How a plumber charges more than a neurosurgeon

So there was a neurosurgeon who called a plumber for a house visit.

The plumber arrived and after spending an hour bestowed the neurosurgeon a bill of $500. The surgeon was stunned; he said, “Even I don’t charge this much after a surgery.” The plumber stood up, gave him a sly look and said, “well that is why I am a plumber now; I used to be a neurosurgeon.”

I mention this as I was talking to a cardiologist few days ago. He said we are one of the few professions where someone else comes in and informs you how much you will get paid, regardless of what you do. Next time when you have a plumber at your house. try telling him what you want to pay him but do not hold your breath. Unfortunately, every year with Medicare cuts we are seeing more and more doctors changing the way they run their practices.

Now we can argue that physicians are still compensated well, but on the other hand they also do a phenomenal job in helping and saving lives. A bureaucrat sitting in his office can decide how much health care institutes and providers will be compensated. However, these bureaucrats do not get up in the middle of the night or drive 80 miles an hour to reach the hospital to save a life. Neither do they have to reach the hospital within 90 minutes because the sooner they perform the procedure, better the outcome. Nor do they perform a cardiac catheterization which literally saves lives.

However one thing they will never be able to share, is the sweet feeling of contentment about making a difference in someone’s life. By the way, this doctor after spending three hours will get a profligate check of $253.

A plumber was actually at my house this week. He charged me $50 for consultation and $260 for fixing a leak. He was out within an hour. On his way out I did ask him, “Hey were you a neurosurgeon before?”

S. Irfan Ali is a hospitalist who blogs at Human Factor in Medicine and Life.

Submit a guest post and be heard.

Comments are moderated before they are published. Please read the comment policy.

  • http://fertilityfile.com IVF-MD

    Great post! This is the type of thing that happens when the free market is interfered with. Over time, a few of the brightest and best students will choose other careers over medicine and as a result, those who need medical care will suffer.

    • Brian

      This, of course, assumes that the free market is in any way a sensible model on which to base health care.

      Arguments in support of this idea tend to be so simplistic as to be useless practically, and I’ve yet to see a compelling reason to suppose that the mythical “free market” unicorn will cure all ills in re: health care.

      • Matt

        Wasn’t healthcare in this country based on the free market for the first 160 years? We can debate whether the care was the most useful, but the fee for service direct from the customer seemed to suffice as a business model.

        • Brian

          Matt, the “free market”, such as it is, hasn’t sufficed since the turn of the 20th century, when medicine started to actually work.

          Our current system is a cobbled-together patchwork of solutions to incremental problems, the culmination of which will, if left unchanged, result in eventual collapse.

          • Matt

            It hasn’t sufficed? How do you reach that conclusion? By what measure?

            I agree with your second sentence though.

          • John Ryan

            A free market would solve many of the cost and maldistribution problems in today’s medical system. The major issues we have now are due to wasteful bureaucracy (1/3 of the premium dollar going to admin costs), fraud (clever gaming of the payment system) and over-utilization (“Americans want the best medical care that other people’s money can buy”).

            Just as the blog post illustrates, the plumber gets paid for the task by the homeowner. No third party.

          • http://Www.twitter.com/alicearobertson Alice

            It has it’s warts, but I am grateful. After dealing with a doctor who should not be a doctor or a plumber….I am pleased with our doctors and would not use any other system in the world. It is funny when people claim other countries have free care…hmmm….try on about 25% of their paycheck just for healthcare, then all the other taxes. Makes a $25 co pay look like chump change.

