Getting a doctor to respond through our digital messaging platform is practically impossible. Unless you're extremely persistent and specifically ask for the doctor's input (and send 3-4 messages back and forth with the nurse, whose responses are less relevant than a google search), it's impossible.
I wonder if charging for these messages will make doctors more likely to respond. I wouldn't mind a modest copay for these. But if I pay $30 for an appointment, a quick message should be under $15. There would also have to be some sort of SLA, or the ability for a patient to specify that a question/email has expired and no longer requires an answer.
I've had situations where I waited for a doctor's callback so long that I ended up calling a friend who was a physician assistant, watching a youtube video about how to fix the problem, and taking care of it myself. The only way that process could be any worse is if I got a reply after I had fixed it — and a bill for the message.
I've never had a problem across several doctors on getting a direct reply to my message. For me, there is an SLA. They explicitly state I'll receive a reply within 24 hours. That has been true across multiple health systems I've used.
Edit: In no way am I saying "American healthcare is just fine!" only that I actually have had a really good experience using messaging to communicate with my care teams.
I don't know what is happening elsewhere I suppose. I'm a PhD clinician at a US public academic medical center and respond to patients within 24 hours even if it's to say "let me check on that...it may take a week to get the answer/letter/etc." I'm pretty sure that's the expectation for all our MD/DOs and other clinicians. We don't bill for it, and it doesn't contribute to our targets, but it just seems like it falls under a salaried expectation to me. It's for the patient.
That said--hospital management, driven by the insurance world, tries to wring as much uncompensated labor out of the medical workforce as possible. Doctors (including my MD colleagues) do not get together to limit the number of doctors available. That's baseless conspiratorial thinking that doesn't withstand a moment's scrutiny when you understand the incentives at work in American healthcare.
Not everyone is accusing the doctors involved, but when I wrote the comment, there were numerous armchair expert opinions squarely blaming the doctors, including at least one who said that doctors limit the number of training slots available to keep their prices high. Thankfully, those perspectives have been addressed or at least outpaced by better thought out criticisms since then.
Ultimately, the number of training slots in the current system is limited by MHA and MBA administrators who see training and instruction as subservient to profits, not the doctors who make up the departments and training faculty. Or, more broadly, they are limited by the healthcare operations not being legislated in a saner way. I was just clarifying.
Hah, in MyChart, my provider has started having an MA answer your emails, and then "I'll forward this to the provider". Waiting to see if I get billed for the MA's "effort".
No-one's saying it takes zero literal effort. Just "Should I be billed by the practice $25-30 for an MA to get my email and say "I have forwarded your question to the provider"?", and then a subsequent $100+ for the provider's response to my question.
Why should that not be part of the intrinsic baseline officework and not a billable service?
Especially when it's a 100% artificial roadblock inserted by the practice? After all, the communication portal in MyChart is "Message My Provider", not "Message An MA To Message My Provider".
> After all, the communication portal in MyChart is "Message My Provider", not "Message An MA To Message My Provider".
That is semantics, could be changed to "Message the office" but that isn't going to be the most clear title for the majority of people to understand what it is doing. It's the same as calling the office, 99.9% of offices (basically all outside of concierge/direct care) are going to be triaged by an MA/nurse first.
As far as the payment requirements I've heard of, I have never seen anyone bill just for the MA reply.
Sometimes I have questions that don’t need the provider’s time, but there is no way to get ahold of anyone else in the office (the practice is part of a large hospital system and calls are answered by a call center that knows nothing)
While waiting 6 weeks for an appointment with a specialist and suffering in pain, my mom diagnosed herself, created a treatment plan, ordered prescription pills from some Chinese site, and started treating her condition herself. She cancelled her appointment because she was feeling much better.
> I wonder if charging for these messages will make doctors more likely to respond.
Why would it do that? If they get money for messages sent (rather than messages sent by doctors) then some flunky can send a message and you can still be billed. Given how this sounds like a profit center, and doctors are cost centers (imagine if they needed to send more messages... now they have to pay more doctors!), I figure physicians will be kept far away from any such system.
If we plot out perverse incentives as a space, I believe that our fate will be to trek through every possible point in that landscape such that we eventually see every single one. This means you will eventually get universal healthcare, most likely as the very last of those perverse incentives.
Interesting point. That could make for some awkward conversations if the patient thinks messages were coming from their doctor but then the director had no memory of the messages. It would also seem fraudulent to have messages signed by the doctor when it wasn’t actually sent by that doctor.
I think it’s much more likely that doctors will end up sending AI-autocompleted messages that take very little time to complete but seem like took much longer.
I have not used a medical messaging system, but if it's anything like the messages my bank or my insurance company sends on their own systems then these will look much more like text messages and less like emails. No place to "sign". No need to risk it looking like fraud. As for awkward conversations, I'd be shocked if many people don't experience circumstances where their doctors act as if they don't remember previous in-person conversations. They're seeing 25 patients a day for 3 minutes at a time after all.
The standard will evolve to something like clinic staff sending the messages which will be overseen/supervised by a medical doctor (who won't be involved in composing the messages or spend any time looking at them before or after they are sent). We'll see trials where the doctor who was supposed to be keeping an eye on the messages wasn't, and some flunky kills a patient by suggesting that drinking used engine oil will cure the sniffles. Keep in mind that the messages can be sent from anywhere too, technically no need to keep that onshore. May eventually get legislation that would guarantee that, but only after a wild west period that lasts a few years.
The medical messaging systems I've used all have "from" fields with the person's name and title. It's important because I take messages from the doctor much more seriously than the messages from the nurses.
There are some codes that can be used for asynchronous portal messages, but to be honest the AMA is still pretty broken as far as how much time we need to spend for things... the codes are 99421 (5-10 minutes over 7 days), 99422 (11-20 minutes), 99423 (21+). It is not clear to me how well these codes are actually paid for by private insurance. In a wRVU system a PCP may get paid like $5-13 for the first code, $15-30 for the 2nd, $24-44 for the 3rd. This is a lot less than a visit... and you must spend the minimum 5 minutes on the portal message or you are billing it fraudulently. I can cover an in person level 4 visit (99214) in 5 minutes in some cases, which pays something like $100.
• I needed refills for two prescriptions that I've been taking for years. This time, for opaque reasons, I needed to talk to a doctor first.
• Fine, but I couldn't accommodate an in-person check-in. I chose a "video visit" that, due to logistics, I had to do while away from home. Because they were a half-hour late, I was effectively forced to do this from the couch of a Costco floor display so I could still pick up my kid on time.
• The appointment was 8m, at an out-of-pocket cost of $160+. I was not warned that I'd be forced to pay $20/minute for the privilege of being blessed with refills.
I moved to Canada recently and caught a flu that I didn't take care of and, in turn, developed into pneumonia. It took me FIVE days to be able sit down with a doctor and get an antibiotic prescribed even thought it was more than evident I needed immediate care. I could have died if I waited another day. But was it free? ... ehrm ... yeah.
In Mexico, doctors are as free market as it can get, downsides and upsides of that considered; with cash in hand you can get any kind of attention you need in the exact moment you need it. And it's not even that expensive, after converting MXN <-> USD. I could've dropped by with any of the 1,000s doctors that are available, many of which don't even require appointments. I would've got the attention I needed and the antibiotic prescription in 2-3 hours. That would had cost me ~60 USD.
"Canadian healthcare wait times" are mostly a myth invented by the American healthcare lobby [1]. Canadian cities are dotted with walk-in clinics you can go to and see a doctor same day. Or worst case scenario you would go to a hospital ER. Neither of these options will cost you any money and you will get same-day treatment and care. If you made an appointment with a GP then yeah you would wait, since those visits are typically for non-medical emergencies. :)
Germany has socialized healthcare and you can just go to your doctor without an appointment in acute cases like yours. Saying that ~60 USD is not that expensive comes from a privileged position where 60 USD doesn't hurt you.
> MEXICO CITY (AP) — Mexico’s president said Friday the country’s minimum wage will rise by 20% in 2024, to the equivalent of about $14.25 per day.
> About one-third of Mexico’s registered workers report earning the minimum wage, which will amount to about $1.75 per hour starting Jan. 1.
$60 is 4 days wages for 1/3 of workers in Mexico. It's the equivalent of $820 for someone making 75k per year in the US. So it's the same as any other free-market healthcare system: easy access for the wealthy at the exclusion of the poor.
Your reasoning is flawed as $75k/year is WAY above the minimum wage in the US. Adjusting for that, it comes to about ~$160.
I'm not saying it's fair, I'm saying it's cheap, compared to the US as that is implied by the context of this conversation.
When you buy a $1 dollar shirt from Malaysia, is it cheap? Yes. Is it fair? Who knows.
It's the same thing.
Also, doctors in Mexico make way more than minimum wage, it's not unusual for some of them to have incomes around 200k-300k USD/year, plus read about RESICO and your jaw will drop to the floor. The average person in the US would kill to have the income and purchasing power doctors have in Mexico.
I'm going to jump in here and offer up an Ayn Rand because you brought her name up.
Ask anyone who has a dog, preferably a big dog, what it costs for a vet visit.
Better yet, talk to someone who has had a sick dog. Something terminal, or possibly terminal. Costs are wayyy lower. Same x-ray, same imaging, many similar medicines. I've talked with vets, human doctors, and doctors who own dogs. They all come to the same conclusion:
Only ONE key difference - there is no insurance or government regulation involved (obvously stuff like taxes, basic health codes, licensing, but I think you know what I mean).
I'm more than happy to agree with you if you could show me a plausible explanation for this enormous disparity in costs.
So why is our healthcare twice as expensive as the countries who actually do have socialized health care? When is that competition going to kick in and bring down costs?
Well, we don't have competition because the much-vaunted doctor's union blocked how many doctors we could have so that they could keep doctor pay up. And that's not me attributing purpose. That's them saying why they did it.
If it were fully free market, there would be more competition. If it were fully socialized, the government would control prices.
Instead, our system is the worst* of both worlds. The government limits the supply to prevent competition, but allows those they've licensed to charge as much as they want.
*(That is, worst for patients; it's the best for profits)
I don't believe there exists a possible free market for health insurance, just like with flood insurance or earthquake insurance. Adverse selection kills it.
Even if there were no insurance, I don't believe there exists a possible free market for expensive emergency medical procedures either.
Because Obamacare legislation ended up as a terrible version of socialism/pork-barrel spending/crony-capitalism in order to get the required support to pass.
The democrats wanted to get subsidized healthcare for low income people and people with existing health issues that would guarantee they would be uneconomical to insure. The healthcare providers, insurance companies and pharma companies wanted to remain viable, profitable businesses.
The compromise was to essentially guarantee profits to healthcare companies by crafting legislation that overcharges young people, healthy people, male people, middle class and affluent people to subsidize costs for other groups, while giving a consistent profit margin regardless of costs to insurance companies.
There is nothing about American healthcare that resembles functioning markets or capitalism. It's a very heavily regulated industry where the government exerts extreme control, while choosing to legislate in a way that maintains a consistent flow of money to influential lobbying groups and political donors.
> There is nothing about American healthcare that resembles functioning markets or capitalism.
This is cope, just like "(socialist catastrophe) wasn't caused by TRUE socialism" is cope.
The mechanism by which capitalism causes concentration of wealth and power, and by which said concentration then creates means, motive, and opportunity for self-dealing is crystal clear.
It was actually worse in that you could be denied health insurance. And I know a lot of people who are denied health insurance for very mundane reasons.
Insurance companies had teams of people who, if you made a substantial claim, would look over your application for anything that was amiss. And if they found it, they'd drop you so they wouldn't have to pay.
Your health record became a criminal record. You just hoped there was nothing on it that would prevent you from getting coverage in the future.
Obamacare has some very serious problems, but at least you can't be denied insurance just because you have back pain.
surgeon here. before Obamacare insurance companies denied payments if they deemed the issue pre-existing and were not told about it in the patient's application. I was in private practice for 10 years and now employed surgeon for 12 bc insurance companies notoriously deny payments for no legitimate reason. One time I saw a patient with an inguinal hernia and then fixed it. We were denied payment because my initial consultation said, 'presents with hernia he's had for 2 years, but now increasing in size and causing discomfort'. Their reason for denial was that he only had coverage for a year and had not told them about the hernia. From then on, my notes were very brief. 'Patient presents with symptomatic hernia'
Before Obamacare, some policies had lifetime limits, which could affect expensive treatments like cancer.
We celebrated the fact that now medicare can negotiate 10 drug prices. It should negotiate all drugs. The organization that gets the lowest prices is the VA. Congress could easily pass a law saying medicare will only pay that much and it would not cost much to implement.
Because Americans don't want to let people who can't pay for emergency care die (which I'd argue is a good thing) but also can't have a serious conversation about how to pay for that.
I like to say that there's blame enough for everyone to share. There's truth to virtually every argument. The entire "system" is so "sloppy" and filled with points where money just leaks out.
The emergency care angle is what drives the socialism / capitalism bickering and that's what I see a the biggest impediment to actually making effective change.
As a paramedic (part-time) and someone who has worked in claims benefit management systems, EMTALA (the rules/laws around emergency stabilizing care) are not what make our healthcare astronomical. It's prescriptions, imaging, and labs. You can easily be charged several thousand dollars for diagnostic imaging. My insurance covers labs 100% but a recent stool sample test charged $780 to see if I had blood in a stool.
Speaking of DI, DI is a money-printing machine, with CT and MRI machines that range from a few hundred thousand to over a million have breakeven points well under two years. And the DI companies work to find and gather physicians who want to start a DI practice. Offer financing, consulting, and then, shockingly, we find that physicians who own a DI practice or a share in one tend to over-refer their patients to imaging.
It’s a false excuse. Plenty of countries that also don’t let poor people die because they cannot afford going to the hospital also spend much, much less per capita. Actually, all of them do, and by far. The US really are an anomaly.
