medical school in the US has distorted the pay and expectations of the medical community. Since the 1960's, the restrictions based on race and gender have been removed, yet the number of slots in medical school and residency have not been significantly increased. White males are still overrepresented.

Re:So what. Doctors SHOULD be paid more.

[sribe]

Then why do nurses and doctors bitch so much if the servers have so much as a hiccup? They spend more time on various software programs than they do with actual patients.

Just because they don't like being held up by being unable to do the things they are required to do with those systems, does NOT mean those things contribute in any way at all the care of patients.

Re:So what. Doctors SHOULD be paid more.

[ebno-10db]

Specialist vs generalist is supply and demand.

If it was supply and demand the AMA wouldn't need a committee to set prices. This is about a guild, not a competitive market.

Re:So what. Doctors SHOULD be paid more.

[Kingkaid]

They do not deserve to be paid more. Did you know in France doctors are paid significantly less, and they have more doctors per patient than the US? Part of the reason why the costs are so high for med school is because the doctors can afford to pay it, justified with the "well I will make it back in a few years".

Re:So what. Doctors SHOULD be paid more.

[ebno-10db]

Good points, but I think you meant to say Canadian med schools are about 1/3 the cost of American ones (39% actually), not 1/3 less. That makes your point even more strongly. Specifically $15k/yr vs. $38k/yr. Wow.

Re:So what. Doctors SHOULD be paid more.

[NicBenjamin]

You do realize that residents get paid? And they get paid MORE then most bunny lawyers, all vets, or humanities PhDs? And that very few PhDs make it through in three years?

So your Doctor has the same amount of schooling our vet or humanities PhD does, then he makes $40-60k for four years, during which time our vet and humanities PhD is making $40-50k. So he's probably made $20k more during his residency then our vets and humanities PhDs. Law-school is three years, but many bunny lawyers do not get legal jobs. Most of them are making $45k, which is again $20k less then the resident. Then this continues for our various PhDs/Vets/ and Lawyers but our Doctor gets a six-figure raise.

Now our Doctor has a 30-year career, making $100k more then any of the others. That's a $3 Million salary premium. If you offered me $3 Million on the condition I pay off a $250k loan I'd take that deal.

The thing you have to keep in mind about Doctors is they live in the world of Mitt Romney. They don't meet public defenders, non-tenure track professors, or vets. They show up at a party with their equals, and it's a bunch of two-year MBAs who make more then them, a smattering of lawyers who made partner at a big firm (and make more then them), and maybe a prof with tenure (who makes less, but not much less). They are incredibly out-of-touch. They personify the upper-crusty-arrogant attitude that $40k is not enough to raise a family.

Re:So what. Doctors SHOULD be paid more.

[Nemyst]

I think certain specialties already make enough or too much money. Over here there's been talks about I believe ophthalmologists making 400k+ for doing basic, fast surgeries. Even accounting for auxiliary costs, they still pocket a lot. I'd rather take some of their cash and give it to emergency MDs, generalists or family docs. The problem's that there's a certain aura around specialists which means the MDs who matter most and who can actually prevent most issues instead of solving them are paid less. This ought to be corrected.

Also, while I'll agree that the salaries for CEOs and Wall Street manipulators are ridiculous, they're paid by private corporations unrelated to the state. Just like salaries for sports celebrities (which are even more bullshit), they're the private sector's own business and we can do nothing about it, nor should we.

Re:So what. Doctors SHOULD be paid more.

[ID000001]

I would have to say no. One example, Radiology system are critical to patient healthcare. Large amount of diagnostic, specially on life threatening illness or injuries, require the use of Radiology system. The advance in Radiology technology is crucial to the delivery of health and procedure. You can't really flips thousands of images physically for a case, with potentially another thousands of priors study that are required to load and reference. Storing physical photograph media are incredibly expensive compare to storing images digitally in hard drive. IF anything. IT in this area saves the Hospital money. They don't need to hire someone to physically sort and organizes film, don't need someone to bring it to the room. Don't need someone to manages the film and flips them for the radiologist. Don't need to copy them and deliver them off site for backup. Don't need a dedicated and incredibly expensive film printer to bring to the emergency room or give to the out patient for transfer. You can just send them across the WAN, and All they need now is an IT who look after a few SANS with consumer replaceable parts. The HIS is another. It saves the hospital money in much the same manner. Paper trail workflow are no longer needed. You don't need to expose every patient information to all staff in a binder, all they need is press a button and let the actual Doctor with the correct permission to view the data. You also don't need to store those information in paper form. Doctor don't need to waste time reading through all of them when a few keyword will produces history and allergy record or other issues. You don't need to hire people to mail or personal deliver those across campus. In fact. IT made specialized clinic possible due to the ease of moving data. Without them being digital, there are no way you can have specialized clinic that are focused on one thing. The overhead of transferring patient information would be far too great for them to handle being a small clinic. You have to be incredibly out of touch regarding to Healthcare to think IT contribute little. IT is what made modern healthcare possible.

Re:So what. Doctors SHOULD be paid more.

[stenvar]

They bitch because they are forced by rules and regulations to use those servers, so when they go down, it gets even even more in the way of patient care than when they are working.

Re:So what. Doctors SHOULD be paid more.

[stenvar]

The kind of radiology procedures you talk about are not day-to-day healthcare. And where they are needed, they can easily be handled by a small, specific IT system, not an all-encompassing IT behemoth. Digital data can also easily be carried around on DVD or memory stick.

I have been to a variety of health care systems over the world, and seen several doctors and clinics go digital, and in each case, patient care, privacy, and control have gotten worse the more IT got involved.

Re:So what. Doctors SHOULD be paid more.