        • tony

          Is it possible to partly socialize Health Care Payment System? Any outpatient services would be paid by Private Insurance and any Hospital services would be paid by Medicare or Medicaid. Is it possible for the government to own Medicare and Medicaid hospitals similar to Veterans hospitals. Is it possible to make all hospitals non-profit? I believe health care is a human right and it is not a privilege only for people who can afford it. Comparing our services to a plumber is simplified and childish if not idiotic. Those plumbers do not drive Mercedez benz and Porches, do not live in big fancy homes. The reality Our profession is the greated profession somebody can have.The reality we are unfairly paid by the system. Let us solve the root of the problem by fighting the powerful private insurance and their lobbyiat and making our government more efficient iby owning all the hospitals. It is like owning your own stethoscope. Can you imagine if you have to pay a rental fee for your stethoscope, I would like to all hospitals, like court houses to be owned by government. Make the government make profits from hospitals and hospital services to pay for medicare and medicaid..

      • Anonymous

        What we have now is not a well functioning free market. Users (patients) are encourage to use as much as possible without caring about the cost, since a third party pays for (almost) everything. The third party payers (private and government insurance companies), of course, try to limit cost by denying claims (often inappropriately) and limiting the amount paid to the providers for each service. The providers (doctors and hospitals) have to deal with different payment rates based not on the user, but on the third party payers, and have a large bureaucratic overhead dealing with them.

        While an ordinary free market may not work that well when costs get very high (but that is what catastrophic cost insurance is for, much like insurance for when your house burns down or you crash an expensive car) or when shopping around is not feasable (emergency room visits), it likely functions a lot better than what we have now for routine costs. When the user and the payer are the same, the user/payer can make his/her own decision on the cost and benefit of a given service offered by the provider at a given price.

  • http://www.facebook.com/sparkspeds.nv kevin m wndisch MD, FAAP

    I don’t know about finances but patients are much more likely to say thank you after I teach them to SCUBA dive than after I save their kid’s life. They are also much more likely to pay their fees to the scuba shop for certification than they are to my office for vaccination of their infant.

  • http://comsi.com Jeff Brandt

    Today anyone with an Internet connection can quickly see what a service cost and if the vendor is within the boundaries. All profession, both blue and white collar (except plumbers) are feeling this changing disruptive environment of the new sales, marketing and pricing model. I am not saying I agree with this imbalance in anyway but as a owner of a company that offers secure mHealth solutions I can feel your pain.

    The changes that we are seeing today in healthcare are just the tip of the iceberg. Once health data is digitized, the sky is the limit to what can be done to reduce cost including the displacement of many currently critical jobs. Just think of all of the disruption EHR are causing. You wouldn’t want to have a printing business that specializes in paper health forms.

    The real issue is that change is guaranteed, it is a smart person that can see ahead and decide how to cope and take advantage of the change.

    Jeff Brandt
    http://mHealthBridge.com – Connecting mHeatlh

  • JPB

    Right, the neurosurgeon’s fee for surgery is gong to be less than $500 for an hour…… Are we in Oz?

  • rezmed09

    A couple of comments:

    There is no free market in medicine. Patients do not shop around for ER’s. There is very little competition. I have never seen a price list anywhere in a hospital. Certainly never in an ER.

    Second, even if you did get a price list, it would not help. When you were through with the plumber, you wrote the check and then you were done. In most hospitals, you get a provider bill, pay it; then get an anesthesiologist bill, a radiologist bill, a pharmacy bill, a lab bill and on and on. There is never anything up front or reliable about this payment process.

    And like plumbing, the outcome is variable.

    • http://medicalpastiche.blogspot.com Peter

      You are assuming that all healthcare is delivered in emergency situations, which in fact is simply incorrect.

      When it comes to non-emergencies, patients have all the time in the world to shop around and find the best prices for things. Unfortunately few people do so because, with third-party payers such as Medicare, Medicaid, and private insurance, there is little incentive to shop around because of the moral hazard involved. If more of the responsibility for paying for non-emergent healthcare such as office visits was transferred to the patient away from insurance, there would be more price-conscientiousness and therefore decreased cost of healthcare in this country.

      For emergencies, shopping around is not necessarily possible, but at least in those situations, insurance is available to cover these costs as it should, just like auto insurance.