Because we don't have death panels like in countries with government-run plans. Your insurance carrier won't deny you a bone marrow transplant because you're 85 (it costs over $1m). Other countries will deny it, because you're 85 and have had a good life.
I think it could be cool to have an evidence-based death panel of experts instead of our ad-hoc death panel of one guy (or one LLM!) running through a spreadsheet and clicking "no."
The American healthcare "system" is dysfunctional because parties who profit from the status quo keep the public bickering about inflammatory issues and distracted from making meaningful change. (My favorite example is "death panels".)
Since the American system doesn't allow people who can't pay for emergency care to die the system ends having a socialist component. Socialism is such a hot-button issue that we can't have mature conversation about funding it. Almost any conversation about it gets caught-up in partisan and "personal responsibility" bickering.
It would be easier if we just let people who can't pay die.
That's repugnant and wrong, but it would certainly make the conversation easier.
Typically one would not do that. You'd shop around ahead of time, sign up for a plan and then if/when the emergency came it would already be taken care of.
It’s been a long time since I’ve seen someone say something this wrong on HN. Calling the American health care system socialist in any way is laughable.
I'm in agreement that healthcare is sorely lacking many individualist incentives, including market ones [0], but can we not pigeonhole anything we don't like as "socialism" ? It just makes for a terrible time talking past one another.
[0] hint: receiving bills for charges you never assented to is not a foundation of a working market, and should obviously be illegal.
I have a partner who's a nurse practitioner in primary care and I just want to emphasize how hellish it is for people on the inside as well. The economic model of running a healthcare business is entirely based on their ability to bill for provider time. Healthcare providers have very high costs to match their very high fees and also pay a bunch of people to 'help' providers see more patients. A big part of this mix is also that it is not enough to provide healthcare - you are actually paid for providing documentation that you carried out the specific care that you "should have done" given the case notes. Ensuring you properly annotate the files of patients (for the benefit of generating the right charge codes! Nothing to do with patient care) is another burden that's required to sustainably provide care. As a result the costs "per provider" are much higher than the provider themselves - you also need medical assistants who do every piece of work the provider isn't legally required to do, billing staff to properly bill that work, admin staff to manage their schedule in detail, etc.
The lack of regard for patient schedules is a direct result of how insanely packed the schedules of providers are. Fifteen minutes per patient is luxurious and my partner spends a lot of time after work entering notes for patients she saw that day (she "works" 32 hours / 4 days a week, which is really closer to 40-45 all told). My understanding is that the clinic does not have a high profit margin (serving medical / medicare patients + high overall costs), so every patient counts, and the admin staff will add people w/o permission. It's common for her to find patients scheduled over her breaks or for her to be scheduled after she should have left the building. Burnout has always been bad but it's reaching epidemic levels now in the wake of covid, which further restricts the supply of healthcare and makes people wait longer to be seen.
I think people tend to get stuck on the ridiculous charges/billing and don't often get to the point where they appreciate just how bad the provided healthcare is, and how much it utterly destroys patient agency by replacing it with bureaucracy. The provider/"insurer" dynamic is really the deep set home of the rot. As a table stakes reform, health "insurance" companies need to be prevented from managing healthcare and relegated to purely financial payers, but doing so would put so many low-level bureaucrats out of work it's politically untenable.
For a recent event, I got a whole nurse calling me from the "insurance" company, out of the blue, seemingly just to chat about the medical situation and how things are going. I haven't figured out what her KPIs are, but I doubt she remains so friendly when you bump up against them! And she obviously represents a severe misallocation of labor - the industry would be better off if someone with her education (and likely experience) was actually providing healthcare.
Somehow, US healthcare is ~ 2-3x expensive as equivalents in other wealthy countries, which get better outcomes. Who is collecting this extra money? It's not the medical professionals, you say (and I believe).
It's partially medical professionals! My partner is better paid than she would be in, say, Canada. US medical worker pay absolutely contributes to our costs - I just meant to point out it's not the only factor and that those jobs, though well paid, can be taxing for the people in them on a day-by-day basis.
No, the worst part is dying of a painful terminal illness while being sued into bankruptcy in your dying days having to fight to keep minimal possessions because the hospitals and doctors want money.
None of that stuff would be possible without government. It's a statism run amok.
It's the same story every time. Something works relatively OK (US health care before 20 century big-gov), huge changes to incentive structure and overheads are introduced by statists ignoring higher order effects, everything goes downhill, statists blame capitalism.
Let me legally not have insurance, pay anyone in cash for my health care (no licensens and government enforced monopolies), and buy any medicine I'd like and opt out of this madness completely and let's compare with real capitalism.
It's always been legal not to have insurance (though there was a brief period where externalizing costs that way was taxed). You can pay cash for health care as you like now with any provider who cares to negotiate with you on a cash basis. There's even a variety of non-MD providers whose licensure ranges from more accessible through informal to non-existent should you object to credentials as distorting.
If you try doing health care this way for long enough, you might even discover which incentives are poorly aligned without collective policy of some kind, but who knows, maybe not.
We can surely fix this mess via same invisible hand that sent people down the horses aisle in the farm goods warehouses to use deworming medicine as a preventative antiviral.
It's really not, it's a frankenstein of a system with capitalist and socialist traits. If it were capitalism run amok, a consumer would be able to figure out the price of something as though it were a cup of coffee. Pricing is completely opaque and provides nearly zero demand for providers to compete.
It's not socialist (Medicaid/Medicare notwithstanding). But, it's definitely not "ECON-101 free-market capitalism" either. Lots of regulatory capture from both medical and insurance providers. Plus a bunch of self-inflicted dysfunction because we keep electing ding-dongs into Congress.
My doctor's office pushes really hard for me to set up a physical if I haven't been in recently and need prescription refills. This includes for allergy and asthma medication, which I have used as-needed since I was a child. This started happening around a decade ago; before that, it was never a problem to have the pharmacy call the doctor's office for the refills, and that was that.
The American sick care system is based around and incentivized to keep you a customer for life. I recommend people find preventative health and longevity specializing medical providers - they prioritize actual health and wellness.
I had a prescription that I used to get updated at my annual physical. I would schedule my next physical when I'd leave the office, but then they started telling me that they couldn't schedule anything more than 6 months out. I waited, and when I tried to finally schedule the physical they couldn't see me for 9 months. So now I order the medicine from India.
Talk to me when you get a $4000 bill for 2 hours in ER where the actual doc saw you for 5 mins and then the nurses did band-aid and over the counter burn ointment. This with Insurance (biggest mafia). AMerican Healthcare system baby!!
I was in one hospital ER for a kidney stone, but they had no urology available, so they sent me via ambulance ("thankfully", as a paramedic, one of our company benefits was that if we were ever transported, they'd bill our insurance and waive any charges to us) to another hospital. Ambulance crew wheeled me into the ER bay, where a 'transport' gurney from surgery, was waiting, and I slid from one to the other, and was wheeled to pre-op.
At no point did the ER staff ever talk to me. At no point was I in a room. Or in an ER bed, hallway or otherwise. Just ambulance, transport, and then to pre-op.
But, because the transfer physically happened in the ER, that second hospital tried to bill my insurance for an ER visit to the tune of $2,800 which I appealed (successfully, at least).
My elderly disabled mom on a fixed income is being billed for an ambulance ride from a hospital to a long-term care facility because Medicare deemed it "unnecessary" even though the shuttle couldn't take her.
I'm sorry. Hospital staff are notoriously bad for incorrectly filling out the paperwork that Medicare requires to justify ambulance transport, such that we (paramedics and EMTs) are constantly explaining it to them.
Shock, horror, you actually need to read through the form and select the appropriate checkboxes (around ability to stand, need for oxygen, fall risk and hazard, danger to self or others, etc., etc.)
Too many of them literally fill out patient demographics and a signature and say "here you go".
We push back because our organization policy is that we will transport those patients, BUT we would also much rather bill Medicare than the patient (our billing staff and C-suite may disagree, but EMTs and paramedics wholeheartedly understand that routine privately paid ambulance transport is not a viable option for 99.998% of the elderly).
How did the determination that you needed urology, "oops, no urology available", and ambulance transport get arranged? It seems like some level of triage, routing, unable, re-routing had to have happened, right?
I think you misunderstood their story. They [rightfully] got charged for the ER at Hospital #1, but were mistakenly charged for the ER a second time at Hospital #2.
Indeed I did. It now says "second hospital" in the last paragraph. I can't know whether I mis-read or if it was edited to clarify, but I definitely did misunderstand the story.
Present with abdominal pain, admitted, CT imaging, pain management. Imaging read, kidney stone diagnosis confirmed (and of such a size that it needed immediate management). No urology available at hospital one, and because of narcotics on-board, transferred to nearby hospital via ambulance that did have a urologist available, so I could go straight to theater.
But yes, hospital two tried to charge me for an ER visit, as well as the surgical billing (which of course was reasonable).
One of our employees decided to go to a random hospital ER room for a small cut on his finger. It only required a bandage, no stitches. The ER charged us $3,300. We are still fighting them.
Fighting the ER or the employee? Sounds like it could have been handled at a PCP or urgent care or with a bandage at home? Staffing a full trauma center is expensive, it should cost a lot to use it.
The system should not be that complex and full of traps. I rarely go to a doctor and when I have to go every few years I have no idea how things work and what to avoid.
Your simplistic description shows that you don't even know what you're talking about! The ER is for far more than life or death. A broken bone -- no matter how minor -- is a perfectly reasonable reason to visit the ER. Urgent care may work just as well, but there are many reasons why urgent care might not be a great option for people in their circumstances.
Sure. I never said otherwise. There’s obviously some judgement, and some areas won’t have an option. Bit to claim it’s too confusing to figure out (as the prior post suggested) is completely hyperbolic as well.
A long time ago, I was once charged for being browbeaten into entering a social security number on a keypad by a belligerent ER security guard at a hospital. Didn't even see anyone, but still charged.
In the US just because a person doesn't get much actual care at an ER that doesn't necessarily mean that they didn't have good cause to go there.
Some ERs don't always provide the level of care that they should, some doctors/insurance companies require patients to go to the ER for anything they need after office hours, and sometimes there's a need to be seen for something because of perfectly reasonable and valid concerns that it might be more serious than it ultimately ends up being.
While it's possible that the commenter's visit to the ER was a "waste of time and resources" I don't think it's fair to assume that from what was said.
Medical providers are constantly telling patients not to self-diagnose/self-treat/play google-doctor, but as soon as there is a billing problem, everyone uses that to victim blame. Kind of messed up if you ask me.
Personally I am not qualified to determine what a treatable and non-treatable burn looks like. Where I went to school they don't teach that.
The ER is not the only place you can go for medical treatment.
My order of operations for medical treatment are:
1) Virtual consultation. Free through my insurance. If you need to pay full price, this about as expensive as option 2. Also worth skipping if you can tell that an in person visit will be needed anyway.
2) A clinic. I use CVS's minute clinic. Looking at their price list [0], a minor burn treatment will run you about $100-$150, which is about what I would expect for talking to a professional.
A component of this is fear of liability in a highly-litigious environment. Nobody wants to be the one who told someone to wait and see instead of going to the ER, only to have the person wind up dying or suffering serious harm.
This is further exacerbated by the limited safety nets in the US–even people who would on principle deign to sue others who tried to help them in a time of bad luck may find that a lawsuit is the only way they'll be able to maintain a decent lifestyle after the loss of a partner, or with a newfound need for long-term care.
One more layer is the fact that doctors are so overbooked. Many people cannot reasonably get appointments with their family doctor (if they have one) on short notice, so some things that, in the past, might have been a "wait-til-morning then call the GP to drop in same-day" are now "GP is booked three months out, guess we're going to the hospital".
I mean I'm not sure that you shouldn't be charged ER prices for taking an over-the-counter-treatable injury to the ER. You probably shouldn't be charged 4000 for going to the ER, but just because you didn't actually need to go to the ER doesn't mean you didn't consume ER resources (the 24/7 staffing, the intake logistics, the trauma expertise, etc).
Probably the biggest surprise there is that a doctor saw you at all instead of you being filtered out by a triage nurse and sent to urgent care.
You have no idea what this person was being seen for.
It is fairly common for someone to be advised to seek emergency treatment out of precaution to ensure that a minor symptom is not indicative of a severe problem.
For example dizziness can be a completely nothing-burger inner ear problem treated with a bunch of motions from youtube, or it can be a stroke. The ER exists to make that distinction.
Part of all those logistics and resources should be used to shunt people to the correct treatment center, but liability suits and extreme profitability mean that the incentive is to treat them in the ER.
Put into other terms, if you were hospital admin incentivized on billing, and could bill someone $5k instead of $160 for a non-urgent issue, wouldn't you? The fixed costs are the same, the ER is running 24/7 with a trauma team, might as well make it profitable.
That was the treatment received, but perhaps they were referred to the ER by EMS for smoke inhalation.
I don't know either, but the broader point is that people are referred to the ED by medical professionals for seemingly minor issues all the time, and that the incentives are all lined up to treat stupid shit in the ER rather than have someone tell them to go somewhere that makes more sense.
> That was the treatment received, but perhaps they were referred to the ER by EMS for...
Isn't it CYA for any EMS to recommend you visiting the hospital, so they just say it to anyone. That allows them to later say that you failed to follow recommended advice.
Maybe so, but so what? If a medical professional tells me I should go to the hospital, I'm going to go. I'm not a doctor. I don't know how to diagnose injuries and illnesses beyond a very basic level.
That's exactly the point. People forget that EMS are not doctors. All they have is way more medical training than the average civilian. That's why it's a CYA for them. So the person that shows up to the ER as advised by EMS which later turns out to be a non-emergency is not the fault of the patient. Why punish them with unholy fees?