[dcw3]

Is that why we see a half dozen commercials for ambulance chasers on every public TV broadcast? Seriously? Between them and the insurance companies, I think about a quarter of them belong in jail.

Re:So what. Doctors SHOULD be paid more.

[sjames]

Our markets in health care are far more open and free than in Canada, Mexico, the U.K. etc and yet we pay twice as much per capita for inferior results.

Re:So what. Doctors SHOULD be paid more.

[stenvar]

No, our markets in health care are not open at all; they are tightly regulated and dominated by a large government insurance system. You can't self-insure even if you try (I have tried) because there are no prices and no market that you can buy in; many doctors don't even know what to charge you. The individual private insurance market is also dysfunctional. We have a collection of oligopolies that insurance companies, politicians, doctors, hospitals, drug companies, and employers each try to abuse for their own purposes.

Re:So what. Doctors SHOULD be paid more.

[sjames]

That is due to inadequate regulation, not excessive. Until recently, the private insurance market had nearly no regulation on it and look how well that worked out!

I'm not sure it's even worth it to argue for a truly free market as that would involve disbanding the FDA and the DEA, and that's not going to happen any time soon.

Re:So what. Doctors SHOULD be paid more.

[thaylin]

None of what you said supports you statement that they are not open at all, or even less open than in the other countries.

Re:So what. Doctors SHOULD be paid more.

[stenvar]

If you can't buy medical services freely and competitively or buy insurance on the open market, then our market isn't open. I have lived in countries where you can do both.

Re:So what. Doctors SHOULD be paid more.

[stenvar]

That is due to inadequate regulation, not excessive. Until recently, the private insurance market had nearly no regulation on it and look how well that worked out!

That's ridiculous; the private insurance market was already highly regulated and strongly influenced by tax policies. In addition, it interacted in weird ways with Medicare/Medicaid.

Re:So what. Doctors SHOULD be paid more.

[thaylin]

you can buy it on the open market, http://bcbs.com/, Also you can buy medical services freely on the competitive market, I have had no issues getting treatment without insurance.

Re:So what. Doctors SHOULD be paid more.

[stenvar]

You "can" in the sense that there is a small number of providers that will do it if you try hard enough. But it's not a competitive, efficient, or free market.

Re:So what. Doctors SHOULD be paid more.

[ID000001]

> The kind of radiology procedures you talk about are not day-to-day healthcare Radiology procedure is not day to day healthcare? What DO we considers Day to day? mammography is most certainly a routine procedure. Half the population needs it on a yearly bias. > And where they are needed, they can easily be handled by a small, specific IT system, not an all-encompassing IT behemoth. What is the cost benefit of having a small system that only do the routine procedure while the emergency procedure are done on a different system given the whole point of the routine check up is to have something in archive to compare for future reference? And how is a "Small IT System" make any different? What do you even defines as an all-encompassing IT behemoth?

Re:So what. Doctors SHOULD be paid more.

[stenvar]

Radiology procedure is not day to day healthcare

Which part of "the kind of radiology procedures you talk about" did you not understand? Radiology procedures, of course, are part of day-to-day medical care, but normal ones do not require complicated IT setups: a tech takes a picture, a radiologist reads it, and a copy is physically stuffed into the patient record. That's the way all my radiological procedures have worked over the last decade (my providers haven't converted yet, thank god).

What is the cost benefit of having a small system that only do the routine procedure while the emergency procedure are done on a different system

Simplicity, privacy, security, proper accounting of costs.

And how is a "Small IT System" make any different? What do you even defines as an all-encompassing IT behemoth?

The kinds of systems that attempt to create a single IT infrastructure for an entire hospital. Requirements like digitization of all patient records; making all records available to all staff securely and privately. Those are really hard problems to solve.

How does a small system make things different? A system that is just used by a single radiologist or shared by a few radiologists, and where archiving and patient records are handled by DVD or memory stick, has much simpler requirements than an equivalent system that is integrated into a hospital network, allows remote access, allows secure exchange and archiving of patient records, etc.

Mind you, the core problem isn't IT or digitization. Some IT infrastructure may be useful. The problem is that requirements are imposed that physicians don't actually have, and that functionality is provided that neither physicians nor patients want or need.

All kudos to the congressmen raising the issue

[Bruce66423]

But they may want to be cautious the next time they go to a doctor; they might be quite upset at the pay cut...

Re: So What

[O('_')O_Bush]

That is a pretty big claim coming from someone who didn't offer realistic or practical solutions given how politics of work in the U.S. and everywhere else. It is almost as if you wanted to America-bash without having much of an idea of what you are talking about.

If you are any smarter than the Americans, let's see an idea that could be written on a piece of paper and pass both houses within a few weeks. Because otherwise, there aren't many options other than violent overthrow, at which point it could be said that America is really no better primed for that than any other developed country.

Re:So What

[Major Ralph]

Impossible to fix it.

Americans are too fucking stupid to fix it.

Pick one

Re:Can we have a real story

[AoOs]

Already posted on the front page, mate:

http://it.slashdot.org/story/13/07/30/010237/students-hijack-80-million-superyacht-with-gps-spoofing

Re:So What

[lightknight]

Nonsense. The public will loot the public treasury...after all, it is a form of the commons!

And in general, no one cares about the commons, until they are gone.

No incentive for accuracy

[Gothmolly]

When the money comes from a Monoply box, there's no incentive for accuracy, only more money.

Re:So What

[NicBenjamin]

Strictly speaking he doesn't have to. If something is inherently unfixable EVERYONE is too fucking stupid to fix it. It's kinda dickish to put it that way, but hey. It's slashdot.

If dickishness were banned my posts wouldn;t get a +1 from karma bonus.

