[parkerhiggins]

Spot on. It becomes more clear when you ask who pays medical professionals salaries?

Insurance companies do.

Insurance companies are medical professionals’ bosses.

The customer receiving treatment has no influence on the standard of care.

[johannbok]

This is partly true. In no small part because they tend to control the bulk (or all) of our patient supply. In part because people have gotten the idea that insurance equals care, and vice versa - so people tend not to think about high-impact moments where it pays to go cash.

For instance, I specialize in neuromodulation for highly-treatment-resistance psychiatry. I'm very good at what I do; my mentor is (IMO) better, and one of the absolute best in the country. A single consultation session with him is around $200 if he happens not to take your insurance. If you have a highly-treatment resistant condition, and are about to embark on a course of neuromodulation, it absolutely behooves you to go to him for a single session consultation to plan out your intervention before going to some local mediocre whatever to actually slap the equipment on your head and carry out the intervention.

For instance, people have incredibly debilitating autoimmune conditions. Rheumatic conditions are notable for their polymorphic presentations. It absolutely behooves you to go to an absolute top rheumatologist for one to three visits to confirm your diagnosis before going on a lifelong adventure of immune modulating drugs.

But folks hear "this guy doesn't take my insurance" and treat it as equivalent to "I can't get care there," even when they can afford it. I have a chronic condition, it's terrible, and my absolute world-famous specialist costs me about $250/yr - a small fraction of my monthly insurance premium. Less than my monthly prescription costs. Yet people will go to whatever specialist happens to be near them, while bearing all those other costs, and not investing in the linchpin.

[syedkarim]

Who is the top rheumatologist? Who would you recommend? My mother is in constant pain and has gone to a dozen different specialists. We are near Chicago, but I am happy to take her anywhere in the country.

[johannbok]

Robert Spiera, currently director of vasculitis at the hospital for special surgery, still maintains a private practice in Manhattan. He's worth every second of the wait time, and every penny of his consultation fee. He is ridiculously good.

[bombcar]

Many people do not realize how cheap it can be to do direct-consultations; and it can't hurt to ask.

Even a doctor pulling down $1m a year is only about $500 an hour, and that could be entirely worth it to get their time and dedicated.

[johannbok]

And if you call to ask, the front desk secretary will have absolutely no clue how to route an out-of-the-ordinary request. If the doc you're calling doesn't already do the type of service you're looking for (e.g., a phone consultation), be absolutely firm about wanting to speak with the office manager.

The office manager may not be able to accommodate you, but if it can be done, they're the ones with the authority and autonomy to make it happen.

[LorenPechtel]

How do you find these top people?

[johannbok]

Generally, you have to ask doctors already in the know. You find the top academic medical center in your area, and you ask the relevant specialist there who the absolute top person in their field is for a second opinion.

It's not always a guaranteed correct answer - I know for a fact of some people at absolutely top ranked institutions, with top pedigrees, who clearly got there by academic skills and are absolute shit as clinicians - but for the most part, it'll get you where you need to go. Generally the only way you'll end up with one of those shiny pieces of shit is if referred to them strictly by reputation; no one that's worked with them would make that referral.

It's also an answer likely to overlook excellent clinicians - many (many!, maybe most) very good clinicians aren't academics, and this won't route you to them. But you're okay with overlooking excellent docs, as long as you end up at a top doc.

Finding excellent doctors without shiny pedigrees is not something a layman can do. It's just something that local docs eventually come to know about other docs in their social-professional network, and by no means is it an unbiased assessment.

If all you have available is people's online CVs, look strongly at people with mediocre or shitty medical schools and highly prestigious residencies and fellowships. Those are people who had networking and social signaling working actively against them, and managed to positively impress everyone they worked with. E.g., a buddy of mine got into a shit medical school, and got one of the country's most prestigious subspecialties in a prestigious institution. He had to impress every single person he worked with, had to do surpass everyone on his standardized exams, and otherwise be top-of-the-top in every way. He's a ridiculously top-notch doc.