>perhaps they were referred to the ER by EMS for smoke inhalation.
In that case part of the treatment they received was emergency evaluation for smoke inhalation. Just because they don't end up giving you drugs or doing surgery about it doesn't mean the assessment wasn't a valuable service.
Maybe true, but as non-doctors, we are not necessarily qualified to self-diagnose the severity of a burn. We shouldn't be financially penalized for injuring ourselves and then -- in the stress and fear of the moment -- not being sure if our injury amounts to an emergency, or something much less urgent.
Well, at least, a functioning health care system shouldn't penalize for that sort of thing. We don't really have that in the US.
Yup, been there, done that. Many years ago I'd gone to the ER for something that ultimately didn't require an ER visit. But I'm not a doctor. I was scared, and didn't know if I needed immediate treatment or not. Much better to err on the side of assuming I do.
Insurance did try to deny coverage, but fortunately I appealed and won.
The sum is not a problem per se, the costs would be similar in many developed countries. Specialists can and do charge a lot (or hospital that employs them).
What matters is who picks up a bill (or challenges hospital and negotiates). I see little protection in US between patients and healthcare corporations, but its true I look from afar.
You could fly to New Zealand, have a scan on a state of the art machine, get a good report, have 3 weeks holiday and fly home. You’d have heaps of money left over.
$26k for a contrast MRI is outrageous. An MRI machine costs $1m at the high end. If you figure the procedure takes 2h and the machine runs 22h/day - which they tend to do - they're making over a quarter of the cost of the machine daily. It doesn't cost anywhere near that to run it; even if we're talking maintenance, salaries, and utilities.
I was in a multiple rollover accident and wanted to get a scan because, well, I was hanging upside down by my seatbelt for a while so I thought it would be prudent to make sure my neck or something didn't get fucked up.
The ambulance ride alone from the accident site to the hospital (like, 5 miles) was several thousand dollars.
Back in 2020, my son needed a Covid test for some event related to school. We called his doctor's office and made an appointment for the test. We showed up for the appointment, and we had to wait an extra 20 minutes because the doctor was late, only to be told "we don't do that testing". Then got a bill for $100 for a doctor's appointment.
I went for a covid and strep test during the tail end of the pandemic, and happened to pick the closest clinic, cuz you know, I felt like shit and didn't want to go far. This costed me $240, which seemed slightly fucking insane, so I called. Because the place was understaffed, I had to be seen by a doctor instead of a nurse, which for added fun was an out of network doctor. I didn't even KNOW he was a doctor at all, and never bothered to check the network status of the clinic because, again, it was a fucking covid and strep test. The strep test costed me about $20, the covid test was free, and the doctor who spent about 60 seconds reading me the results on the page was $220.
In my country (Brazil) it's illegal for doctors to require an appointment just to give a prescription. I see them doing it all the time anyway. It's sad.
The whole prescription business is such a grift. Doctors deliberately give you max 2 years of a prescription that you know you will need for longer (such as allergy meds, eye prescriptions) and then you have to waste your time and spend money just to renew it.
Is this part of the reason those online pharmacy platforms (which include a doctor who will do a very quick exam/diagnosis) took off in recent years? I mostly heard about them with regard to ADHD meds but wonder if they are also useful because they don't require you to have checkups all the time for maintenance medication.
That is accurate. But those virtual visits are 50% cheaper than full telemedicine visits and 70% cheaper than in-person renews.
It should be noted their virtual visits are mostly performative. You're filling in a survey beforehand and the doctor is just there to read the survey and push a big green button.
How long do the refills last? I would think that even with the cheaper cost of medicine, and the discounted telemedicine visit, it would still be more expensive than seeing a doctor annually and getting refills for all prescriptions for the rest of the year without needing additional appointments. But perhaps I'm underestimating how cheap these platforms are (both the meds and the docs)?
They aren't that cheap. But when your doctors appointment is $120+/each, they don't need to be that cheap, just cheaper. They're like 20% cheaper all-in compared to the traditional way, and you don't need to leave the house.
Plus many of these places specialize in stigmatized products like anti-bolding, ED meds, anti-depressants, etc.
Agreed. I have been on the same generic blood pressure medication for ~15 years now. I was recently on a vacation in Mexico and surprised to see that you can just buy it off the shelf there. That being said my healthcare plan includes a free yearly checkup with my doctor so it's kind of nice to have a yearly baseline of bloodwork/labs and be able to see it my patient portal.
Many (most) antihypertensives need periodic monitoring for electrolytes or kidney function. In Mexico, they are not going to get sued if you go into renal failure as compared to the US. Partly done for you and partly because of the sorry tort system in the US
When I need a prescription refilled I request a refill from the pharmacy. If the prescription has expired the pharmacy calls or faxes my doctor's office and they send a new prescription to the pharmacy. There is no charge for this.
I've only ever had doctors that worked that way so didn't even know that there were some that did not.
I now wonder which is more common, and if there is some way to tell beforehand when choosing a new doctor which kind they are?
It can be good for some things, and is more convenient to schedule (don't have to drive there, no risk of getting sick from other patients). Plus, there's a chance that in the future it could enable people in HCoL areas to get medical care from providers in LCoL areas, which would lower costs dramatically. I think for now the state-by-state cartel is still quite strong though.
But I agree that for some appointments it obviously doesn't work because you can't examine the patient or take vitals the same way/at all.
My son takes ADHD meds and it would be great if we could do the med checks (which are almost entirely questions for the parents) remotely, instead of taking him out of school and one of us out of work for several hours.
For certain things, like common illnesses, it is pretty good.
But that being said, use caution. I had something minor turn into an ER visit because I used telemedicine instead of going to my GP. Telemedicine prescribed antibiotics, which was correct, but GP would have done a drain too. Lack of drainage caused uhh unpleasant problems down the road.
Call me new-fashioned, but I don't want to spend a few hours of a workday several times per year to see a doctor for less than 5 minutes for prescription refill for a drug that I have been taking for years.
Why in the world would either of us need to see each-other in person when he can ask me the same 3 questions he always does over the phone?
One of the side effects is increased risk of suicidal thoughts, so I think it’s not unreasonable to have a medical professional ask every once in a while. OTOH, the pharmacist dispensing it could handle that
I love it -- I have an annual blood test to check on a condition, after the blood test results come in, it's followed up with a doctor appointment to discuss. It's so convenient to be able to Zoom in for a 5 minute visit instead of driving 30 minutes away to the doctor's office and waiting 30 minutes to see him for that 5 minute visit.
Just go to Mexico or an online pharmacy and get your meds at cost. /s
The US healthcare system is completely broken. Hospital systems and doctors offices in general lost a shit ton of money last year. There has been massive layoffs throughout this sector. There will continue to be this year. This year they all are going to try to survive by recouping their prior losses. Get ready for more fees.
In addition - there is consolidation in the physicians groups. Mom and pop groups are almost unfeasible at this point. Look for venture capitalists to scoop in. Guess what - you won't have better care with after those changes - I can promise that.
Lastly, the pharmaceutical industry is out of control. They hike prices on any and all medications that they are able to. They recently hiked flovent to a cost that no insurance companies or hospital will pay for it. There are limited alternatives at least for kids. This is medications that that has been out since the mid 80s. It is a controlled market, with high barriers to entry - you can either permit a wide west time of pharmaceutical environment or you can understand the need for a regulated marketplace and meet with with equivalent regulation in terms of pricing.
Finally the insurance companies are the worst. I don't know anyone with a good experience...the only ones that have a positive experience are those that don't use it. I try not to hate any single group but I hate insurance companies.
The system needs to be burned to the ground. It is fragmented and burdensome for healthcare providers and for patients. It benefits no one at this point. It creates additional workload for providers hospitals and patients alike.
I am afraid of what will come in it's place but can't we worse that this shit.
> Hospital systems and doctors offices in general lost a shit ton of money last year.
It costs 2-3x of healthcare in equivalent countries, with worse results. Where is that money going?
> In addition - there is consolidation in the physicians groups. Mom and pop groups are almost unfeasible at this point. Look for venture capitalists to scoop in.
Maybe we need a revolution, or at least an outsider rule breaker in the office from time to time, to break established monopolies, cartels etc. Any system gets rotten given enough time.
Just went out and bought a bottle of Avamys (more modern version of Flovent) for $15 without any hassle. Shed a tear for poor Americans.
Uhm... in Poland there are usually "refill forms" at your chosen / doctors office, you fill it out, drop at the reception and then you get prescription code via sms with which you can claim it at any pharmacy (that has the drug)
Only 10% of the increase in medical cost in the US is attributable to doctor salaries. The remainder is administrative overhead, Rx costs, insurance administration, etc.
There are now 10 administrators for every 1 doctor.
Since 1970, the number of physicians has increased by 2x. The number of administrative staff has increased by 38x.
If each administrator is making 100k+ - 150k+, that's significant cost.
Some of these crazy billing practices are due to the private equity buy-ups and consolidation, creating workflows and fee structures that are hostile to patients and doctors, but benefit the PE firms.
That kind of lazy thinking drives me up the wall. There's a huge swatch of America that thinks elementary school teachers are bringing home FAT BUCKS because college tuition costs are high.
Absolutely. I used the number of administrative personal * administrative salaries because it's a quick mental visualization.
I just reviewed United Healthcare's 2022 10k.
In 2022, they had $324B in revenue, and paid $210B in medical expenses. Of the $114B remaining, $85.5B was various operating costs, $28.5B (25%) was corporate profit / operating income (before interest & taxes).
Even if all 40,000 employees of UnitedHealth Group were making 200k (they're not), that'd only account for $8B of their $85.5B in non-medical costs.
https://www.unitedhealthgroup.com/content/dam/UHG/PDF/invest...
I worked in healthcare and this McKinsey report (exhibit 2 on page 81) is probably the best analysis I've seen that tries to isolate where the extra money is going.
The biggest driver of higher US healthcare costs is outpatient care. And it's not just that each healthcare event is more expensive (though it is), it's that Americans get a lot more outpatient care than other OECD countries.
Well, we also do have an overhead here and doctors usually make way more than the average person but still majority of the doctors work in public sector. It's not completely rosy though - the biggest downside is that quite often you have to wait quite long to visit a specialist, especially if it's any good (our previous government said "let them leave" so lots of medical stuff just migrated to the west...) but hopefully with the increase of spending on health (we are around 6% of gdp...) things will improve.
Had an eye doctor set up a follow visit appointment for my wife. We went for the follow up and he said “I don’t know why i’m seeing you for this” said it looked fine and then asked us to come back again in a month.
One Medical charges $9/month (through Amazon), all video visits are free (if you click the proper link), and I've had multiple prescriptions renewed that way. Three times waited less than a minute, longest wait was 15 minutes, and the app will call you back if you wish so you don't have to keep the app open.
+1. They also will write new prescription for low-risk things. And you don't necessarily need video, they do it over messages and just ask for photos of symptoms, in some cases.
My company pays for One Medical, and it’s honestly the best practice I’ve been to in the US. I can typically get an appointment the next day, there are tons of offices (in SF), and everyone is kind and efficient.
They ask you to set a primary care doctor, but I have had more success with seeing a small group of their more available non-MD physicians.
This is why I think US medicine should be deregulated, especially licensing laws.
Everything you're describing is screaming monopoly and artificial lack of competition.
If providers of class X are too busy to see you, then there's plenty of people who could, or you're just going to do it on your own. It needs to be more like that.
Obviously there are some limits, but educational pathways could be much more diverse, and there are many things that patients are capable of accessing on their own or through providers like pharmacists.
Reading a lot of the responses here, I've realized another reason why the fight for a better health care system in the US goes so poorly. People are so used to the costs and being jerked around by the system that they've completely normalized it. "Oh, you should have known those symptoms didn't require an ER visit; it's your fault you got such a large bill." "Every hospital or doctor is going to try to push extra charges like that; you have to contest them or just not pay and hope the problem goes away; that's just how it is."
Then someone from outside the US says, "that would never happen in my country; here's how it works here..." and it's immediately assumed there's some sort of huge catch, that never, nowhere could a health care system work that well without some sort of major trade off or downside.
No! Stop this! A health care system should work for patients, not against them! Injured or suddenly-sick people are not in the best head space to make rational, informed decisions as to what level of care they need in the moment. Even if they were, nearly all lack the specific medical training that would always allow them make that decision with a comfortable level of certainty.
And even if someone should have known better, I just don't get the ire. Why should we put people into tenuous financial situations just because they made a mistake in how they sought medical care? Medical care! What the hell is wrong with people?
The US health care system is awful, despite having so many great and talented doctors, nurses, and staff! Let's get that through our heads! We pay so much more than other developed countries, for so much less care. And the reason we don't have something better is because the right public policy is labeled "socialism". This is so exhausting.
I met with a new accountant yesterday. He told me that if I email him and ask if I can expense a lunch and it's a 1 minute answer, he's not gonna charge me. But if it's gonna take him a good amount of time to respond, then he will. And I think that this is completely fair.
I'd expect the same from a doctor. If I am asking a very occasional and non-urgent question with a quick answer (e.g., can I take my medicine and drink alcohol safely) then yeah, I'll be annoyed if I get a $25 fee. But typing out responses to question might take my doctor 30 minutes, so it's fair if they charge me, so long as I get a good answer in a reasonable timeframe.
Obviously there's exceptions. If it's a brain surgeon who just made $25,000 on a single procedure and I have a 15 minute followup question, it seems a little nervy to bill me $25 more, but not if I'm emailing my kid's pediatrician a picture of a rash.
1. The accountant will tell you that pricing up front, so you can make a decision before you send an email. No doctor in America will answer any question about pricing ahead of time.
2. The vast majority of Americans know precisely when they need to pay taxes and roughly how much work they will be, how many accounts they're dealing with, what types of questions might arise, etc. It is extremely rare for most people to ever have an urgent question for an accountant. Healthcare on the other hand is inherently unpredictable, and urgent questions are very common.