Maybe we could try capitalism & light regulati

[gestalt_n_pepper]

The light regulation being complete price and quality transparency, with the prices for all procedures and outcome statistics easily available online. Put the prices for the 100 most common procedures on posters in large type every 200 feet in every hospital. Put a booklet in every hospital and clinic room. Even insured people frequently have a high co-pay. Think prices wouldn't drop?

Other prices would come down quickly if congress were to deregulate. Allow insurance and prescription drug purchases across state and international lines and prices would drop in a hurry.

Moreover, the whole "prescription" idea is a bit of a racket. If I want to buy a stronger zinc oxide cream for foot problems, I have to see a doctor and get a prescription. For foot cream with 5% zinc oxide. I mean, WTF? It's time to release all but the most dangerous drugs into the wild.

My 2 bitcoins.

Balance

[Some Guy]

What about the opposite problem? Doctor performs a procedure in his office which includes the use of a $100 disposable device. Medicare pays him $35 for that procedure. Doctor either eats that difference, or chooses not to see Medicare patients.

This is a red herring. If they are looking to save money, look at the lawyers, insurance companies, and drug companies.

(I am not a doctor, nor do I play one on TV.)

Re:Balance

[h4rr4r]

Then Medicare should instead provide the device. Let them buy those in bulk and give them to the dr for this procedure.

Tort reform does not lower cost, it only shifts the risk to the patient. Since with it a doctor can cripple you and payout less than you make in a decade. So we can rule out the lawyers. The insurance companies sure make good money, but they take a percentage so if procedures were cheaper they would make less. Drug companies are a problem, but the solution there is to stop them from advertising and giving free stuff to doctors.

Step 1 should be to require doctors to publish their rates for procedures. Then let my insurance company reward me if I save them money by choosing good value doctors. Step 2 should be to forbid any form of advertising by drug companies. Buying a doctor lunch should be a felony for a drug company rep.

Re:Balance

[SJHillman]

And you think doctors don't already prescribe medication based on which pharmaceutical company buys them lunch?

Re:Balance

[Svartalf]

It's not just insurance companies, lawyers, and big pharma to blame. You fingered a solid part of the cause and then you go and blame insurance companies (which are part of the problem, but not the root cause...they typically only pay 30% over what Medicare pays- and typically, they'd have paid only $25, not $35- that's more the private insurance payout in most cases...)- go for one of the root causes. Big pharma just simply comes out of your pockets in most cases and not out of the doctor's hide. Not so sure about the malpractice story. Some of this is legitimate. Much of it isn't. Thing is...could you tell? Could anyone else? In the end, what you're seeing is government regulation causing a LOT of these woes.

Re:Balance

[Svartalf]

Actually, Medicare's out of touch with reality.

It's bureaucrats determining what is medically necessary and when they do how much they're willing to pay for it so that they can cover their own *sses and make their budgets look "good" so they can get more from Congress.

Supplying the device? I don't think so. It'd probably injure you. Honest.

Re:Balance

[h4rr4r]

The pharma companies would not do it otherwise. Try to remember that this lunch comes from an attractive person of the sex you prefer. Who also controls if you get to go to that "educational" meeting in a nice tropical location.

Re:Balance

[h4rr4r]

Considering how many doctors have tried to kill me, I don't see the risk really changing.

Some education on end of life spending would be nice too. I have seen many doctors spend what had to be tens of thousands to give people a couple more pain filled days of torture.

Re:Balance

[sjames]

Why is the doctor using a $100 disposable device in the first place? Probably because it's someone else's money.

Re:Maybe we could try capitalism & light regul

[thaylin]

So in order to fix under regulation, we reduce regulation.. To me that does not sound like the fix.

15 minutes triggers the BS detector

[chooks]

15 minutes for a colonscopy? Where do they get this number? Getting informed consent can take 15 minutes just by itself (and is something the doc has to do). 15 minutes sounds like the best-case scenario (e.g. a screening colonscopy on a healthy 50 year old with no findings) and a number to sensationalize the article. What is the distribution of times that the procedure takes? Maybe 75 minutes is actually a reasonable time to expect the procedure to take on average?

That the health care system in this country is screwed up is not at issue. The article wants to point out the ludicrousness of the reimbursement mechanisms in place. Putting in a context-free and unexplained statistic only weakens its argument.

Re:15 minutes triggers the BS detector

[jittles]

15 minutes for a colonscopy? Where do they get this number? Getting informed consent can take 15 minutes just by itself (and is something the doc has to do). 15 minutes sounds like the best-case scenario (e.g. a screening colonscopy on a healthy 50 year old with no findings) and a number to sensationalize the article. What is the distribution of times that the procedure takes? Maybe 75 minutes is actually a reasonable time to expect the procedure to take on average?

That the health care system in this country is screwed up is not at issue. The article wants to point out the ludicrousness of the reimbursement mechanisms in place. Putting in a context-free and unexplained statistic only weakens its argument.

I just had an upper GI done yesterday. I was wheeled back at 9am and was back in recovery (and in and out of consciousness) by 9:30am. That was with them leaving a sensor in my throat to test for acid reflux. I wasn't fully sedated, they just medicated me to cause me to forget what was going on, and to not feel any pain during the procedure. I'm a bit resistant to the medication, which explains why I remember things starting at 9:30

Re:15 minutes triggers the BS detector

[rollingcalf]

So what if it's not really 15 minutes for a colonoscopy? The 15 minutes was just an example to demonstrate a point, which is that for various procedures the payment is based on an assumed X minutes for a particular procedure although it actually takes X/5 minutes.

Yes, the writer could have done a better job on choosing numbers more consistent with reality, but the point they're making still stands.