[Buttons840]

I worked at a company that did background checks on doctors. Part of that involved involved checking doctors licenses in all 50 states, which all do things a little differently. I was paid 6 figures a year to help automate this, and this company had a few hundred other employees who would make calls and do other things to support that. It was all very expensive and could have gone away if only there were some standardized ways for all the states to report these things.

I realized then that I was part of the problem, not on a personal level, but part of everyone's high medical bills ended up in my pocket as a developer at this random healthcare company awkwardly filling our niche.

15% of US workers are in the healthcare industry, and they're not all doctors and nurses. All those people have to be paid, and all of them have to be paid by that ridiculously high medical bill you just received. Sadly, making healthcare cheaper will involve pushing a lot of these people out of the industry, and that won't be politically popular. The insurance companies are going to have to become smaller and lose some profits before things get better.

[Gibbon1]

> Sadly, making healthcare cheaper will involve pushing a lot of these people out of the industry

As someone 20 years into a chronic condition who has to deal with this mess constantly. We'd be ahead if we paid those people to stay home and drink themselves to death. Because it's not just the money it's also the interference in care. That sounds harsh but above and beyond the stress they are actually killing people.

[lotsofpulp]

Most customers could not afford the treatment at the standard of care they want anyway, hence the reason they purchase via insurance.

[amalcon]

People (in the US) purchase insurance mostly because the insurance premium is 90%+ paid by either their employer or the government. Everyone understands that the total price is a scam, but the <=10% that you pay out of pocket has an excellent ROI.

[User23]

Interestingly this wasn’t the case in living memory in the USA. The insurance cartels have effectively greatly increased prices while commensurately lowering the standard of care.

[kingkawn]

Medical institutions have been kept onboard with massive increases in revenue that subsequently led to expansions of the institutions that are now dependent on that higher revenue to exist.

[lotsofpulp]

My dad told me in the 90s to avoid injury because the family could not afford healthcare. I distinctly recall hospital bills being in the tens of thousands even back then.

I doubt newer cancer care, medicines, imaging, or other care would be cheap in any world, with or without insurance.

[uoaei]

A large portion of patients (customers seems like a dirty word in this context...) can't even afford insurance!

[lotsofpulp]

Of course, because the root problem in the US is most people cannot afford the healthcare that they expect to receive. Hence all the political maneuvering to redistribute wealth, and the corresponding efforts to avoid having one’s (present or future) wealth redistributed.

[selectodude]

That's half true - we've also made it difficult, if not illegal, for people to receive a lower standard of care.

Anybody with a chronic condition needs to go see a doctor at least once a year in order to get the same prescriptions they've been on for decades. There are dozens, if not hundreds of conditions that could be handled by a pharmacy.

I need an asthma inhaler every so often. I have to call a medical doctor in order to receive a prescription for an asthma inhaler. They're non-narcotic, I will always have asthma. But I need to bother a doctor for a medication that should be over the counter. It's silly.

[VancouverMan]

And those pricing distortions are due to significant government-imposed regulations and restrictions that tightly limit the supply of doctors and medical services, even in the face of increasing demand.

[johannbok]

Government regulations have been dragging back price of care for ages. Multi-month waiting lines to see a doctor are largely about price ceilings. If docs could price up, their waiting lists would go down commensurately.

Constrained physician supply doesn't do much when physicians can't raise prices in the face of greater demand.

People in these discussions always make things about physician costs. The majority of expenditures in the healthcare system are on drugs and equipment, followed by procedures - physician visits make up a tiny fraction of that.

[gamblor956]

That's false, but why let the truth get in the way?

The limitation on doctors in the U.S. is based on the available funding for residents. The government supplies the money because private institutions largely are unwilling to do so.

[lotsofpulp]

Is it true that unsubsidized residencies would not be profitable? If so, I would not expect private institutions to opt to lose money.

https://www.reddit.com/r/medicine/comments/a0pufi/comment/ea...

[gamblor956]

Your citation literally proves my point...