      • rezmed09

        Peter,
        Say you need back surgery. Just try to find out what every department of the hospital will charge you for a micro diskectomy and overnight in the hospital. Just try calling the different neurosurgeons, the anesthetists, the hospitals and on and on – do you really think they will give you a straight answer let alone bargain with you before surgery is done? The surgeon says he will give you a discount for cash up front, but you have no idea what every other department in the facility will charge.

        I can’t imagine trying to do this if you don’t know the medical terminology. I am a doc and whenever someone in my family goes into a hospital, I am amazed at the number of different bills I get. The complexity of the system and the frequent lack of bundling makes competition impossible for anyone except large insurance companies and the government. Competition in medicine does not exist for the little guy – only defaulting or bankruptcy.

        • http://medicalpastiche.blogspot.com Peter

          Rezmed, what you are describing is precisely the problem with our current system: no price transparency. In an ideal market, a patient can do what you described: go to a hospital website and get a list of prices for every component of a proposed surgery, including the surgeon’s price, anesthesiologist’s, hospital bed cost per night, etc.

          Why don’t hospitals list these prices? The absence of price transparency to the patient is due to a culture ingrained from decades of third-party payers where the patient is hardly involved in the financial details between the actual payer and the hospital, and where the low payments from Medicare/Medicaid and the uninsured need to be balanced with higher charges to the insured. It is nearly impossible to define a specific price for an entire hospital stay because some payers pay less than the price quoted and some payers pay more. Additional regulation and interference from these third parties brings more obfuscation of prices to the patient.

        • ninguem

          “Just try to find out what every department of the hospital will charge you for a micro diskectomy and overnight in the hospital………..”

          Ah, the old, very old trope about how do you shop for spine surgery. Cancer surgery, etc.

          I have a HDHP and HSA. I price shop for the routine matters, which in fact constitutes a big portion of healthcare spending. We spend more for incontinence than we spend for coronary bypass and kidney dialysis, put together. Choosing the generic over the branded drug (as one example) saves a lot of money, and it’s reflected in the performance of HSA-related insurance products.

          What about big-ticket items? I don’t need to negotiate price for spine surgery. The HDHP has already done the price shopping, it’s called a “network”.

          But if you do want to negotiate price for certain packages of treatment, and spine surgery can be one such treatment, the price negotiation is done in other countries. Here’s one example.

          http://www.nuffieldhealth.com/Individuals/Hospitals/

          In the land of socialized medicine, there are private hospitals that will allow you to price shop. Heck, they will finance the surgery if you want.

          One difference between what they do there, compared to what’s being contemplated in the USA, is British physicians are allowed to have a private practice in parallel to a NHS practice. Look up a Web page for a doctor out there, you will often see mention of “private hours” and “NHS hours”. The reforms contemplated here, usually involve being either 100% in, or 100% out, nothing in between.

          • gzuckier

            Note, however, that in Canada where medical treatment outside the provincial health plans is generally prohibited (with exceptions, for instance American medical tourists), the head of the medical plan in Alberta, probably the most right-wing province, was just forced to resign due to a scandal merely alleging a general intent to introduce such treatment.

  • Matt

    “Now we can argue that physicians are still compensated well, but on the other hand they also do a phenomenal job in helping and saving lives.”

    Which is why they make about 500% more than plumbers on average. And they make that regardless of whether the job they do is phenomenal or not.

    Average plumber salary: $32,000-$53,000
    http://www.payscale.com/research/US/Job=Plumber/Hourly_Rate

    Average general surgeon: $150,000-$286,000
    http://www.payscale.com/research/US/Job=General_Surgeon/Salary

    A physician who would pursue this line is incredibly, incredibly tone deaf.

    • Jack

      Surely you don’t want your plumber to be your doctor.

      I sure don’t want my doctor to be paid at that level.

      You probably get what you pay for.

  • Max

    Enjoy your 23% paycut, fellas. You lie with dogs, you get fleas..isn’t that the old saying?