Re:15 minutes triggers the BS detector

[chooks]

My point is that putting in that number needlessly detracts from what they are trying to say. You could easily counter their example with the fact that some colonscopies can take hours (e.g. complications occur, perforations, etc...) and thus doctors are getting UNDERPAID. Without any context, it comes across as sensationalist. The point they are making (medical reimbursement is non-transparent and is not aligned with primary care of populations) but this is not helped by their hook.

You know the worst part?

[NicBenjamin]

The way private sector insurance companies determine prices is even more fucked up, because they always end up paying more then Medicare.

Granted frequently that's because hospitals flat-out refuse any proposal to pay less then Medicare offers, but you'd think if the private sector was actually good at setting health prices they'd have found a way to do so that was better-sounding then "pay whatever the government will pay, plus 20%, because that asshole plays hardball."

Re:Punish efficiency

[SJHillman]

I have two barbers I like. One is an old guy who has been doing it forever. He does a good job, but only uses scissors and a comb so it takes about 30 minutes for him to cut my hair. He charges $18. The other guy is in his early 20's and has a nice selection of electric razors. The end result is just as good (maybe better), and takes less than 15 minutes. He charges $11.

The first guy is struggling because he's not willing to get the training or the tools to be more efficient, so he can't see as many people and he's already at the upper limit of what the market will bear in this area. The second guy has taken right off because he can deliver a cheaper, faster haircut with no loss in quality. I'd be surprised if he hasn't already recouped his investment several times over. I'd also be surprised if this didn't scale to the medical industry with prices is the three, four and five figure ranges.

Who pays for the Technology?

[DodgeRules]

While it is stated: "... technology has advanced and now the images are processed and displayed on a large screen in high-definition video.", the cost of the technology and the "overage" in cost per procedure goes hand in hand. It may now only take 15 minutes to preform what used to take 75 minutes, but if the doctors are only reimbursed for their time for the procedure, they would never be able to afford the technology which would put them back to 75 minute procedures.

This technology not only helps to produce more accurate test results, but allows more patients to be able to have these tests each day. That all comes at a cost. If a procedure is reimbursed $100 for a supposed 60 minute procedure using older technology, and that procedure now only takes 15 minutes using newer technology, More of the $100 has just been shifted from doctor salary to technology cost.

Instead of cutting the cost of the procedures, they need to find the doctors and facilities that are scamming the system, billing for procedures that aren't actually performed. (Like Columbia/HCA that Governor Rick Scott of Florida resigned from as Chief Executive in 1997 amid a controversy over the company's business and Medicare billing practices. He was not implicated, but the company ultimately admitted to fourteen felonies and agreed to pay the federal government over $600 million.)

Re:Who pays for the Technology?

[sjames]

But because the tech sped things up by a factor of 4, the doctor can now do 4 times as many procedures in a day and the cost of the tech is amortized over 4 times as many procedures. So even if the tech costs double what the old and slow device does, each patient should be paying half as much for the tech and the doctor should be making the same as before even while charging each patient 1/4 the amount he used to with old and slow.

That's how it works everywhere else in the economy.

Wait...

[argStyopa]

Let me see if I understand this: A centralized, bureaucratic, government-run program is sclerotically unresponsive to the market, cost-inefficient, and ultimately impairs the ability of
- individuals to get the care they need
- professionals to get compensated to the degree due based on current practices, technology, understanding, etc.
- competitive forces to keep prices down. ...seriously?

That's unpossible. I'd ask my friend Adam Smith to comment, but I think he's banned from Slashdot.

Re:Wait...

[timeOday]

Why are you assuming this issue is worse within medicare than in private insurance or cash-for-services? Everything I've read is that people who pay cash, without an army of bureaucrats fighting on their side against the medical establishment, get reamed the hardest. And why wouldn't they? It's medicine. The customer doesn't know what they need, doesn't know how much it will cost, and doesn't know how much it would cost elsewhere. It's a guaranteed recipe for financial disaster.

Re:So what. Doctors SHOULD be paid more. -- Wrong

[blahbooboo]

Huh? Did you even read my comment?

Re:Maybe we could try capitalism & light regul

[stenvar]

Health care has been heavily regulated for decades and costs have spiraled out of control. Obviously, regulation isn't working, and hence we should have less of it, not more. In different, the problem is overregulation.

Re:Auto Mechanics

[SJHillman]

My mechanic never charges me extra hours, but damned if I don't need to have my flasher fluid changed every time I go there...

Re:Punish efficiency

[NatasRevol]

So you're ok with your taxes going to pay for 26 hours of work in an 8 hour day?

Efficiency is doing things faster AND/OR cheaper.

The truth of the matter...

[Svartalf]

Is that Medicare pays approximately 25% of those so-called rack-rates. Private insurance typically pays 30% over the Medicare pay rates.

Overcharged? Perhaps. It's all this BS, though, that we're discussing right now (and Congress is mandating) that's causing it.

Want to actually make affordable healthcare? FIX THAT FIRST.
(Hint: It doesn't get fixed by bureaucracies like this and it doesn't get fixed by doing socialized medicine.)

Re:The truth of the matter...

[sjames]

Except that comparable countries with socialized medicine spend half as much per capita and get better outcomes overall.

Re:The truth of the matter...

[happyhamster]

>> (Hint: It doesn't get fixed by bureaucracies like this and it doesn't get fixed by doing socialized medicine.)

You pulled your "hints" out of your ass; you should check if you have hemorrhoids there as well.
The fact is that most developed European countries as well as Canada have single-payer (a.k.a. by conservative dipshits as "socialized medicine") for decades. It's quite successful; most patients are happy, and, most importantly, the patients are utterly horrified when they hear about "free-market" pricing in the U.S.