3. Most people don't have, and never will have, an accountant. Every single living human of any age needs at least one doctor, and often quite a few.
4. If you don't like your accountant's pricing, you can easily shop around for a different one. You can't do that with a doctor (see point 1). You can sort of do it with insurance, but that isn't the same thing, can only be done once a year, and the options are very limited for most people.
5. If you don't like dealing with an accountant at all, you can just get a normal job and never talk to one again. It's entirely within your control. If you don't like dealing with doctors, you're out of luck unless you want to die.
Doctors very much charge for time. By definition, their work doesn't scale. But because of their immense training, they get to charge _a lot_ for that time.
The same is true in law. Just because you have 10,000 hours of training doesn't mean you aren't billing by the hour.
This is why there are many many doctor and attorney millionaires and very few doctor/attorney billionaires.
Well, it would be occasional for you to ask questions to your doctor, but your doctor wouldn't be just occasionally answering questions from their patients
> Non-urgent questions
Imagine everyone sending non-urgent questions... Isn't it even more irritating to be receiving non-urgent questions than urgent ones if you're a doctor? I guess the doctor could reply with a FAQ.
Honestly, this is where I think personal LLMs should come to the rescue. Just ask a doctor-sanctioned/fine-tuned LLM for trivial questions.
I don't mind paying for my Dr's time. If my insurance starts doctor blocking by making me chat with an AI first AND charging me for that? No, that's not going to be acceptable.
Yeah that wouldn't be a good outcome. How would you feel if the doctor were messaging you through a platform that had extensive predictive text features, possibly trained on that particular doctor's past messages, and allowed her to send a message in 30 seconds that would have taken 10 minutes to type out? If you used that system for years and paid for it happily, would you be upset to learn that the doctor was spending so little time?
The difference here really is that the doctor is reviewing what is being sent in some practice. Sure, there's some possibility that the doctor is over influenced by the suggestion and goes "it seems right", but that's true even if they effectively google it as GPs often do today. Whereas a LLM trained on the internet at large seems about as useful as WebMD, which sometimes feels like it would tell you bleeding after an accident chopping food is a sign of cancer.
Most EMR's allow for certain boilerplate things to be inserted easily. My wife is a neurologist; it's very common for her to dictate a note saying "insert seizure precautions" and it puts in a paragraph of things that you can't do if you have seizures: take a bath, drive, get on ladders or other elevated surfaces, that sort of thing.
I've customized the hell out of my own hospital's Epic system (I'm an anesthesiologist) to make notes as easy as possible. 95% of the things I do are done the same way, every time. Back when we used paper, they had all of that in checkboxes on forms. Basically a way to say "yes, I did this legal and proper" very quickly. It was very useful because you knew that if you skipped over that and went straight to the written description on an old record, you'd actually get the important information.
Before billing criteria took over medical documents, doctors could do more because a board-certified pediatrician doing a well-baby visit could just write "18 mo WM, PMH NC, PE WNL, f/u 6 mo" (18 month old white male, past medical history noncontributory, physical exam within normal limits, follow up in six months). We had "skeletons" for reporting the most common labs in notes - just a graphic representation so you didn't have to write "Sodium 139, potassium 4.3, chloride 122, bicarb 24, BUN 9, creatinine 1.1, glucose 85".
As another commenter said, EMR have allowed Drs to dictate messages for some time now, filling in important details for them. I worked on a very popular one some 12 years ago. No, I wouldn't care if it takes them 30 seconds vs 10 min. as long as it is my Dr driving it.
In some countries in Europe, if you have private insurance they'll pull off the "call charge" trick as often as they can. Need to make or reschedule an appointment? Make a call. Did some blood test and need the results? Call to get them. They call you to tell you they can't make the appointment and need to reschedule? You still get charged. If it's not a call it's a fake shot. Fake disinfection charge. And so on. The principle is "anything that can be charged, will be charged". The level of insurance fraud with this is ridiculous.
> they tend to not be well supported by the number
Personal opinion or did you ever talk to anyone investigating these things?
First of all, the fraud is committed by the patient, they're the one submitting the claim to their private insurance without validating it. Secondly, it will always be called a mistake if you object to it. But nobody does because remember, private insurance pays anyway. On top of it once you object and have a few arguments with them you may even find yourself having difficulties to get an appointment if it's a desired doctor with a queue at the door.
There are no numbers because this is not investigated, there just aren't resources for this. Nobody with a private insurance bothers reporting a $5-10 shot they never received and nobody wastes resources to investigate it. I've seen attempts to swindle me out of 5 digit sums of EUR that would have otherwise been blindly paid by the insurance. I actually checked everything, I objected, it was called a system error. I have acquaintances who work with the authorities and they confirmed that even if you find a pattern it's impossible to prove intent, so it never goes further than "we correct the mistake for those who report it".
Politician corruption is basically non-existent, and Al Capone just didn't pay tax. According to the numbers.
I worked for a mature healthcare company and much of our marketing centered around healthcare provider surveys of doctors and nurses. The results were unsettling. Extremely high rates of burnout, typically due to administrative overhead. Horrifying medical error rates.
Doctors should be compensated for the amount of time to send an email. Every other industry is capable of restructuring support to satisfy demand. It's up to the healthcare providers to manage this channel properly as any other would.
The real question is: what would it take for the healthcare industry to restructure itself to actually function?
that's a poor excuse. We can provide much better care for the elderly. the bulk of the operating cost growth in the past generation has been from administration.
> Strike the words "over 65" from the medicare bill.
If you mean "universal single-payer", its worth noting that Medicare is very much not single payer and striking the population restriction for Medicare would not produce universal single payer (or even a single comprehensive plan for each individual, unless they are opting for privately-provided, publicly subsidized main insurance -- otherwise hospital [Part A], outpatient [Part B], and prescription drug [Part D] are separate insurance systems, and only the first two are public.)
Medicare is a particularly complicated implementation of partially publicly subsidized private insurance with an (incomplete) public option.
Medicare only covers 80% and the providers are specifically prohibited from waiving that copay. Yes we need single payer but the Trojan horse of expanding Medicare to lower the age incrementally is just PR it is a way for insurers to reduce the average age of their insured cohort.
Maybe it wouldn't fix everything but I'd like to see a great increase on the cap of the number of medical residencies supported by the government. The AMA and doctors in general shouldn't be artificially limiting the number of doctors.
I'd like to see the other usual suspects addressed too but it seems like the doctor shortage is a big part of the problem.
Do you think if there are more doctors, they are going to be more willing to provide free services? I don't - doctors want to get paid for their services - insurance companies (in general) don't pay for doctors to respond to emails - having more doctors doesn't solve this problem.
Not saying we don't need more doctors, but seems unrelated to to the problem being discussed.
If there are more doctors they won't need to choose between working unpaid overtime or charging an overtime rate. Patient workloads could be adjusted that doctors could respond to messages during their regular work hours.
This is one of the major issues underlying the perversity of US healthcare. That and high-level executive churn incentivizing "innovative" initiatives and policy changes just so the executive makes their mark and leaves for the next rung elsewhere.
> what would it take for the healthcare industry to restructure itself to actually function?
I can't quote it precisely, but here's a gist from The Glass Bead Game:
> Intelligence can find its own way, the teacher's job is to address stupidity.
Overlooking the crudeness here, I think it's a good idea, and translates to medicine. Most of us are not qualified to define good care, but we know bad care when we see it.
One example of bad care is when you don't discover how expensive a treatment will be until 3 months after it has occurred.
Another might be cases where medical professionals are expected to work insane long shifts with insufficient sleep time in between.
Whatever the examples are, let's make a list of them. Build consensus around the worst offenders, and then start revoking counts-as-medical-insurance tax status from the insurers who fund the bad behavior. If you want pre-tax-medical-insurance dollars, you must:
- be able to turn a "what if" treatment scenario into a dollar amount in less than 10 minutes
- not have organizations be in-network which create unsustainable working conditions for medical personnel
- [other example of bad care goes here]
...and we add to that list over time. Markets don't do design, they do evolution. We have to kill off the ones we don't like if we want more of the ones we like.
We dont even recognize bad care. People are overweight and suffering from chronic disease , but since they are “alive “ and taking meds we still call that a good outcome
sadly, a lot of patients consider that good care - around me, doctors stopped weighing patients, and don't ever discuss lifestyle changes or dietary changes (patients by and large don't want to hear it) - they just give the patients the pills they want to offset the poor lifestyle choices.
On the flip side: It's so frustrating to go in search of guidance re: lifestyle changes and they don't wanna hear it, instead all that do is recommend drugs.
Maybe we need to remove gatekeeping access to drugs from the primary care physician's job so that they can focus on the other parts.
I think you have that backwards. Gatekeeping (certain) drugs requires expert clinical knowledge to achieve the right results without harming the patient. This is one of the primary focus areas for physician training.
If patients need lifestyle advice then going to a highly paid physician is a waste. Those patients should start with a (cheaper) therapist, personal trainer, dietician, or social worker. We can't reasonably put the entire burden on physicians; it's too much for one profession to handle.
If you go to those people and tell them you have pain and you need to know which muscles to strengthen and which muscles to stretch, whether to rest or work out or get an x-ray, etc. they tell you to go to a physical therapist. But you need a referral for a physical therapist, so you have to go to a primary care physician first. All they do is throw drugs at you so you basically have to lie about taking the drugs because no I don't need painkillers I need answers, and then you can finally get your referral and go to the physical therapist who can help.
I've had this experience once and my wife has had it thrice (different doctors, different injuries).
By asking primary care physicians to gatekeep drugs, we're introducing a bias where when you walk in the door they assume you're after drugs. I don't have a solution for how best to gatekeep drugs, I just wish I could find a doctor who was unencumbered by that task so they could focus on healthcare instead.
if this were true, why do the pharmacy rules vary considerably among different countries. In the US the rules are very strict. In Europe moderate and in Mexico very lenient.
Every time you try to change a medical policy the threat is "you'll kill grandma". the fact is that grandma's care is awful and we need radical changes.
i totally agree. the drugs are a huge health problem, but also psychological. Having to care for the elderly I've noticed the drugs serve another more concerning purpose. They create a psychological dependency from the patient onto the doctor / healthcare provider. The patients treat the doctors like magicians because of their control over meds.
Breaking drugs out to pharmacies, Mexican style, would go a long way to interrupt this dependency.
Every time my lawyer replies to my email, it costs me $35. At least. That's just for one or two line responses. Anything that requires research or (gasp) looping in a partner gets a lot more expensive, very quickly. This doctor sounds like a good deal.
Typically, when you are talking to a lawyer, you have signed a contract, paid a retainer, and have an explicit hourly rate negotiated for interactions with that specific firm.
Yeah, and typically when you do the same with a doctor the fee you pay has been negotiated with your insurance provider. This is no worse than anything else billing-related in healthcare.
There's also quite a difference between the ethics of healthcare and legal services.
Most of the time if you need a legal answer from a lawyer who charges like that, it's because you know you'll net more money from having the answer than it will cost to get a reply.
With healthcare, you're not trying to make money you're just trying to live.
There's a lot to unpack here, but in the US healthcare is delivered in a fee-for-service model very much like any other service you use. Unless and until we change that model, why do you expect doctors to give up income they could receive from seeing patients in-person in order to read and respond to your emails for free?
It’s both much harder and more expensive to become a doctor than a lawyer.
And usually I’m paying my lawyer to protect me from risks to my financial health, not because I think checking with them will make me money. My doctor helps protect me from health risks. It’s pretty similar. A mess-up in either area could easily mess up my life very badly.
There are many situations in the ordinary course of life where, if not strictly required, an attorney is at least strongly advised. Things like immigration, adoption, divorce, disputes with your landlord, probate, personal bankruptcy, seeking power of attorney for a family member with dementia, etc.
You're correct that I'm in the privileged position of being able to afford my lawyer. (And my doctor and health insurance provider.) I'd just point out that not everything that involves a lawyer is about making money.
But you raise a fair point, and I apologize if my somewhat flip comment came across as insensitive.
Every time the topic gets of healthcare comes up I always wonder how many doctors have tried themselves to interact with their own clinic (has to be their own)
Trying to do simple things like:
- Setting or getting an appointment.
- Calling to sort out their office’s coding error that resulted in me getting an erroneous bill
- Trying to get access to their portal or getting results for tests transferred in a realiable manner to another doctor’s office.
I truly think that they would be mortified beyond words and wouldn’t believe their name is on the sign up front.
Trust me, they are all aware of this. The problem is that, for the majority of doctors now, they do not own or control their clinics. They are either: 1)employees of the health system or 2)partners or employees of a provider's group that essentially contracts with the system to provide doctors. The doctors themselves have no real control over how their clinics operate outside of contractual negotiations.
The doctors are just cogs in a machine. The problem is that if your compensation is $200k-$1000k why would really want to tackle the issue.
Specialists make so much money they can hire a personal assistants to handle all the annoying things.
I know several pharmacists, one is highly intelligent and she is the only one who wants to get out of the field because healthcare in the US is toxic and profit driven.
Yeah, most of the time when patients send emails, they get responses from a nurse. At least at my wife's clinic, they do not always charge for emails. They only choose to charge when an email is asking something non-obvious or for the doctor to take some action that requires additional work/time outside of just reading and responding to an email.
That is basically scenario #2 (which is common), but for whatever reason they haven’t been very successful at pushing back against some of the changes that cause these issues. I don’t have much insight to offer there since I’m not at the negotiating table there.
I mean I think the answer is that good doctors do form employee-owned co-ops, which are often very successful and establish a great deal of trust in their community, but then when the time comes for them to retire they very understandably cash out and sell to the private organizations that proceed to run them for profit first.