  • http://comsi.com Jeff Brandt

    A friend of mine didn’t believe in healthcare coverage and self insured himself, He is in great shape and exercises a lot and eats well. Severally years ago he decided to go see a doctor about this mark on his arm. After having it removed for $45k, minor surgery and hospital cost. He check into the radiation therapy and decided to shop it around in the Bay area. The quotes ranged from ~600k to ~250k. He decided on the $350k option because of location. Transparency does work in some cases.

    • Anonymous

      Whether or not he believes in medical insurance, he probably does not have a choice. Will any insurance company offer him insurance with his medical history? Though if he can easily afford $350k medical bills, it likely does not matter and self-insuring may be the best route for him anyway (people of more ordinary income and wealth who do not like the idea or cost of first dollar coverage would probably want to have a catastrophic cost insurance policy for the uncommon huge expenses, just like how they buy insurance for their house burning down, etc.).

    • Rezmed

      The beauty of this story, is that if he had insurance, the insurer very likely would have only paid 1/2 of what your friend paid. It’s transparent only if you really know what everyone actually pays. That is so far from happening.

  • everyman

    we docs are compensated well, the fact is that we really don’t want a true fee for service model, no one likes to pay upfront, the fact is no matter how draconian insurance and the Gov’t may seem there is less than 1% of the population who can pony up the cash to pay for a major stay in the hospital, which can be over 20000 dollars, all the healthy people who give their money to insurance companies help make up for the sickest people, it’s not pretty but it definitely is better than regular patients paying out of pocket, as an internist my business will go completely down the drain if i went completely fee for service. Neurosurgeons will always make a ton of money, general sx and primary care are defintely underpaid but the alternative is worse

  • http://comsi.com Jeff Brandt

    In the Ninety I owned and managed a very successful consulting company with Fortune 100 clients. Our rates were not the highest but we did ok. I had been aware of the H1B Visas for a while and the loss of engineering jobs; thanks to the gov and big business. I suggested to one of my chief consultants that we should consider partnering with an offshore company. His personal experience with offshore was not a good one and he threaten to leave if I moved forward with this venture. I decided not to, which was a critical mistake. My point is, once our services become commoditized which is where many professional services in the US are headed then we have to realizes that the rates are going to go down. One of the reasons there is a shortage of PCP and software engineers in the US, there is no money in it.

    Jeff

  • http://paynehertz.blogspot.com Payne Hertz

    I had a plumber come to my house to snake out a blocked sewer line. Two guys showed, and it took them an hour to do the job. The bill? $100.00 plus the cost of a new wax seal for the toilet bowl. You can’t say hello to a doctor for that kind of money.

    A general surgeon charged me $800.00 15 years ago to remove a cyst in office and it hurt like bloody hell as he didn’t have enough local anesthetic, or was too cheap to use it. My plumbers did what they were paid to do, did it well, did it cheerfully and with respect, and didn’t skimp on materials.

    The doctor crying poverty routine is melodramatic at the best of times. Here, the performance transcends the barriers of observed reality.

    • r watkins

      “You can’t say hello to a doctor for that kind of money.”

      Completely untrue. Statements like this invalidate everything you are saying.

      • http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp

        “You cant say hello to a doctor for that kind of money”

        I just did a 30 minute prenatal visit yesterday. Total charges $0.00 (Industry standard in pediatrics that this is free). We did more than just say hi and I was free. so I guess you can say hello and ask questions for 30 minutes for less than that kind of moneyl.

    • gzuckier

      Personal anecdote; a couple of decades ago I had occasion to have a growth removed at a dematologist’s office in Canada, cash only (as an American whose provider network didn’t include Canadian doctors, as a rule). Total expense: $40. Canadian dollars, mind you, which were worth 60 cents American then. I know there’s been a lot of medical inflation since, but even at the time, in comparison to what an American MD would have billed, even at the insurance company’s cut-rate…..

  • http://fertilityfile.com IVF-MD

    This, of course, assumes that the free market is in any way a sensible model on which to base health care.