Re:Maybe we could try capitalism & light regul

[thaylin]

Costs have spiraled out of control because of insurance and underregulation. Have you ever looked at a demand chart for medical usage with and without insurance? I have and it is not pretty.

Re:Maybe we could try capitalism & light regul

[Svartalf]

And you'd regulate the heck out of it. The more regulation you have the more costs you have. Pure and simple. Got to be a happy medium- and YOU aren't asking for that.

Re:Maybe we could try capitalism & light regul

[Svartalf]

Try a little different line there and you'd have it.

Private insurance typically pays out 30% of what Medicare pays out.

Medicare pays out 25-30% maximum in most cases with a few exceptions like powered wheelchairs for the disabled. They don't do dental. They don't do vision.

Tell me again that it's JUST the for-profit industry...

Washington Post Accurate?

[dcw3]

Having just had my first colonoscopy just last week, I can vouch that it took the doctor much longer than the Washington Post is claiming. I spoke with him before and after the procedure. Did it take 75 mins? Maybe slightly less if you consider that he wasn't with me the entire time, and I couldn't even confirm that it was him who did the procedure, since I was knocked out. How much time should the doctor spend talking to you, and reviewing the results, even if the specific procedure was 15 minutes?

Charge master BS needs to stop

[Joe_Dragon]

Each hospital needs to have an price list that is easy to find and must show the all in price for doing X it's ok to show an rage but there will be limits on how big it can be.

Also any ER care must be an fixed price for all hospital in the same area

I'm not a gastroenterologist but I am

[mark_reh]

a dentist, and even I can tell you there's more to the story here. That 75 minute colonoscopy is probably an average. No one can predict exactly how long any given procedure will take on any specific patient. If a patient has no polyps, the procedure goes faster. If they find polyps and remove them (that's how colonoscopies prevent cancer) it takes longer. Patient anatomical variations and other medical complications can affect the time required.

I run into the same thing with my patients. A simple 15 minute restoration on a cooperative adult patient can turn into an hour long ordeal on an uncooperative 5 year old, but insurance pays the same for either one.

Re:I'm not a gastroenterologist but I am

[Anne_Nonymous]

Next time I go to the dentist I'm going to be a big pain-in-the-ass just to get my money's worth.

Re:I'm not a gastroenterologist but I am

[zlives]

i think you mean proctologist...

Re:So What

[Gr8Apes]

Incorrect. Something can be inherently unfixable: passing beyond the event horizon of a black hole, for instance. Too stupid to fix: the GP providing a constructive post.

Things are starting to change...

[Kingkaid]

The outdated data reared its ugly head in Ontario recently when the provincial doctors were negotiating with the province regarding pay. The province is feeling cash strapped and realized it should maybe update its pricing structure from the 70s. It is interesting that while they are moving doctors to more of a salaried model here, they are moving the hospitals towards more of a fee for service model (sort-of).

easy way to fix malpractice suits

[RobertLTux]

Depending on how bad the problem was either put the doc up on assault charges or on murder charges.

of course you could also have a third party run a listing of how many "errors" doctors have made.

To be fair with this list show the National Average Local Average also.

of course any fines should be split 85%+ to the "victim" and the balance to The State.

Re:easy way to fix malpractice suits

[h4rr4r]

All of those would be good ideas, none of them limit how much I can recover when a doctor cripples me.

There is no reason for the people to pay for a person on disability when it results from malpractice. If they want that deal then doctors wages need to come way down.

Re:easy way to fix malpractice suits

[nitehawk214]

Depending on how bad the problem was either put the doc up on assault charges or on murder charges.

of course you could also have a third party run a listing of how many "errors" doctors have made.

To be fair with this list show the National Average Local Average also.

of course any fines should be split 85%+ to the "victim" and the balance to The State.

You will have nobody wanting to be a doctor, and resulting procedure costs of the ones that remain go straight through the roof.

The 3rd party listing thing is a good idea though. Way better then "yelp for doctors".

Re:easy way to fix malpractice suits

[RobertLTux]

the deal would be under this system you would not "need" malpractice insurance (or it would have Sane Pricing).

its basically driving Primum Non Nocere into a doctors head with a 4X6 (crucifix sized Nails Optional)

It doesn't matter.

[StormyWeather]

If a 15 minute colonoscopy costs 2000 dollars, or a 75 minute colonoscopy costs 2000 dollars it's the same thing.

What these articles are really pushing is to lower the pay of doctors by 75 percent. I'm not going to argue for or against that, but it's the actual argument here. Can we as a society give doctors and surgeons a 75 percent haircut on salary and still expect the same level of service.

Also what profession exists that charges no base time and at a 15 minute interval? Most IT people I know charge a 1 hour minimum even for a phone call, and a trip fee on top of that if they have to go somewhere.

If I have to go out and show someone how to reboot their computer by holding down the power button for 5 seconds it will be 85 dollars plus a 50 dollar trip fee even if that customer is 3 minutes away, and I'm there for 5 minutes.

Re:It doesn't matter.

[jon3k]

They wouldn't take a 75% paycut across the board obviously, just that some procedures duration need to be updated. Ever wonder why your doctor always seems to want to stick a camera in your ass? Turns out he gets paid 5x his time to do it. So bend over -- KA-CHING!

Re:It doesn't matter.

[zlives]

you have the wrong doctor, my advice will be for you to find a better doctor.

Oversimplification

[sjbe]

We are talking specifically about how much time the doctor is working on the case of the patient.

The average time a doctor spends on a single patient isn't even close to the entire story. Bit of background: I'm an industrial engineer and also a cost accountant. I have degrees in both and have worked in healthcare doing six sigma projects, time studies and cost analysis.