I've been playing with the idea for a while that any time a company uses its name, it has to disclose its ownership (first the company at the top of the chain, then the ownership structure of that company). So like for example the company name "Gerber" would have to always be coupled with "owned by Nestle, a publicly traded company.", and "Dave Franklin, a Dentist in your Community You can Trust" would have to be coupled with "Owned by Private Equity Incorporated, mostly owned by pension funds".
This would make it easier to keep track of if the same company is just screwing you over and over again with different faces, while still allowing some value to remain to brands that are consistently good for customers.
actually, the problem is that Congress continues to LOWER physician reimbursement, but RAISE hospital reimbursement. When I became a surgeon in 2002, medicare paid $600 for me to take out a gallbladder. I had to pay my overhead (50%) so my take-home was $300. Today, in 2024, after price reductions, medicare pays $600.
That is why I have to be employed. I guarantee that after 22 years, office expenditures (rent, salaries, supplies, health insurance) would eat up the remaining $300. So taking care of Medicare patients would be charity. Medicare is 60% of my practice. Private insurance is 25%. Medicaid is 10% and unfunded is 5%.
Well, despite that physician-owned hospitals have better outcomes than profit-above-all-else hospitals run by MBAs, Congress outlawed future physician-owned hospitals in the Affordable Care Act (Obamacare).
> I truly think that they would be mortified beyond words
My primary knows and gives me tips for navigating the administration of their own (as in, they own it) practice. I guarantee they hear quite a bit of griping and moaning from patients about phone tree and waiting room delays.
Retaining good admin staff in my area is very difficult, but doctors aren't going to close their practices because of it.
My wife is a doctor. They all know the problems, but there's often either not the incentive or time to fix it. The system they work in doesn't care to fix it.
> Dr. Lauren Oshman, a family physician and associate professor at the University of Michigan Medical School, says she initially experienced some patient resistance and anger about the prospect of being billed for emails.
> Now, she says, patients are typically pleased that they are able to get a direct response from her through a portal message.
> “They’re thrilled when they get me directly,” she says.
> Geez, this could make corporate PR people blush.
Yeah, it’s embarrassing. I am not “thrilled” to talk to a doctor directly. I pay for it, and when I do it’s because I have a reason to, which kind of limits the thrilling aspect. I expect it, and I need it, sure. But it’s not being able to talk to my doctor that elicits an emotional response, and it tends to be anger.
Hmm. I'm not sure if this is just a difference between private practice and hospitals, but there is a ton of questions that can and should be serviced by non-physicians (e.g. RNAs, nurse practitioners, physician assistants). Their role in patient care is consistently growing in importance. It's rare for me to send a message through a patient portal and have a physician answer it. It's always someone on the staff.
It's ironic because I almost never want to message my doctor - there just simply isn't another option.
In the Michigan Medicine system the 3 main message options are: refill a medication, ask a medical question, and ask a billing question. If you select "ask a medical question" the next and final choice is whether you're submitting a question in English or Spanish.
Most often I want to ask a scheduler (because each office/department schedules differently) or a nurse a question, but for that you have to call. Something as simple as scheduling a flu or covid shot can't be done via messaging.
That's nicer than my experience! My attorney charged me to respond to my emails without reading them. And when the relationship inevitably ran aground at the 11th hour, he feigned ignorance of everything I had been telling him. I do my own low-pressure legal work now.
I honestly think we'd be better off if doctors and nurses charged for their time like the good lawyers and paralegals due.
No fixed fees. No per-visit charges. Just bill for the time spent (including pre- and post-visit paperwork) and the direct expenses actually incurred. Everything else is built into the hourly rate.
It will never happen, but it would be much better.
Did you ask for a refund of those billings? If they refuse, you should report them to the State Bar if they're doing that. It's unethical to charge for services not rendered.
Speaking as an attorney myself, I'm not the least bit surprised that a bunch of my peers are claiming that they can charge to merely view emails. Many attorneys -- especially bad ones -- are particularly defensive of the practice.
The problem is that without demonstrating somehow that they read it, they cannot prove they actually read that correspondence when they claim to have. This puts them in a difficult position because the client can plausibly claim that they did work they didn't actually do. Perhaps they don't need to send an explicit acknowledgment (even though it's the right thing to do), but if they don't even act like they received and read it, yet charge you for it, that's a real problem.
FWIW I've had little trouble getting my attorneys to credit me for activities I didn't ask them to do. Somewhat different situation, but most good attorneys aren't scumbags.
> I'm not the least bit surprised that a bunch of my peers are claiming that they can charge to merely view emails. Many attorneys -- especially bad ones -- are particularly defensive of the practice.
Having received many email tomes from clients, I wouldn't think twice to charge for reading their email. I would typically respond, but not necessarily if they weren't asking a question, or if we were going to be meeting soon to discuss.
I don't know any attorneys (note: all the attorneys I know are corporate attorneys, so may be less bill-sensitive) who would not bill for time spent reading emails. Lawyers spend tons of time reading emails!
> FWIW I've had little trouble getting my attorneys to credit me for activities I didn't ask them to do.
This makes sense, but is somewhat orthogonal to the email question. If a client sends his lawyer a long email, he is implicitly asking the lawyer to spend the time reading the email.
Doctor-patient written communications (email, whatsapp whatever) can put doctors in legal risk whether they answer or not. Answering in a meaningful way also takes from the physician's time, much of it during their after-hours.
The clinic where I practice requires making a telephone number and email available to patients. A lot of patients might use them sensibly but some patients just abuse this.
If it were up to me, I would also put a cost on each form of communication as if it were a visit to the office!
> The clinic where I practice requires making a telephone number and email available to patients
I wonder if contacting your doctor directly is a US thing? Before this discussion I had never heard of such an option. I definitely don't have any way of directly contacting any medical staff, neither a nurse nor a doctor, it will have to be through an appointment.
This might finally explain why this "ask your doctor" is so often repeated online as a realistic option? You definitely won't ask your doctor about every minor thing if it's behind an appointment.
I think the ridiculous thing here is not the doctor charging but that all insurance doesn't cover it.
I bet there are a ton of consultants and lawyers (and maybe some accountants) on HN and most of them will charge you for time spent replying to emails.
Edit: inserted the word "all" before insurance to clarify my intent.
> Health plans covered the full cost of about 82% of claims, according to the Peterson-KFF analysis. Patients who shared the cost paid $25 on average.
I would be very curious to know if my insurance is paying for the useless messages that my doctor's office sends. I sure hope not — they are next to worthless!
Regardless of if you feel they are worthless, IMO, the people who create them should not be asked to work for free. I've never found the notes from mine to be "worthless", you may want to find a new doctor.
Also, your TFA is kind of unnecessarily vulgar (You do know what the F in TFA is for?) here seeing as it doesn't change the point of my original comment. I did, however, add the word "all" incase someone took my comment to read that I didn't think any insurance covered it.
> I've never found the notes from mine to be "worthless", you may want to find a new doctor.
Thanks for the thought, but unfortunately our whole system (Stanford Health Care, FWIW) is like this. My doctor is better than my kids' doctor, and my wife's doctor. The incentives are just not there for them to engage, so mostly I get nurse messages that are useless. It appears to be a copy/paste from google (or some internal system), basically.
As for "TFA", I do know what it means and see it used here regularly [1] and without meaning anything harsh. It's not like some people say "TA" and some people say "TFA". It's just TFA. Regardless, I didn't meant to offend you or make it seem like I was demeaning you. I was just pointing out that the article addressed your complaint, and indicated that the vast majority of insurance plans don't leave the cost up to the patient. I nonetheless appreciate your feedback and will consider "TFA" more carefully in the future. If you have any equally pithy alternatives, I would welcome them!
Maybe there would be an incentive for them to engage if they were getting paid for it... granted there would also need to be an incentive for them to not abuse it. But that's already an issue, for example: I had a dentist who would routinely recommend procedures I didn't need.
I know a few primary care doctors and they are all overworked and overbooked. I can't imagine any of them going above an beyond unfortunately (not because they don't want to but because they don't have the time). But most of the one's I know hate the system too.
I appreciate the clarification on tone. As a dev I read TFA in the same time as RTFM (as in: why didn't you read the article you moron?). But I get your usage as well.
I would think that there are very few scenarios where an email isn't cheaper than the alternative.
I would guess that fully covering patient emails would save insurance companies money in the long run, but why do that when you can boost short-term profits?
There's a really interesting clip in the documentary "What The Health" where the interviewer attempts an interview with one of the doctors and gets rejected by the hospital PR person:
Transcript:
actually i understand that doctor said that you could film here today but
51:04
unfortunately that's not going to be able to happen i know that he advocates for patients changing their diets but the
51:10
hospital makes money off these surgeries and the reality is he does too so we can't do anything that's gonna
51:16
negatively impact the hospital so unfortunately you're not gonna be able to film here today
A 15 minute email from my lawyer costs about $150, I don’t see why we should be outraged about $25? It’s much harder and more expensive to become a doctor.
Lawyers did pricing better than doctors. Medicine hid costs through a payment plan lumped in with hazard insurance. Now that the game of hide the money has played out, people see real costs and they act shocked.
Perhaps, but doctors get paid through opaque insurance. While that can be a hassle, it also introduces the huge benefit of OPM (Other People's Money). Convince your patients to come in for a 20 minute physical, for which they pay $25, and you get 20x as much from their insurance company. Lawyers don't have that play in their playbook!
I can assure you that in a hospital system, the doctor is not getting much of the $25 either. For my situation, we don't charge for messages, but for other services we need to hit a target (messages don't count) based on our salary, and productivity bonuses above that target are about 5-10% of the billed amount.
Honestly, I wish I could pay my doctor $25 after insurance and get a prompt response from him to an e-mail. That would be incredible.
As things stand, I have to call. He doesn't take e-mails. If I have a quick question, I can schedule a virtual appointment. There is usually a 2-3 month wait. The appointment is scheduled for a day, not a time, and is limited to 15 minutes. They'll let me know the time about 30 minutes in advance, and it could be any time of day. If I miss or can't make the video call, it's usually another 2-3 months before he has availability again. There are no other doctors with the relevant specialty nearby, so this is what I get.
People talk a lot about prescription drugs, but the real driver of costs are the hospitals, both public and private. Drugs account for 10-15% of total healthcare spending; it’s the hospital reimbursement & compensation framework along with private insurance that is driving the bulk of costs. It’s evolved into a patchwork, opaque, dysfunctional system where the end consumer has little view into the inner workings and is left staring at a massive bill.
"Non-Profit" hospitals with incredibly bloated administrations paying a CEO $10MM a year to order constant hospital expansions and ever growing outpatient care so they can reliably spend off any possible profits.
Last I checked about 15 to 20 percent of all US workers were in the health industry. It's basically a patriotic duty to pay your medical bill, because you have to pay all the insurance industry workers, and all the hospital administrators and CEOs, and all these people, and there might even be a few bucks left over for the doctor in the end. I don't see how healthcare can ever cost less until we simplify these systems and eliminate a lot of jobs (which wont be politically popular).
> Drugs account for 10-15% of total healthcare spending
And still, drugs are too expensive in the USA, especially old drugs like insulin and albuterol (asthma inhalant) that seem to find new ways of being re-patented (e.g., through new delivery devices that are just novel enough to be granted a patent, but provide no significant improvement to the patient).
If drugs, pricey as they are in the USA, are only 10-15% of healthcare spending, that should frighten you as to how cost-inefficient our health care system is.
My spouse is a physician, and "patient messages" (aka "non-face-to-face" encounters) usually aren't reimbursed by insurance. Having a friendly online conversation with a patient doesn't generate the "RVUs" they need (contractually!), so time spent messaging is time taken out of their personal day on top of their regular workload.
Responding to messages can also just be very difficult and time consuming. Maybe you ask concise, clear, pertinent messages to your doctor (or think you do!), but most do not. It's similar to problems HN readers might be more familiar with: user-created support tickets, and comment moderation. Medical office staff help with this triage and moderation, but it has become a big problem to manage with how easy it now is for bored/sick/scared patients to send messages.
If my actual doctor responded to my messages within some SLA (2 days?) then I'm more than happy to pay much more.
Now a days what happens is I send a message with photos or many details, and some poor nurse who is assigned message triage is going through many and responds with generic pointless text for my issue.
I agree that charging a fee can be fine. For me it's often a win-win. I spend less time having to go there, and the doctor can spend less time than an in-person visit and even do it on some down-time. But it's still a service, so paying about same as a regular doctor visit (about ~$20 or so here in Norway) is fine.
My biggest gripe here is that if the doctor answers me outside office hours, an additional "emergency / inconvenience fee" is added. Like, I can't control when you answer, and I didn't choose it. If I send in something during daytime and you didn't get to it, answer me the next day, then. Or make it a choice that I want a prioritized answer so at least I decide. It's just bonkers.
I recently was informed that the question to my doctor over messaging qualifies as “e-visit” and was giving 3 different CPT codes(differing by time physician would spend answering it)
The CPT is how services are identified for medical billing and I called my hospitals financial assistance line to find the contractual “allowed amount” they would charge my insurance(and therefore me since I did not hit my deductible)
The cost for this e-visit message would range from $65 if it took less than 10 minutes to $438 if it took more than 25 minutes.
With absolute zero accountability on how this time was spent.
Lawyers are way more transparent than medical billers
My wife works at an academic hospital and bills for messages sent through the portal. If it hasn't arrived yet, it will. Patient care specialists (nurses, physicians, etc.) are spending a ton of time everyday responding to patient "text" messages.
A friend is a vet and frequently rolls their eyes when I mention that I'm going into a doctor's office to review lab results. But in that meatspace discussion, we talked about dietary changes, upcoming medications and potential interactions, how my primary should get some records from another doctor, and I was able to ask about if an elective medical procedure was advisable, given my medical history. It was easily 20 minutes of relaxed discussion about an actual medical plan.