    Arguments in support of this idea tend to be so simplistic as to be useless practically…

    ANY argument made in 25 words or less on a comments section tends to be simplistic.

    I’d be more than glad to have a detailed discussion about the advantages of a free market model over the mess that we have now. It might be good for those in favor of central planning to enlighten me on its merits and meanwhile. In return, I will share what my views are in support of a free market.

    • Brian

      Well, to start with, I have a problem with what a “free market” in health care would actually look like. First, let’s not forget the fact that the free market is an unattainable ideal; an entirely theoretical construct. The assumptions underlying a free market are absurd in practice. It is as if to say, “These equations prove that a free market works best, provided it’s a perfectly spherical free market traveling in a vacuum.”

      But more than that: 1) Free-market proponents hand-wave the fact that every health care decision involves more than just one market, and the market forces at play in any one market have resounding consequences for the others. There’s the insurance market, the medical device market, the hospital market, etc., etc. I’m not saying it invalidates your beliefs, but it is nevertheless an added layer of complexity that seems lost on market proponents.
      2) What is the measure by which the market adjusts? This isn’t a product like a car, where the consumers can decide they don’t like this car’s shape, or that cars optional features, and the outcome is measured in sales. These are patient outcomes we’re talking about, and in some cases, that means life and death. I don’t know about you, but as a potential consumer, I’d really prefer that oversight be applied on the front-end rather than by the market (which is historically irrational).

      • Matt

        Why should it be different from any other professional service? You hire architects, engineers, and attorneys absent government intervention. At the end of the day, it’s professionals providing a service utilizing their skill and knowledge.

        • Brian

          Providing a service utilizing their skill and knowledge according to the laws and regulations set forth by the government specifically pertaining to the practice of those professions. The government is very involved in the oversight of those professions (to say nothing of the fact that citizens have a right to legal representation).

          • Matt

            You’re incorrect on a number of counts. First, you don’t have a right to legal representation, except in certain situations involving criminal charges. Second, the government is not “very involved”. Take lawyers, the government involvement stops at the state Supreme Court, which has the power to suspend or disbar an attorney in again, very limited circumstances. That’s the most government involvement you’ll get in the day to day practice of any profession.

            So tell me again why it wouldn’t work for physicians?

        • gzuckier

          Because the simplistic free market equation is, you balance the utility of your intended spending versus the possible utility of the amount of said spending, where it to be spent on other goods or services, and optimize the equation for highest utility. However, in a case where the lack of spending results in death, the utility on the other side of the equation falls to zero (except for things like leaving your family an inheritance), which means that the cost of medical care is not constrained by any limitation less than infinite.

          • http://fertilityfile.com IVF-MD

            Gzuckier, your view is valid. I would add that it only applies in its purest form in a situation where the purchase of the healthcare service bought results in survival 100% of the time if bought and results in death 100% of the time if not bought. In reality, when a patient purchases healthcare services, he is buying the doctor’s (and supporting staff’s) time, energy and expertise in the hopes that it will increase his odds of a good outcome. Sometimes the medical tremendously boosts the odds of a good outcome. Sometimes it only boosts it a tiny bit. And there are even times when the drug / surgery / healthcare actually makes things worse. So it’s all a calculated risk. Now who do you want to judge that risk and make the appropriate decision — YOURSELF or A COMMITTEE OF “EXPERTS” who don’t know you personally? I don’t have an answer for everyone, but for myself, I’d rather make my own decisions.

          • Paul Watson

            IVF-MD,

            if you make your ‘own decisions’ you are surely basing them on those of experts. And if you chose to go against those experts, you can’t expect your insurance company to pay. But you may be able to pay out of pocket for something that is not recommended if you can find someone to do it/prescribe it.

          • http://fertilityfile.com IVF-MD

            Paul, I face this issue every day in my work. You have a childless couple who want very much to be parents. There is a treatment that based on their age and other factors has only a 10% chance that it will result in them having a baby to love. The powers that be (government and insurance) tell them NO, we won’t pay for it. It’s a waste of your money.

