[goshx]

The entire healthcare system seems to be built against the population. I've come to see healthcare providers like doctors, nurses, technicians, and the like, as a conniving, essential part of the scheme. They're incentivized to make you wait hours unnecessarily, rush every visit, and involve as many different people as possible in your care. And then, in the end, send ridiculous bills to both your insurance provider and to you at home. The person who spends the most time with you is usually the one trying to collect the payment. It's absurd.

There is absolutely no reason for a doctor to make over $1000 for a 15 minute conversation.

There is absolutely no reason for a medical equipment provider to bill more than the retail price of a piece of equipment, especially after insurance has already paid more than the full cost of the equipment on each installment.

There is absolutely no reason for a family to receive a bill of almost one million dollars because their baby was premature and was in the NICU (see @thepasinins on instagram).

There are too many layers in the system making a fortune off the public's back while adding little to no actual value.

[tptacek]

There is a reason that doctors in the US make multiples of what doctors in Europe makes: the AMA lobbied the US CMS, back in the 1990s, to limit the number of residencies opened up every year, to avoid a "glut" of doctors. We have artificial scarcity of doctors.

[s1artibartfast]

>We have artificial scarcity of doctors.

What is artifical when talking about a program that subsidizes residency?

Focus on limited federal residency funding seems to be a red herring. Most modern economic analyses seems to show residency programs are net profitable before federal subsidies.

IMO the problem is largely structural, around how these are positions and services are handeled by regulation and insurance.

[tptacek]

The number is deliberately set to avoid a glut of doctors. We have the opposite problem.

[s1artibartfast]

This seems to missing the point. Why is the number of doctors so so dependent on federal residency funding (or is it?).

I suspect people overweight it for reasons above. Underweight factors would the long US education path to become a doctor being twice that of many countries, and extremely high cost and high accreditation of medical schools.

[tptacek]

Because Medicare funds residency slots. I don't really understand what you're getting at here.

[s1artibartfast]

Im asking if or how much that actually matters. Im asking if it must matter.

By way of hypothetical, if we doubled residency funding. Would new doctors double, go up 10%, or stay the same?

If education time and obscene school costs are the bottle neck, it might not matter much. Some 25% of residents are already paid out of pocket by hospitals because residents make hospitals money.

If we cut it entirely, what would happen?

[cogman10]

That's part of the problem, but we also have a problem with limited medical schools in general and with those schools charging through the nose because of that scarcity.

I have a nephew training to be a doctor now. He's looking at $500k in student loan debt by the end. That's a major problem.

[sssilver]

When my surgeon charged $250,000 for my hand reconstruction surgery, how much of it did he personally pocket, and how much of that went towards that $500,000 debt vs. his brand new S-class Mercedes?

[cogman10]

Depends entirely on how he's employed.

If it's his own private practice then yeah, he pockets a lot of that 250k. If he's working for a hospital, then he has basically no influence on the price he's not payed per surgery.

[troosevelt]

That's why I have ahrd time getting mad at doctors. What else are they supposed to do besides charge absurd rates?

[runtime_terror]

Blaming nurses and technicians feels a bit of an exaggeration. It's not as tho they're high in the hierarchy and have little say in pricing or other facets of why our healthcare system sucks. Maybe start the blame at politicians, insurers, pharmas and hospital owners and work your way down from there. Those with power and control should be the first to attack.

[shalmanese]

The entire "blame" paradigm is unproductive. Does Lyft "blame" Uber for it's lowered market share?

The entire system (including nurses and technicians) are just agents making semi-rational decisions in their own self interest. Is it important to judge people within an existing system or is it important to look at locus points that, when pressure is applied, can make durable changes to the system?

[jjav]

> There is absolutely no reason for a doctor to make over $1000 for a 15 minute conversation.

The doctor isn't making $4000/hour, although you might be getting billed for that.

That doctor (unless some exotic specialist) is probably making not too far from ~300K, so that's around 144/hr, or $36 for that 15 minute conversation.

All the rest is being siphoned off by the system.

[cogman10]

> There are too many layers in the system making a fortune off the public's back while adding little to no actual value.

Yeah, it basically all comes down to the bureaucratic nightmare that ultimately benefits the owners of all things medical. Prices have nothing to do with the value of the good or service and everything to do with the maximum amount of profit that can be extracted from a 3rd party.

One of the worst moves in the last 30 years was Clinton adding private insurance options onto Medicare. In the last 60 years was making medicaid a state run program rather than a national program (or just medicare all together). It's actually crazy that we have 53 different government healthcare options. 1 for every state, medicare, and the VA. It's even more crazy that the government doesn't simply directly employ doctors and medical equipment. It's so crazy inefficient to involve 3rd and 4th parties into something that should be direct care.

The US remains one of the only wealthy nations in the world without nationalized healthcare. And we pay through it through the nose.

[bryanlarsen]

The standard GP consult fee in Ontario Canada is $77.15. (just over us$50). That's gross, the nurse, receptionist and rent have to be paid out of that.

Some doctors will do 4 of those an hour, but most will do 6. And they'll try and find ways to bill additional codes above the consult.

[verzali]

Couldn't multiple doctors band together? Seems like nurses,rents, and receptionists should benefit from economies of scale.

[bryanlarsen]

That pay scale assumes you are banding together. A typical doctor has 30-50% overhead. Without sharing nursing/receptionists/offices the overhead would likely be > 100%.

[insane_dreamer]

nurses are just following the protocol established by their organization; as are technicians; they have very little authority to deviate from prescribed protocols or they will be fired; it's unfair to ascribe any blame to them

physicians bear responsibility if its a private practice, but otherwise they're operating within the constraints of their org's protocols too, though they do have more autonomy (depending on the situation)

but really, your beef should be with the health organizations themselves

and also, many of these protocols are in place because _insurance companies_ require them to be in place

[watwut]

> They're incentivized to make you wait hours unnecessarily

How exactly?

[sandworm101]

The best way to ensure maximum throughput is to maintain a large buffer. A waiting room of patients is that buffer. No matter how many cancel or come late, the doctors/nurses will always have another patient "on deck". Zero downtime is the goal. An empty waiting room, and potentialy underworked staff, is waste.

[no-name-here]

But why mention it as the first item when specifically mentioning doctors - isn't most every kind of business or even non-profit ‘incentivized’ in that way - they can serve more customers if there is a large waiting buffer?

[gilbetron]

Choice and competition greatly alleviate that in other markets. With the medical system in the US, you often don't have much of a choice as switching doctors can be tough, and even if you can find one accepting patients, they are all controlled by the same administration and effectively collude to maximize their profits.