If it was three minutes of "these are your lab results; you should/shouldn't come in for a follow-up," I'd agree that it should be a phone call that's covered under the cost of the original appointment. But given that vet friend is constantly pressed for time and doesn't get to bill separately for those callbacks, I can't imagine why my primary doctor would want to do the same.
I don't want medical professionals responsible for my care to squeeze things in when they have time. Insurance is likely to be even more of a pain in the ass, and cramming in tasks because they're unpaid means lower quality of care.
American health care is basically about 550,000 parasites in the US economy ensuring their own stream of income by denying people health care and price gouging those who can afford it.
The culmination of the American middle-man capitalism.
$39 a each message seems expensive - but I don't think $39 per thread/conversation is unreasonable with the actual doctor (would not pay not that for staff).
I’m making up numbers but if a private practice physician earns $250k/year for 2000 hours that’s $125/hr + taxes and benefits + rent/overhead + nursing and staff, you figure that cost is probably closer to $300/hr then you you assume they have to do ~30min of prep/admin for every patient hour that’s closer to $450/hr that’s ~$37.5 per 5 min of patient time (and none of that is factoring in reimbursement rates), people can disagree as to how those costs should be borne but let’s not kid ourselves as to what the cost of doctors time is…
This could potentially increase the number of useful questions being asked. My spouse is a physician. Recently she had to answer a phone call from a patient in the middle of the night where they were asking a question from a party about something non-urgent for their child. In another case, she got called by a parent at 2am because their kid was having trouble sleeping but nothing else was wrong with them (welcome to parenthood). If people had to pay, maybe they would _think_ before asking questions.
I've been in meetings with healthcare providers about incorporating LLMs into text-based patient-physician messaging to improve triage and routing. It is just overwhelming for many providers. A large percentage are getting burnt out, and much of their time is uncompensated.
Did those patients press “4” for “urgent problems to be responded to immediately” or something?
> If people had to pay, maybe they would _think_ before asking questions.
Be careful, a lot more people might be calling at 4am because they figure it’s okay because they’re paying for it. At least other contractors can give people a “fuck off” quote for work they don’t want to take, but might be difficult to implement that here.
371 comments
[ 2.8 ms ] story [ 286 ms ] threadI wonder if charging for these messages will make doctors more likely to respond. I wouldn't mind a modest copay for these. But if I pay $30 for an appointment, a quick message should be under $15. There would also have to be some sort of SLA, or the ability for a patient to specify that a question/email has expired and no longer requires an answer.
I've had situations where I waited for a doctor's callback so long that I ended up calling a friend who was a physician assistant, watching a youtube video about how to fix the problem, and taking care of it myself. The only way that process could be any worse is if I got a reply after I had fixed it — and a bill for the message.
Edit: In no way am I saying "American healthcare is just fine!" only that I actually have had a really good experience using messaging to communicate with my care teams.
That said--hospital management, driven by the insurance world, tries to wring as much uncompensated labor out of the medical workforce as possible. Doctors (including my MD colleagues) do not get together to limit the number of doctors available. That's baseless conspiratorial thinking that doesn't withstand a moment's scrutiny when you understand the incentives at work in American healthcare.
There are limited slots each year at the accredited schools you must attend in order to acquire your role.
Nobody's accusing you of doing it - but the number of doctors is limited
Ultimately, the number of training slots in the current system is limited by MHA and MBA administrators who see training and instruction as subservient to profits, not the doctors who make up the departments and training faculty. Or, more broadly, they are limited by the healthcare operations not being legislated in a saner way. I was just clarifying.
How long until administration figures out that they can juice revenue by shitting up the emails to increase back-and-forth traffic?
Why do you think someone else's 'effort' should be free?
No-one's saying it takes zero literal effort. Just "Should I be billed by the practice $25-30 for an MA to get my email and say "I have forwarded your question to the provider"?", and then a subsequent $100+ for the provider's response to my question.
Why should that not be part of the intrinsic baseline officework and not a billable service?
Especially when it's a 100% artificial roadblock inserted by the practice? After all, the communication portal in MyChart is "Message My Provider", not "Message An MA To Message My Provider".
That is semantics, could be changed to "Message the office" but that isn't going to be the most clear title for the majority of people to understand what it is doing. It's the same as calling the office, 99.9% of offices (basically all outside of concierge/direct care) are going to be triaged by an MA/nurse first.
As far as the payment requirements I've heard of, I have never seen anyone bill just for the MA reply.
My comment on this was in response to a comment positing the potential for exactly this:
> How long until administration figures out that they can juice revenue by shitting up the emails to increase back-and-forth traffic?
And then, the reply I got was basically "Well, why shouldn't they be able to do that?"
Sometimes I have questions that don’t need the provider’s time, but there is no way to get ahold of anyone else in the office (the practice is part of a large hospital system and calls are answered by a call center that knows nothing)
Why would it do that? If they get money for messages sent (rather than messages sent by doctors) then some flunky can send a message and you can still be billed. Given how this sounds like a profit center, and doctors are cost centers (imagine if they needed to send more messages... now they have to pay more doctors!), I figure physicians will be kept far away from any such system.
If we plot out perverse incentives as a space, I believe that our fate will be to trek through every possible point in that landscape such that we eventually see every single one. This means you will eventually get universal healthcare, most likely as the very last of those perverse incentives.
I think it’s much more likely that doctors will end up sending AI-autocompleted messages that take very little time to complete but seem like took much longer.
The standard will evolve to something like clinic staff sending the messages which will be overseen/supervised by a medical doctor (who won't be involved in composing the messages or spend any time looking at them before or after they are sent). We'll see trials where the doctor who was supposed to be keeping an eye on the messages wasn't, and some flunky kills a patient by suggesting that drinking used engine oil will cure the sniffles. Keep in mind that the messages can be sent from anywhere too, technically no need to keep that onshore. May eventually get legislation that would guarantee that, but only after a wild west period that lasts a few years.
Physicians won't see a dime of that money unless it's through RVUs and even then it's marginal at best. The real money is in procedures.
• I needed refills for two prescriptions that I've been taking for years. This time, for opaque reasons, I needed to talk to a doctor first.
• Fine, but I couldn't accommodate an in-person check-in. I chose a "video visit" that, due to logistics, I had to do while away from home. Because they were a half-hour late, I was effectively forced to do this from the couch of a Costco floor display so I could still pick up my kid on time.
• The appointment was 8m, at an out-of-pocket cost of $160+. I was not warned that I'd be forced to pay $20/minute for the privilege of being blessed with refills.
Land of the fee, baby.
It’s terrible and the only thing worse than the exorbitant fees is the complete and utter lack of consideration to the patient’s time.
I moved to Canada recently and caught a flu that I didn't take care of and, in turn, developed into pneumonia. It took me FIVE days to be able sit down with a doctor and get an antibiotic prescribed even thought it was more than evident I needed immediate care. I could have died if I waited another day. But was it free? ... ehrm ... yeah.
In Mexico, doctors are as free market as it can get, downsides and upsides of that considered; with cash in hand you can get any kind of attention you need in the exact moment you need it. And it's not even that expensive, after converting MXN <-> USD. I could've dropped by with any of the 1,000s doctors that are available, many of which don't even require appointments. I would've got the attention I needed and the antibiotic prescription in 2-3 hours. That would had cost me ~60 USD.
[1]: https://www.washingtonpost.com/outlook/2020/08/06/health-ins...
I went through that ordeal ~4 months ago, me, personally, I didn't read it on a magazine or whatever.
> About one-third of Mexico’s registered workers report earning the minimum wage, which will amount to about $1.75 per hour starting Jan. 1.
$60 is 4 days wages for 1/3 of workers in Mexico. It's the equivalent of $820 for someone making 75k per year in the US. So it's the same as any other free-market healthcare system: easy access for the wealthy at the exclusion of the poor.
https://apnews.com/article/mexico-minimum-wage-increase-peso...
I'm not saying it's fair, I'm saying it's cheap, compared to the US as that is implied by the context of this conversation.
When you buy a $1 dollar shirt from Malaysia, is it cheap? Yes. Is it fair? Who knows.
It's the same thing.
Also, doctors in Mexico make way more than minimum wage, it's not unusual for some of them to have incomes around 200k-300k USD/year, plus read about RESICO and your jaw will drop to the floor. The average person in the US would kill to have the income and purchasing power doctors have in Mexico.
Ask anyone who has a dog, preferably a big dog, what it costs for a vet visit.
Better yet, talk to someone who has had a sick dog. Something terminal, or possibly terminal. Costs are wayyy lower. Same x-ray, same imaging, many similar medicines. I've talked with vets, human doctors, and doctors who own dogs. They all come to the same conclusion:
Only ONE key difference - there is no insurance or government regulation involved (obvously stuff like taxes, basic health codes, licensing, but I think you know what I mean).
I'm more than happy to agree with you if you could show me a plausible explanation for this enormous disparity in costs.
https://www.healthsystemtracker.org/chart-collection/health-...
Instead, our system is the worst* of both worlds. The government limits the supply to prevent competition, but allows those they've licensed to charge as much as they want.
*(That is, worst for patients; it's the best for profits)
Even if there were no insurance, I don't believe there exists a possible free market for expensive emergency medical procedures either.
The democrats wanted to get subsidized healthcare for low income people and people with existing health issues that would guarantee they would be uneconomical to insure. The healthcare providers, insurance companies and pharma companies wanted to remain viable, profitable businesses.
The compromise was to essentially guarantee profits to healthcare companies by crafting legislation that overcharges young people, healthy people, male people, middle class and affluent people to subsidize costs for other groups, while giving a consistent profit margin regardless of costs to insurance companies.
There is nothing about American healthcare that resembles functioning markets or capitalism. It's a very heavily regulated industry where the government exerts extreme control, while choosing to legislate in a way that maintains a consistent flow of money to influential lobbying groups and political donors.
This is cope, just like "(socialist catastrophe) wasn't caused by TRUE socialism" is cope.
The mechanism by which capitalism causes concentration of wealth and power, and by which said concentration then creates means, motive, and opportunity for self-dealing is crystal clear.
[0] https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
Frankly the difference I noticed post Obamacare was a friend of mine was able to get insurance in time to not go bankrupt treating her colon cancer.
I can't get behind the idea that Obamacare is somehow what broke our medical system.
Insurance companies had teams of people who, if you made a substantial claim, would look over your application for anything that was amiss. And if they found it, they'd drop you so they wouldn't have to pay.
Your health record became a criminal record. You just hoped there was nothing on it that would prevent you from getting coverage in the future.
Obamacare has some very serious problems, but at least you can't be denied insurance just because you have back pain.
Before Obamacare, some policies had lifetime limits, which could affect expensive treatments like cancer.
We celebrated the fact that now medicare can negotiate 10 drug prices. It should negotiate all drugs. The organization that gets the lowest prices is the VA. Congress could easily pass a law saying medicare will only pay that much and it would not cost much to implement.
System is very broken.
The emergency care angle is what drives the socialism / capitalism bickering and that's what I see a the biggest impediment to actually making effective change.
Speaking of DI, DI is a money-printing machine, with CT and MRI machines that range from a few hundred thousand to over a million have breakeven points well under two years. And the DI companies work to find and gather physicians who want to start a DI practice. Offer financing, consulting, and then, shockingly, we find that physicians who own a DI practice or a share in one tend to over-refer their patients to imaging.
The UK's death panel is called NICE: https://en.wikipedia.org/wiki/National_Institute_for_Health_...
We should have something similar in the US. 80% of all healthcare spending is consumed by people in the last 3 years of their life.
Your experience with insurance in the US is very different from mine.
My experience is insurance denying my 34 year old sister's MS meditation until she ended up in the ER.
Since the American system doesn't allow people who can't pay for emergency care to die the system ends having a socialist component. Socialism is such a hot-button issue that we can't have mature conversation about funding it. Almost any conversation about it gets caught-up in partisan and "personal responsibility" bickering.
It would be easier if we just let people who can't pay die.
That's repugnant and wrong, but it would certainly make the conversation easier.
SF Bay Area peninsula -> Stanford
Austin -> St David's
[0] hint: receiving bills for charges you never assented to is not a foundation of a working market, and should obviously be illegal.
The lack of regard for patient schedules is a direct result of how insanely packed the schedules of providers are. Fifteen minutes per patient is luxurious and my partner spends a lot of time after work entering notes for patients she saw that day (she "works" 32 hours / 4 days a week, which is really closer to 40-45 all told). My understanding is that the clinic does not have a high profit margin (serving medical / medicare patients + high overall costs), so every patient counts, and the admin staff will add people w/o permission. It's common for her to find patients scheduled over her breaks or for her to be scheduled after she should have left the building. Burnout has always been bad but it's reaching epidemic levels now in the wake of covid, which further restricts the supply of healthcare and makes people wait longer to be seen.
For a recent event, I got a whole nurse calling me from the "insurance" company, out of the blue, seemingly just to chat about the medical situation and how things are going. I haven't figured out what her KPIs are, but I doubt she remains so friendly when you bump up against them! And she obviously represents a severe misallocation of labor - the industry would be better off if someone with her education (and likely experience) was actually providing healthcare.
Worse the odds are good she was hired to help the insurance company prevent people from getting healthcare.
It's the same story every time. Something works relatively OK (US health care before 20 century big-gov), huge changes to incentive structure and overheads are introduced by statists ignoring higher order effects, everything goes downhill, statists blame capitalism.
Let me legally not have insurance, pay anyone in cash for my health care (no licensens and government enforced monopolies), and buy any medicine I'd like and opt out of this madness completely and let's compare with real capitalism.
If you try doing health care this way for long enough, you might even discover which incentives are poorly aligned without collective policy of some kind, but who knows, maybe not.