1) Procedure times are NOT normally distributed. Not all cases are identical and some take considerably longer than the average. These longer cases typically are much more expensive. On a weighted cost basis the average cost will be higher than you would expect if you make the mistake of assuming a normal distribution.
2) You have to account for the time of the doctor PLUS the time of all the support staff. The time a doctor spends on a procedure frequently is not the biggest cost driver. My wife is a doctor. For the work she does her average time per case is about 10 minutes. For every minute she spends on a patient there is about 3-5 minutes of support staff time - sometimes more. On some cases she might spend an entire hour or more plus have to consult with other doctors for a particularly difficult diagnosis.
3) The value of a doctor's time isn't just driven by the average time for a procedure times some arbitrary hourly rate. What makes a doctor (particularly a surgeon) valuable is the value of his time when something unexpected happens. Patient goes into arrest on the operating table for instance. At that point the value of the doctor's time grows exponentially. If everything was just routine all the time, you could use nurse Now granted you can normalize the value of their time with enough study but the number you will get is going to be higher than if everything was routine and identical.
4) Time studies of procedure times are expensive and relatively difficult to perform. I've done a lot of time studies personally and trying to get an industry average for each and every procedure is far more difficult and expensive than most people realize. While there is no excuse for using outdated or wrong information, it is important to realize that maintaining an accurate and authoritative listing of expected procedure times is not a trivial exercise.

Re:Oversimplification

[jeffporcaro]

Mod parent up - insightful. I'm a cardiologist, and while I'm making more money than a Wal-Mart greeter, the days of doctors getting rich, and the days of hospitals making a profit, are essentially over, despite the large numbers thrown around. The costs associated with providing high-level, subspecialty medical and surgical care are enormous, and the reimbursement is continually declining. Congress continually nibbles away at the margins, dictating the rules of the game, and then acts shocked when the rules they implement don't result in free care.

The time and money that I've spent in training has value. The specific skills I have as a result of that time and money are significant, and useful to many people. I'm happy to use my skills to help people - it has intrinsic reward. However, the current climate requires that I do so 10 hours a day, plus nights, plus weekends, always with a smile, every 15 minutes, and job satisfaction has mostly gone the way of the dodo.

4 years of college. 4 years of medical school. 3 years of residency training. 3 years of cardiology fellowship training (gastroenterology, the example from the article, is also a 3 year fellowship). College & med school leave most of us with >$200k of debt. Residency and fellowship pay essentially minimum wage when you account for the insane hours, all the while collecting interest on our college and med school debt. I didn't have kids until I was in my late 30's because we didn't think it was fair to raise them without seeing their father.

We all have this same conversation when discussing the issue of money in medicine. In the beginning, there was a binary relationship - patient, doctor. The doctor provided services, the patient provided cash. These facts haven't changed, except now the care provided is better, the patient spends much more, the doctor gets paid much less, and everyone else in the system siphons away the money without the hours or the liability we incur.

In any event, you're not paying for 15 minutes of colonoscopy time, you're paying for the 14 years of training necessary for the doctor to do the colonoscopy.

Not to mention the cost of the colonoscope and its upkeep, the techs, the sedatives and management of their associated risks, the endoscopy suite constructed and maintained to restrictive code standards, cleaning of the endoscopy suite between each case, archiving and storage of the images, time to interpret and create a report from the colonoscopy, conversations with the patient, the patient's family, the patient's primary physician, time lost from providing other services (office and hospital visits - people are always clamoring for more availability), the enormous billing apparatus, a significant cut to the insurance company, maintenance of certification & credentialing (which requires many hours a year away from the office in a hotel conference room watching Powerpoint slides, at great expense), etc.

What's it worth to you?

Re:Oversimplification

[TemporalBeing]

So how about:

1. Having the board consist of the reps from the AMA (as now) and then also have reps from Insurance and the FDA, none overlapping.
2. Let the charges be what they are, and the time gets reported too; charges/time outside the norm would have to carry explanation.

Thoughts?

Re:Oversimplification

[sjbe]

Having the board consist of the reps from the AMA (as now) and then also have reps from Insurance and the FDA, none overlapping.

The AMA is not representative of many doctors. Supposedly around 15% of doctors are members. I know the AMA has campaigned for some rules that would directly hurt my wife's practice. The AMA is an important organization but they don't remotely represent all doctors.

Let the charges be what they are, and the time gets reported too; charges/time outside the norm would have to carry explanation.

You are talking about a standard cost accounting system. You establish an expected cost and then any variations from that cost show up in a variance report which can be analyzed for changes. The calculations in a system like this are pretty complicated and standard costing systems have some meaningful drawbacks. It tends to create some distorting incentives that drive inappropriate behavior. Standard costing systems work best when you are producing a small number of products with fairly stable cost structures. Medicine tends to have a HUGE number of products and thanks to technology and differences between processes in institutions the variance reports would be very difficult to use. Furthermore standard costing is rather poor at drilling down to individual unit variances - it tends to work on overall numbers.

Re:Oversimplification

[Anonymous Coward]

Yes, it looks like such rough times for cardiologists.

This may not be making as much money as you wanted, but you are well above the income that most people would call "rich". You should be able to pay off those student loans in no time if you can manage to live frugally (by this I mean not spend too much more than twice the average US income) for under one year.

Re:Punish efficiency

[SJHillman]

Your barber shop savings are nothing compared to the savings of getting ibuprofen at Rite Aid compared to getting the same stuff at a hospital ($5 a bottle vs $10 a pill).

Not Only That, But This

[hduff]

Doctors routinely overbill (based on the insurance pay scale) or procedures knowing they will be paid less from insurance, but the higher billing amounts are factored in to what insurance will pay in the future.