            So should they be permitted to make their own decision and pay for it anyway? This assumes they know full well how low the odds are. I can tell you that many couples in this situation decide against it and that many decide to go for it. But I’ll also tell you that if the couple know someone else is paying for it, they they almost always go for it. That’s a rare situation though and would require them to have the most generous insurance plan in the world (or live in a state where infertility treatment is mandated which is not where I work).

            It’s certainly an interesting debate.

          • Paul Watson

            IVF-MD,

            ‘I face this issue every day in my work. You have a childless couple who want very much to be parents. There is a treatment that based on their age and other factors has only a 10% chance that it will result in them having a baby to love’

            You’ve picked the wrong example, as IVF is not treating an illness as such (although I agree childlessness can cause psychological harm). IVF is more like cosmetic surgery, which is not covered by most insurance systems, or at least only maybe one or very few attempts, unless it has a big mental impact. Most IVF is self-funded.

            ‘It’s certainly an interesting debate.’

            It might be if you addressed the points.

      • http://fertilityfile.com IVF-MD

        Brian, I’m interested to hear your support for the statement “the free market is an unattainable ideal; an entirely theoretical construct”.

        Having multiple participants makes it complex. I agree. When things are complex, that is when the free market does best in comparison to central planning. You are making MY argument for me. I disagree your broad assertion that free-market supporters claim that every decision is simple one-market decision. I, for one, do not.

        Can you please also clarify your statement “the market (which is historically irrational)”. Are you stating that in our CURRENT system (which is by no means free market any more, but more a mercantilism-style system where special interests use political might to impede the free market)

        It’s just as easy for someone like me to come here say “the free market is the answer” as for someone like you to say “the free market will never solve our problems”. I believe we are making progress when we start discussing the details and YES, I agree it’s complex. That’s what makes it so stimulating to learn about.

        • Brian

          I suppose my philosophy is that a completely free market can not safely and effectively address all of the contingencies of the health care system. That said, I certainly do not believe (nor, I hope, have I implied) that an entirely controlled market is desirable, either. Free market proponents often seem to communicate (or, admittedly, perhaps I choose to interpret) an all-or-nothing approach.

          Me, I’m of the opinion that the health care market MUST be a mixed market. I assume you’re not a laissez-faire fundamentalist, but if you disagree, I’d love to know why. Any substantive debate to be had is really about the degree to which the market should be regulated.

          • http://fertilityfile.com IVF-MD

            Thank you for your intelligent reply. Brian, if you are asking me to argue that the free market can safely and effectively address all of the contingencies of healthcare, I will not even try. I agree with you that it can’t. Absolutely not.

            A 100% free market can not perfectly address things. A 100% central planned system can not perfectly address things. A system that is 50% free / 50% central-planned can not perfectly address things. It is impossible to perfectly address things, because that is the nature of life itself. With life, there is the risk of illness and the risk of death. Nothing can prevent that.

            Therefore, the question we can certainly debate is which system is BETTER, not which system is perfect.

            Before we can embark on this monumental journey, we would have set some ground rules on what criteria we are using to judge which is better. That’s beyond the scope of this comments area, but if you find a nice safe discussion location with cool background music and good food, I’ll be glad to join you :)

            I still think that a 100% free market system (which will naturally bring with it a lot of altruistic charity, because I believe that people are naturally good, especially if not aggressed against themselves) is the optimal system, but I’d be satisfied even with a 80% free / 20% central planned world. I judge our country today has deteriorated to 20% free / 80% central planned, but of course these figures are just gut-feeling and mean little without us defining what determines what % free-market a country is. One benchmark is the overall rate of taxation. By definition the higher the taxation rate, the more central-planned a country is because instead of each individual deciding where to spend the fruits of their labor, it’s some committee or bureaucrat or politician somewhere far away who is deciding.

  • emt.dan

    At least the plumber doesn’t think he’s a urologist (or urological surgeon)!