[1]: https://laeger.dk/media/mjpbsm2a/honorartabel-2023-januar.pd...
At no point did the ER staff ever talk to me. At no point was I in a room. Or in an ER bed, hallway or otherwise. Just ambulance, transport, and then to pre-op.
But, because the transfer physically happened in the ER, that second hospital tried to bill my insurance for an ER visit to the tune of $2,800 which I appealed (successfully, at least).
Shock, horror, you actually need to read through the form and select the appropriate checkboxes (around ability to stand, need for oxygen, fall risk and hazard, danger to self or others, etc., etc.)
Too many of them literally fill out patient demographics and a signature and say "here you go".
We push back because our organization policy is that we will transport those patients, BUT we would also much rather bill Medicare than the patient (our billing staff and C-suite may disagree, but EMTs and paramedics wholeheartedly understand that routine privately paid ambulance transport is not a viable option for 99.998% of the elderly).
How did the determination that you needed urology, "oops, no urology available", and ambulance transport get arranged? It seems like some level of triage, routing, unable, re-routing had to have happened, right?
But yes, hospital two tried to charge me for an ER visit, as well as the surgical billing (which of course was reasonable).
ER - life or death (if you can drive yourself, it's probably not an emergency)
Urgent Care - you have the flu, and your PCP isn't available; minor emergencies (but you can still drive yourself)
PCP - flu, check-ups, whatever
The balance billing and OON charges are separate issues from over-use of the ER.
That solution doesn't really scream "emergency" and seems like a waste of their time and resources...
Some ERs don't always provide the level of care that they should, some doctors/insurance companies require patients to go to the ER for anything they need after office hours, and sometimes there's a need to be seen for something because of perfectly reasonable and valid concerns that it might be more serious than it ultimately ends up being.
While it's possible that the commenter's visit to the ER was a "waste of time and resources" I don't think it's fair to assume that from what was said.
Personally I am not qualified to determine what a treatable and non-treatable burn looks like. Where I went to school they don't teach that.
My order of operations for medical treatment are:
1) Virtual consultation. Free through my insurance. If you need to pay full price, this about as expensive as option 2. Also worth skipping if you can tell that an in person visit will be needed anyway.
2) A clinic. I use CVS's minute clinic. Looking at their price list [0], a minor burn treatment will run you about $100-$150, which is about what I would expect for talking to a professional.
3) Urgent Care
4) Emergency Room
[0] https://www.cvs.com/minuteclinic/services/price-lists
This is further exacerbated by the limited safety nets in the US–even people who would on principle deign to sue others who tried to help them in a time of bad luck may find that a lawsuit is the only way they'll be able to maintain a decent lifestyle after the loss of a partner, or with a newfound need for long-term care.
One more layer is the fact that doctors are so overbooked. Many people cannot reasonably get appointments with their family doctor (if they have one) on short notice, so some things that, in the past, might have been a "wait-til-morning then call the GP to drop in same-day" are now "GP is booked three months out, guess we're going to the hospital".
Or maybe the patient didn't know what was required.
Probably the biggest surprise there is that a doctor saw you at all instead of you being filtered out by a triage nurse and sent to urgent care.
It is fairly common for someone to be advised to seek emergency treatment out of precaution to ensure that a minor symptom is not indicative of a severe problem.
For example dizziness can be a completely nothing-burger inner ear problem treated with a bunch of motions from youtube, or it can be a stroke. The ER exists to make that distinction.
Part of all those logistics and resources should be used to shunt people to the correct treatment center, but liability suits and extreme profitability mean that the incentive is to treat them in the ER.
Put into other terms, if you were hospital admin incentivized on billing, and could bill someone $5k instead of $160 for a non-urgent issue, wouldn't you? The fixed costs are the same, the ER is running 24/7 with a trauma team, might as well make it profitable.
I feel fairly comfortable assuming that they were being seen for a minor-to-moderate burn.
I don't know either, but the broader point is that people are referred to the ED by medical professionals for seemingly minor issues all the time, and that the incentives are all lined up to treat stupid shit in the ER rather than have someone tell them to go somewhere that makes more sense.
Isn't it CYA for any EMS to recommend you visiting the hospital, so they just say it to anyone. That allows them to later say that you failed to follow recommended advice.
In that case part of the treatment they received was emergency evaluation for smoke inhalation. Just because they don't end up giving you drugs or doing surgery about it doesn't mean the assessment wasn't a valuable service.
Well, at least, a functioning health care system shouldn't penalize for that sort of thing. We don't really have that in the US.
Insurance did try to deny coverage, but fortunately I appealed and won.
What matters is who picks up a bill (or challenges hospital and negotiates). I see little protection in US between patients and healthcare corporations, but its true I look from afar.
Now the doctor has to put an appeal to explain medical necessity, I'm at his mercy.
An MRI shouldn't cost $26k, even with contrast, and at a hospital.
If this was non-emergency, it should have been pre-cleared with insurance per their policy.
You could fly to New Zealand, have a scan on a state of the art machine, get a good report, have 3 weeks holiday and fly home. You’d have heaps of money left over.
The ambulance ride alone from the accident site to the hospital (like, 5 miles) was several thousand dollars.
It's effectively a scam, don't give in to scammers.
Fucking. Ridiculous.
It should be noted their virtual visits are mostly performative. You're filling in a survey beforehand and the doctor is just there to read the survey and push a big green button.
Plus many of these places specialize in stigmatized products like anti-bolding, ED meds, anti-depressants, etc.
I've only ever had doctors that worked that way so didn't even know that there were some that did not.
I now wonder which is more common, and if there is some way to tell beforehand when choosing a new doctor which kind they are?
But I agree that for some appointments it obviously doesn't work because you can't examine the patient or take vitals the same way/at all.
For certain things, like common illnesses, it is pretty good.
But that being said, use caution. I had something minor turn into an ER visit because I used telemedicine instead of going to my GP. Telemedicine prescribed antibiotics, which was correct, but GP would have done a drain too. Lack of drainage caused uhh unpleasant problems down the road.
Call me new-fashioned, but I don't want to spend a few hours of a workday several times per year to see a doctor for less than 5 minutes for prescription refill for a drug that I have been taking for years.
Why in the world would either of us need to see each-other in person when he can ask me the same 3 questions he always does over the phone?
The US healthcare system is completely broken. Hospital systems and doctors offices in general lost a shit ton of money last year. There has been massive layoffs throughout this sector. There will continue to be this year. This year they all are going to try to survive by recouping their prior losses. Get ready for more fees.
In addition - there is consolidation in the physicians groups. Mom and pop groups are almost unfeasible at this point. Look for venture capitalists to scoop in. Guess what - you won't have better care with after those changes - I can promise that.
Lastly, the pharmaceutical industry is out of control. They hike prices on any and all medications that they are able to. They recently hiked flovent to a cost that no insurance companies or hospital will pay for it. There are limited alternatives at least for kids. This is medications that that has been out since the mid 80s. It is a controlled market, with high barriers to entry - you can either permit a wide west time of pharmaceutical environment or you can understand the need for a regulated marketplace and meet with with equivalent regulation in terms of pricing.
Finally the insurance companies are the worst. I don't know anyone with a good experience...the only ones that have a positive experience are those that don't use it. I try not to hate any single group but I hate insurance companies.
The system needs to be burned to the ground. It is fragmented and burdensome for healthcare providers and for patients. It benefits no one at this point. It creates additional workload for providers hospitals and patients alike.
I am afraid of what will come in it's place but can't we worse that this shit.
It costs 2-3x of healthcare in equivalent countries, with worse results. Where is that money going?
> In addition - there is consolidation in the physicians groups. Mom and pop groups are almost unfeasible at this point. Look for venture capitalists to scoop in.
Private equity already has, from what I've read.
Just went out and bought a bottle of Avamys (more modern version of Flovent) for $15 without any hassle. Shed a tear for poor Americans.
There are now 10 administrators for every 1 doctor.
Since 1970, the number of physicians has increased by 2x. The number of administrative staff has increased by 38x.
If each administrator is making 100k+ - 150k+, that's significant cost.
Some of these crazy billing practices are due to the private equity buy-ups and consolidation, creating workflows and fee structures that are hostile to patients and doctors, but benefit the PE firms.
https://www.commonwealthfund.org/publications/issue-briefs/2...
Lots more data here: https://www.healthsystemtracker.org/
It's the corporations, stupid.
https://www.mckinsey.com/~/media/mckinsey/dotcom/client_serv...
I worked in healthcare and this McKinsey report (exhibit 2 on page 81) is probably the best analysis I've seen that tries to isolate where the extra money is going.
The biggest driver of higher US healthcare costs is outpatient care. And it's not just that each healthcare event is more expensive (though it is), it's that Americans get a lot more outpatient care than other OECD countries.
They ask you to set a primary care doctor, but I have had more success with seeing a small group of their more available non-MD physicians.
Everything you're describing is screaming monopoly and artificial lack of competition.
If providers of class X are too busy to see you, then there's plenty of people who could, or you're just going to do it on your own. It needs to be more like that.
Obviously there are some limits, but educational pathways could be much more diverse, and there are many things that patients are capable of accessing on their own or through providers like pharmacists.
Then someone from outside the US says, "that would never happen in my country; here's how it works here..." and it's immediately assumed there's some sort of huge catch, that never, nowhere could a health care system work that well without some sort of major trade off or downside.
No! Stop this! A health care system should work for patients, not against them! Injured or suddenly-sick people are not in the best head space to make rational, informed decisions as to what level of care they need in the moment. Even if they were, nearly all lack the specific medical training that would always allow them make that decision with a comfortable level of certainty.
And even if someone should have known better, I just don't get the ire. Why should we put people into tenuous financial situations just because they made a mistake in how they sought medical care? Medical care! What the hell is wrong with people?
The US health care system is awful, despite having so many great and talented doctors, nurses, and staff! Let's get that through our heads! We pay so much more than other developed countries, for so much less care. And the reason we don't have something better is because the right public policy is labeled "socialism". This is so exhausting.
I'd expect the same from a doctor. If I am asking a very occasional and non-urgent question with a quick answer (e.g., can I take my medicine and drink alcohol safely) then yeah, I'll be annoyed if I get a $25 fee. But typing out responses to question might take my doctor 30 minutes, so it's fair if they charge me, so long as I get a good answer in a reasonable timeframe.
Obviously there's exceptions. If it's a brain surgeon who just made $25,000 on a single procedure and I have a 15 minute followup question, it seems a little nervy to bill me $25 more, but not if I'm emailing my kid's pediatrician a picture of a rash.
1. The accountant will tell you that pricing up front, so you can make a decision before you send an email. No doctor in America will answer any question about pricing ahead of time.
2. The vast majority of Americans know precisely when they need to pay taxes and roughly how much work they will be, how many accounts they're dealing with, what types of questions might arise, etc. It is extremely rare for most people to ever have an urgent question for an accountant. Healthcare on the other hand is inherently unpredictable, and urgent questions are very common.
3. Most people don't have, and never will have, an accountant. Every single living human of any age needs at least one doctor, and often quite a few.
4. If you don't like your accountant's pricing, you can easily shop around for a different one. You can't do that with a doctor (see point 1). You can sort of do it with insurance, but that isn't the same thing, can only be done once a year, and the options are very limited for most people.
5. If you don't like dealing with an accountant at all, you can just get a normal job and never talk to one again. It's entirely within your control. If you don't like dealing with doctors, you're out of luck unless you want to die.
Doctors charge for identifying and telling you things non-doctors can't, with a high degree of non-harm-doing.
They've already put in the 10,000 hours to know which bolt to turn.
The same is true in law. Just because you have 10,000 hours of training doesn't mean you aren't billing by the hour.
This is why there are many many doctor and attorney millionaires and very few doctor/attorney billionaires.
Well, it would be occasional for you to ask questions to your doctor, but your doctor wouldn't be just occasionally answering questions from their patients
> Non-urgent questions
Imagine everyone sending non-urgent questions... Isn't it even more irritating to be receiving non-urgent questions than urgent ones if you're a doctor? I guess the doctor could reply with a FAQ.
Honestly, this is where I think personal LLMs should come to the rescue. Just ask a doctor-sanctioned/fine-tuned LLM for trivial questions.
I've customized the hell out of my own hospital's Epic system (I'm an anesthesiologist) to make notes as easy as possible. 95% of the things I do are done the same way, every time. Back when we used paper, they had all of that in checkboxes on forms. Basically a way to say "yes, I did this legal and proper" very quickly. It was very useful because you knew that if you skipped over that and went straight to the written description on an old record, you'd actually get the important information.
Before billing criteria took over medical documents, doctors could do more because a board-certified pediatrician doing a well-baby visit could just write "18 mo WM, PMH NC, PE WNL, f/u 6 mo" (18 month old white male, past medical history noncontributory, physical exam within normal limits, follow up in six months). We had "skeletons" for reporting the most common labs in notes - just a graphic representation so you didn't have to write "Sodium 139, potassium 4.3, chloride 122, bicarb 24, BUN 9, creatinine 1.1, glucose 85".
The paper medical record was subject to handwriting, but it was extraordinarily space- and time-efficient.Chef's kiss.
Personal opinion or did you ever talk to anyone investigating these things?
First of all, the fraud is committed by the patient, they're the one submitting the claim to their private insurance without validating it. Secondly, it will always be called a mistake if you object to it. But nobody does because remember, private insurance pays anyway. On top of it once you object and have a few arguments with them you may even find yourself having difficulties to get an appointment if it's a desired doctor with a queue at the door.
There are no numbers because this is not investigated, there just aren't resources for this. Nobody with a private insurance bothers reporting a $5-10 shot they never received and nobody wastes resources to investigate it. I've seen attempts to swindle me out of 5 digit sums of EUR that would have otherwise been blindly paid by the insurance. I actually checked everything, I objected, it was called a system error. I have acquaintances who work with the authorities and they confirmed that even if you find a pattern it's impossible to prove intent, so it never goes further than "we correct the mistake for those who report it".