Re:Maybe we could try capitalism & light regul

[gestalt_n_pepper]

I'm more interested in intelligent regulation. The current regulations are obviously a result of congressional bribery (Oh sorry, I meant "campaign contributions"). These benefit specific corporate interests and are blatantly anti-competitive. At the moment, neither party has the slightest interest in changing that, regardless of the ideology they publically espouse.

Re:Punish efficiency

[NatasRevol]

Don't whine if I use the 'AND' in my definition, ok?

They are actually doing things much cheaper. The higher cost of the equipment is not as high as the cost of paying the doctors to take longer to do the procedures.

Re:Maybe we could try capitalism & light regul

[stenvar]

That's a nice fantasy, but it doesn't agree with reality. There is little difference between the rise in health care costs in partially regulated and fully regulated/nationalized systems. Therefore, there is no reason to believe that adding more regulation to the partially regulated US system is going to fix the problem.

Other issues/costs too

[TheCarp]

(Dusts off Healthcare industry sysadmin cap)

It just so happens, I have a tiny bit of insight on this after sitting through a presentation by one of our Doctors which could have been titled "Why your department sucks because IT costs sunk my grant application".

Back in 1992, a proctologist stared through a scope and any video they did capture was crap by todays standards. Today, they are talking about very high resolution video, and a good sized department does a lot of these. Their data storage requirements just for these are huge (big enough to have sunk this Doctors grant application when the review said that it accounted for almost half of the proposed spending...about 40% if my memory serves)

Not to mention all of the other costs associated with maintaining an ongoing medical operation... training and retraining staff, equipment maintenance, data storage meeting DR and medical privacy requirements.

Outdated data is a problem but, its not really just about doctors pay or the amount of time it takes. Also, while the procedure time is shortened, it often involves heavy sedation, which means patients being given some time in a recovery bed to sleep it off for a little while (not long, but, it still uses up resources).

Easy fix.

[xtal]

Put the doctors on salary.

The artificial shortage of doctors is a national embarassment and goes to the root of why you can't get a GP. There are thousands of perfectly qualified, intelligent, well-manners people who would love to be GPs and can't - because of entry restrictions protecting salaries.

Not much else to it. *shrug*

Re:Auto Mechanics

[hawkfish]

My mechanic never charges me extra hours, but damned if I don't need to have my flasher fluid changed every time I go there...

Please don't ever use the phrase "flasher fluid" around anyone who lived through the 1970s...

Re:Auto Mechanics

[dcw3]

Your flasher has fluid? I missed that option on my new car.

Incentives?

[Miros]

Aside from the question of how and when to update the 'time and motion' study data, does this setup the right incentives for the industry? It essentially says 'we will set the benchmark for adequate, and then you try to do whatever you can to beat it economically.' If the revenue at the margin is fixed, the way to drive profit is to decrease costs as much as possible. Of course, the benefits are not passed on to the consumer if the price fixer is asleep at the switch...

Doctors SHOULD be paid less, and here's why:

[Anonymous Coward]

I am surrounded by doctors, professionally and personally, in multiple settings. And here's what the problem is:

They have an artificial monopoly over services, which inflates their compensation.

The problem isn't that they're evil, it's that many of the same tasks could be performed by other service providers for much less. It's a simple case of "government grants a monopoly, and you get inflated prices as a result." This permeates everything, so that MDs essentially control the health care market without any sort of competition or questioning. Recent battles over nurse anethestists and psychologist prescription privleges are just two examples where the same services could be provided by others for much less; greater freedom with physicians' assistants are others; so is a need to essentially eliminate drug control, illegal as well as legal.

To be honest, there *are* other fields where you go to school as long, and get compensated even less, and studying that long doesn't make you a good doctor.

Also, many of the factors you cite are arguably driven by this monopoly as well. For example, medical school tuition is raised that high partially because of this bottleneck in care--medical schools can charge this because physicans are guaranteed large salaries because of government-assured lack of competition. They work so long in part because of artificially created demand.

Think of it this way: right now the government prevents you from getting services, drugs, etc. from whoever you want. So lets say you want to go to an RN for antibiotics, or have your psychologist (who did neuroimaging studies of drug effects in graduate school) prescribe. You cannot. Moreover, you couldn't even if those individuals wanted to train as much as they possibly could to provide those services to you as best as possible, because the government makes it illegal. There's probably some harmless medication that you know how to take safely that you could go get from a pharmacist that you cannot because you need a middle man (the prescriber) to prescribe it for you.

What we have now is a cargo cult health care system, where people provide services under rules without any real concern for what's actually best or cheapest.

The reason why these reimbursements mentioned in the target article haven't been checked before is because MDs control so much of the health care system, and we operate every day assuming they know best, even though this isn't true.

Just to be clear: I'm not anti-physician (they're in my close family, and I think they do wonderful things). I just think that people should be able to choose whatever they want for health care, or at least have those services provided on the basis of skill, and not degree.

Primary care underpaid/specialists overpaid

[Cryptosmith]

My wife is a board-certified family physician, and she does a lot of things an obstetrician does - deliver babies "normally" or through surgery (how does one spell "caesarian" anyway?) and does a lot of in-office procedures. Since she's not board certified in obstetrics, she is paid less for doing these procedures than someone who is so board certified. The work is identical and meets the same practice and safety standards - otherwise she wouldn't have hospital privileges to perform the procedures.

So why does identical work cost more depending on which professional organization certifies you?

If you can do the work, the hospital grants you privileges to do it, and the malpractice insurer is satisfied with the hospital's oversight process, then why shouldn't everyone be paid the same for the same work?

Re:Maybe we could try capitalism & light regul

[thaylin]

except that you added a nationalized system, that is not jsut more regulation, that is more insurance, which the latter means more demand, therefore higher prices.