Politician corruption is basically non-existent, and Al Capone just didn't pay tax. According to the numbers.
Which is almost ~2% of GDP alone...
0.1% of credit card payments are fraud: https://www.federalreserve.gov/newsevents/pressreleases/othe...
That's a more typical number.
Something is extremely broken with US healthcare.
The interesting thing is that every side seems to be losing.
The winners are certainly not average doctors.
Compared to the size of the market - health insurance is one of the worst insurance businesses.
Hospital administration is also not a great business.
Doctors should be compensated for the amount of time to send an email. Every other industry is capable of restructuring support to satisfy demand. It's up to the healthcare providers to manage this channel properly as any other would.
The real question is: what would it take for the healthcare industry to restructure itself to actually function?
Strike the words "over 65" from the medicare bill.
If you mean "universal single-payer", its worth noting that Medicare is very much not single payer and striking the population restriction for Medicare would not produce universal single payer (or even a single comprehensive plan for each individual, unless they are opting for privately-provided, publicly subsidized main insurance -- otherwise hospital [Part A], outpatient [Part B], and prescription drug [Part D] are separate insurance systems, and only the first two are public.)
Medicare is a particularly complicated implementation of partially publicly subsidized private insurance with an (incomplete) public option.
I'd like to see the other usual suspects addressed too but it seems like the doctor shortage is a big part of the problem.
Not saying we don't need more doctors, but seems unrelated to to the problem being discussed.
I can't quote it precisely, but here's a gist from The Glass Bead Game:
> Intelligence can find its own way, the teacher's job is to address stupidity.
Overlooking the crudeness here, I think it's a good idea, and translates to medicine. Most of us are not qualified to define good care, but we know bad care when we see it.
One example of bad care is when you don't discover how expensive a treatment will be until 3 months after it has occurred.
Another might be cases where medical professionals are expected to work insane long shifts with insufficient sleep time in between.
Whatever the examples are, let's make a list of them. Build consensus around the worst offenders, and then start revoking counts-as-medical-insurance tax status from the insurers who fund the bad behavior. If you want pre-tax-medical-insurance dollars, you must:
- be able to turn a "what if" treatment scenario into a dollar amount in less than 10 minutes
- not have organizations be in-network which create unsustainable working conditions for medical personnel
- [other example of bad care goes here]
...and we add to that list over time. Markets don't do design, they do evolution. We have to kill off the ones we don't like if we want more of the ones we like.
Maybe we need to remove gatekeeping access to drugs from the primary care physician's job so that they can focus on the other parts.
If patients need lifestyle advice then going to a highly paid physician is a waste. Those patients should start with a (cheaper) therapist, personal trainer, dietician, or social worker. We can't reasonably put the entire burden on physicians; it's too much for one profession to handle.
I've had this experience once and my wife has had it thrice (different doctors, different injuries).
By asking primary care physicians to gatekeep drugs, we're introducing a bias where when you walk in the door they assume you're after drugs. I don't have a solution for how best to gatekeep drugs, I just wish I could find a doctor who was unencumbered by that task so they could focus on healthcare instead.
Certain health insurance plans may require a referral in order be reimbursed but that's not universal.
Every time you try to change a medical policy the threat is "you'll kill grandma". the fact is that grandma's care is awful and we need radical changes.
Breaking drugs out to pharmacies, Mexican style, would go a long way to interrupt this dependency.
I don't think I've ever seen a lower bar.
There's also quite a difference between the ethics of healthcare and legal services.
Most of the time if you need a legal answer from a lawyer who charges like that, it's because you know you'll net more money from having the answer than it will cost to get a reply.
With healthcare, you're not trying to make money you're just trying to live.
And usually I’m paying my lawyer to protect me from risks to my financial health, not because I think checking with them will make me money. My doctor helps protect me from health risks. It’s pretty similar. A mess-up in either area could easily mess up my life very badly.
You're correct that I'm in the privileged position of being able to afford my lawyer. (And my doctor and health insurance provider.) I'd just point out that not everything that involves a lawyer is about making money.
But you raise a fair point, and I apologize if my somewhat flip comment came across as insensitive.
Trying to do simple things like:
- Setting or getting an appointment.
- Calling to sort out their office’s coding error that resulted in me getting an erroneous bill
- Trying to get access to their portal or getting results for tests transferred in a realiable manner to another doctor’s office.
I truly think that they would be mortified beyond words and wouldn’t believe their name is on the sign up front.
Specialists make so much money they can hire a personal assistants to handle all the annoying things.
I know several pharmacists, one is highly intelligent and she is the only one who wants to get out of the field because healthcare in the US is toxic and profit driven.
I've been playing with the idea for a while that any time a company uses its name, it has to disclose its ownership (first the company at the top of the chain, then the ownership structure of that company). So like for example the company name "Gerber" would have to always be coupled with "owned by Nestle, a publicly traded company.", and "Dave Franklin, a Dentist in your Community You can Trust" would have to be coupled with "Owned by Private Equity Incorporated, mostly owned by pension funds".
This would make it easier to keep track of if the same company is just screwing you over and over again with different faces, while still allowing some value to remain to brands that are consistently good for customers.
That is why I have to be employed. I guarantee that after 22 years, office expenditures (rent, salaries, supplies, health insurance) would eat up the remaining $300. So taking care of Medicare patients would be charity. Medicare is 60% of my practice. Private insurance is 25%. Medicaid is 10% and unfunded is 5%.
My primary knows and gives me tips for navigating the administration of their own (as in, they own it) practice. I guarantee they hear quite a bit of griping and moaning from patients about phone tree and waiting room delays.
Retaining good admin staff in my area is very difficult, but doctors aren't going to close their practices because of it.
> Now, she says, patients are typically pleased that they are able to get a direct response from her through a portal message.
> “They’re thrilled when they get me directly,” she says.
Geez, this could make corporate PR people blush.
Yeah, it’s embarrassing. I am not “thrilled” to talk to a doctor directly. I pay for it, and when I do it’s because I have a reason to, which kind of limits the thrilling aspect. I expect it, and I need it, sure. But it’s not being able to talk to my doctor that elicits an emotional response, and it tends to be anger.
In Canada I had no such option.
In the Michigan Medicine system the 3 main message options are: refill a medication, ask a medical question, and ask a billing question. If you select "ask a medical question" the next and final choice is whether you're submitting a question in English or Spanish.
Most often I want to ask a scheduler (because each office/department schedules differently) or a nurse a question, but for that you have to call. Something as simple as scheduling a flu or covid shot can't be done via messaging.
No fixed fees. No per-visit charges. Just bill for the time spent (including pre- and post-visit paperwork) and the direct expenses actually incurred. Everything else is built into the hourly rate.
It will never happen, but it would be much better.
https://lawstuffexplained.com/can-a-lawyer-charge-you-for-em...
The problem is that without demonstrating somehow that they read it, they cannot prove they actually read that correspondence when they claim to have. This puts them in a difficult position because the client can plausibly claim that they did work they didn't actually do. Perhaps they don't need to send an explicit acknowledgment (even though it's the right thing to do), but if they don't even act like they received and read it, yet charge you for it, that's a real problem.
FWIW I've had little trouble getting my attorneys to credit me for activities I didn't ask them to do. Somewhat different situation, but most good attorneys aren't scumbags.
Having received many email tomes from clients, I wouldn't think twice to charge for reading their email. I would typically respond, but not necessarily if they weren't asking a question, or if we were going to be meeting soon to discuss.
I don't know any attorneys (note: all the attorneys I know are corporate attorneys, so may be less bill-sensitive) who would not bill for time spent reading emails. Lawyers spend tons of time reading emails!
> FWIW I've had little trouble getting my attorneys to credit me for activities I didn't ask them to do.
This makes sense, but is somewhat orthogonal to the email question. If a client sends his lawyer a long email, he is implicitly asking the lawyer to spend the time reading the email.
I wonder if contacting your doctor directly is a US thing? Before this discussion I had never heard of such an option. I definitely don't have any way of directly contacting any medical staff, neither a nurse nor a doctor, it will have to be through an appointment.
This might finally explain why this "ask your doctor" is so often repeated online as a realistic option? You definitely won't ask your doctor about every minor thing if it's behind an appointment.
I bet there are a ton of consultants and lawyers (and maybe some accountants) on HN and most of them will charge you for time spent replying to emails.
Edit: inserted the word "all" before insurance to clarify my intent.
> Health plans covered the full cost of about 82% of claims, according to the Peterson-KFF analysis. Patients who shared the cost paid $25 on average.
I would be very curious to know if my insurance is paying for the useless messages that my doctor's office sends. I sure hope not — they are next to worthless!
Also, your TFA is kind of unnecessarily vulgar (You do know what the F in TFA is for?) here seeing as it doesn't change the point of my original comment. I did, however, add the word "all" incase someone took my comment to read that I didn't think any insurance covered it.
Thanks for the thought, but unfortunately our whole system (Stanford Health Care, FWIW) is like this. My doctor is better than my kids' doctor, and my wife's doctor. The incentives are just not there for them to engage, so mostly I get nurse messages that are useless. It appears to be a copy/paste from google (or some internal system), basically.
As for "TFA", I do know what it means and see it used here regularly [1] and without meaning anything harsh. It's not like some people say "TA" and some people say "TFA". It's just TFA. Regardless, I didn't meant to offend you or make it seem like I was demeaning you. I was just pointing out that the article addressed your complaint, and indicated that the vast majority of insurance plans don't leave the cost up to the patient. I nonetheless appreciate your feedback and will consider "TFA" more carefully in the future. If you have any equally pithy alternatives, I would welcome them!
1: https://hn.algolia.com/?q=tfa
I know a few primary care doctors and they are all overworked and overbooked. I can't imagine any of them going above an beyond unfortunately (not because they don't want to but because they don't have the time). But most of the one's I know hate the system too.
I appreciate the clarification on tone. As a dev I read TFA in the same time as RTFM (as in: why didn't you read the article you moron?). But I get your usage as well.
I would guess that fully covering patient emails would save insurance companies money in the long run, but why do that when you can boost short-term profits?
Unless your lawyer is an equity partner, he's not getting much of that $150.
In the US, the median doctor makes almost 75% more than the median lawyer...
I’d venture to say that people with chronic illnesses that require ongoing intervention to sustain daily life are more likely.
If you just have a migraine out of the blue you’re gonna need a full appointment to provide context.
As things stand, I have to call. He doesn't take e-mails. If I have a quick question, I can schedule a virtual appointment. There is usually a 2-3 month wait. The appointment is scheduled for a day, not a time, and is limited to 15 minutes. They'll let me know the time about 30 minutes in advance, and it could be any time of day. If I miss or can't make the video call, it's usually another 2-3 months before he has availability again. There are no other doctors with the relevant specialty nearby, so this is what I get.
And still, drugs are too expensive in the USA, especially old drugs like insulin and albuterol (asthma inhalant) that seem to find new ways of being re-patented (e.g., through new delivery devices that are just novel enough to be granted a patent, but provide no significant improvement to the patient).
If drugs, pricey as they are in the USA, are only 10-15% of healthcare spending, that should frighten you as to how cost-inefficient our health care system is.
Responding to messages can also just be very difficult and time consuming. Maybe you ask concise, clear, pertinent messages to your doctor (or think you do!), but most do not. It's similar to problems HN readers might be more familiar with: user-created support tickets, and comment moderation. Medical office staff help with this triage and moderation, but it has become a big problem to manage with how easy it now is for bored/sick/scared patients to send messages.
We're not even making money yet due to student loans. Sucks.
Now a days what happens is I send a message with photos or many details, and some poor nurse who is assigned message triage is going through many and responds with generic pointless text for my issue.
Then I get charged $15.
You owe me $3.99
My biggest gripe here is that if the doctor answers me outside office hours, an additional "emergency / inconvenience fee" is added. Like, I can't control when you answer, and I didn't choose it. If I send in something during daytime and you didn't get to it, answer me the next day, then. Or make it a choice that I want a prioritized answer so at least I decide. It's just bonkers.
In the US, a regular doctor's visit can cost hundreds of dollars.
The cost for this e-visit message would range from $65 if it took less than 10 minutes to $438 if it took more than 25 minutes.
With absolute zero accountability on how this time was spent.
Lawyers are way more transparent than medical billers
If it was three minutes of "these are your lab results; you should/shouldn't come in for a follow-up," I'd agree that it should be a phone call that's covered under the cost of the original appointment. But given that vet friend is constantly pressed for time and doesn't get to bill separately for those callbacks, I can't imagine why my primary doctor would want to do the same.
I don't want medical professionals responsible for my care to squeeze things in when they have time. Insurance is likely to be even more of a pain in the ass, and cramming in tasks because they're unpaid means lower quality of care.
The culmination of the American middle-man capitalism.
I’m making up numbers but if a private practice physician earns $250k/year for 2000 hours that’s $125/hr + taxes and benefits + rent/overhead + nursing and staff, you figure that cost is probably closer to $300/hr then you you assume they have to do ~30min of prep/admin for every patient hour that’s closer to $450/hr that’s ~$37.5 per 5 min of patient time (and none of that is factoring in reimbursement rates), people can disagree as to how those costs should be borne but let’s not kid ourselves as to what the cost of doctors time is…
I've been in meetings with healthcare providers about incorporating LLMs into text-based patient-physician messaging to improve triage and routing. It is just overwhelming for many providers. A large percentage are getting burnt out, and much of their time is uncompensated.
> If people had to pay, maybe they would _think_ before asking questions.
Be careful, a lot more people might be calling at 4am because they figure it’s okay because they’re paying for it. At least other contractors can give people a “fuck off” quote for work they don’t want to take, but might be difficult to implement that here.