Re:Maybe we could try capitalism & light regul

[stenvar]

I don't know what you mean by "you added". Do you mean the fact that the US added Obamacare means that prices go up? Yeah, they do, both for insurance and services.

Re:So what. Doctors SHOULD be paid more. -- Wrong

[colinrichardday]

Every year, the med school cohort is about 20,000 per year (~80K in school at any given time https://www.aamc.org/data/facts/). The total bill for this (assuming your $250K/student/year) sums to $20 billion / year. In 2011, total healthcare spending was $2.7 trillion (http://go.cms.gov/13juHDi).

Actually, it's closer to $250,000 per student over four years.

http://gradschool.about.com/od/medicalschool/f/MedSchoolCost.htm

Question: How Much Does Medical School Cost?

Medical school can be expensive and therefore, it would be beneficial to consider the cost of med school before applying.

Answer: According to the Association of American Medical Colleges, the median tuition in 2010-2011 was $28,685 at a public institution and $46,899 at a private institution. Note that tuition does not include books, lab fees, etc. In 2010-2011 the median total cost of attendance was $49,298 and $66,984 for public and private universities, respectively.

I would like to know if they calculated that per school or per student.

Gods yes.

[Etherwalk]

Hourly billing penalizes efficiency, improvements and outcome. Do you really want a doctor that spends an hour on your colonoscopy if a better process can get better results in 2 minutes with less discomfort? With time based billing, the doctor taking an hour gets paid more than the one taking 2 minutes, yet the patients experience would be improved with the shorter duration.

Gods yes, I do.

First, not all colonoscopies are created equal, nor are all surgeries or surgeons. If you pay the same amount for a procedure regardless of the time, then it discourages doctors from performing thorough procedures, and when you're dealing with cancer, you would rather have the thorough procedure.

Doctors are busy enough that they aren't going to start overbooking time just because they're paid hourly. And I would be willing to trade slightly higher costs for transparent costs. Going to a doctor now is like going to a restaurant with no prices on the menu, where the waiters can guess at the prices but your chef will tell you what they actually billed you a few months later, and nobody will be able to tell you what is actually in the food.

Transparency rocks. Medicine is not transparent.

Bull

[Etherwalk]

anti-trust laws and specific legislation prevent hospitals and doctors for sharing price information (aka Sherman Anti Trust Act [wikipedia.org])

Bullshit. Nothing prevents them from sharing price information and from setting prices in a competitive market. What they are not allowed to do is *conspire to set prices a certain way if they're competitors*, at least not without an act of Congress or (possibly) approval of the courts. Certainly every insurance company and hospital could be transparent--set prices for everything and post them on their web sites. Adjust them periodically to make them more competitive. That's perfectly legal.

They just can't agree amongst themselves not to set the price for X no lower than value Y.

In fact, if prices were transparent, they would have a more competitive market. That would not be in restraint of trade, but would promote trade, and I'd be willing to argue that in any court in the country.

Re:Maybe we could try capitalism & light regul

[thaylin]

It means that combined, as in added, both regulation and nationalization (IE insured). 2 seperate issues, but you failed to break out the one responsible. One, the insurance, I blamed already.

Re:Maybe we could try capitalism & light regul

[tacokill]

Yes, do you not see that it's the very regulation you espouse that is part of the problem?

Or are you one of those people who see all regulation by our benevolent government as good? If you are one of those people, then no amount of discussion will change your mind. Just keep adding rules and regs until you naively watch it collapse in a pile of ashes.

Re:Maybe we could try capitalism & light regul

[stenvar]

They are not separate issues; nationalization is the ultimate in regulation.

Re:Maybe we could try capitalism & light regul

[thaylin]

They are separate issues which can be combined at some point. In our case the issue with be with the mandate of insurance.

A few comments from the other side

[LeeMeador]

Supposing we do something that ties the rates doctors are paid to the amount of time they spend doing something. The next batch of things we become incensed and appalled about will be how they always take too long to do something. That is, if we pay more when things take longer. Why shouldn't we pay the doctor the same amount for a procedure if they figure out a way to do it better or faster or with less side effects or a smaller possibility of significant damage? Perhaps its a little much to pay for 75 minutes, which it took 15 years ago, instead of the 15 minutes it takes now. But paying for just the 15 minutes is a recipe for disaster. People will maximize their own benefit. Things won't become better and faster and safer. That's just the way it works. Additionally, there has got to be some range of effectiveness in medicine. Some doctors, surely, can do a good job on a particular patient in 10 minutes while another will take 20 to accomplish the same thing or 10 to do a crummy job. To some degree, those that do poor work will eventually be weeded out or see their practice decline to some degree. Word does get out. People talk. The summary mentioned someone who got 26 hours worth of doctoring done in one day. Should we not reward him or her for efficiency. I see it as better when I get things done in less time than someone else provided I do a good job. Why would it be different for doctors? I'm not making any attempt at being fair minded here. The arguments for the other side of this are plain and well enumerated so far. But there's more to it than that. Be careful what you measure. Its true in software development and true in medicine.

Regarding the hours. Does it include

[lsatenstein]

Re outdated rates. Do the rates include pre operative preparation -- steralizing the operating table, wiping down cabinet knobs, clean towels, etc. And does it include cleanup immediately after. Of course the doctor does not do it. But if he was in the boonies, he would do all three, pre and post and operate.

The system is, however being milked. Most general doctors after 3 years following internship become nothing more than skilled triage experts. They can do triage and send you to the specialist. Do you really need a doctor for that triage assessement, or can a skilled nurse do the job as well.

Re:Can we have a real story

[geirlk]

That can't be. It wasn't modded funny.