  • SmartDoc

    My plumber makes far more than I do.

    And cash only, thank you.

  • Muddy Waters

    It’s not just with plumbers, but every arena of capitalism where prices continue to skyrocket. I can’t even get a service guy to show up for a job unless there is a large financial incentive. Everyone is out for themselves, and will gladly charge whatever the market will yield…fair or not.

    • http://fertilityfile.com IVF-MD

      MW, “whatever the market will bear” IS by definition fair. Unless there is some sort of coercive interference. That’s the beauty of the market. If somebody is overcharging for pineapples, there will be a prime opportunity for another person to come in and charge a more affordable price and prosper from all the new business. This then motivates the other guys to come in and change their prices to be more affordable. This will keep going until everybody is working at the level that they are willing to work for – No More. No Less. The market adjusts. This beats some central planner trying to keep up with the ever-changing supply and demand and trying to set so me arbitrary price.

  • http://www.PhysicalTherapyDiagnosis.com Tim Richardson

    The free market is the worst economic system there is – except all the other options.

    Just because Friedman, Rand and Hayek argued persuasively for the free market in guns, butter and bread doesn’t automatically make medicine the next logical product to pander to the people.

    Without central intervention we would still be trading house calls for chickens and there would be one doctor for every 1,000 people (the doctor-patient ratio for Brunei) instead of 1 doctor for every 434 American citizens (2002 data).

    Without Medicare there would be no complex instrumented spinal fusions, no drug eluting stents and no Nobel-prize winning little purple pills to drive demand and inflate health care prices.

    Without Medicare to siphon off the high-risk pool of older, sicker, more complicated patients there would be no viable commercial insurance market for the rest of us young, healthy “invulnerables” who pay for employer-sponsored health care but rarely use it.

    If we had never allowed Fee-for-Service in 1965 we would never have passed Medicare – FFS was the carrot for the AMA.

    Plumbers don’t charge more than neurosurgeons – neurosurgeons charge way more but their fees are deeply discounted – so S. Irfan Ali, MD only collected $253 – plus the co-pay, plus any follow-up, plus any “ancillaries”, like imaging and physical therapy, that he also owns and refers to himself.

    If plumbers charged like neurosurgeons I’d go find a bush and a bunch of leaves an say let the plumbing go – I don’t need it anyways!

    Tim Richardson, PT
    http://www.PhysicalTherapyDiagnosis.com

  • Alina

    Haven’t been here in a while, but nice to see that I haven’t missed anything. Same old article crying about how doctors don’t make enough money, and how the plumbers make so much more. Can’t you guys post something real for a change? It’s really aggravating to see this kind of non-sense and compare that to my doctors’ bills. In my area every PCP charges $145 for a 10-min consult, at least for my company’s plan. One of them had the nerve to show a rack rate of no less than $422 to show what an “incredible” discount he gives to the insurance company. Such a travesty. I’m only paying a $15 copays, but nonetheless I find this practice appalling.

    • http://medicalpastiche.blogspot.com Peter

      The $145 visit likely accounts for a billing coder being paid by the hour, a secretary being paid by the hour, a nurse being paid by the hour, office rent paid by the month, electricity paid by the month, water paid by the month, internet service paid by the month, phone bills paid by the month, malpractice insurance paid by the year, student loans paid by the month, opportunity cost from the 12 years of post-high school education and training to become a primary care physician paid over a lifetime, medical licensing costs paid by the decade, office medical devices and tools paid, floor cleaning costs and time paid by the week, etc.

      All that needs to be paid for before the primary care physician gets one cent.

      I do not understand how you would find the practice of making enough revenue to offset the costs of providing you with a medical service to be “appalling”. Perhaps this is why some people argue healthcare is a right, that is, a patient has every right to enter a physician’s office and demand medical services without paying a dime.

      • Alina

        Peter – you may be new to this site, but the same argument about the cost involved and the education has been made over and over again. If you are a physician you need to change your strategy b/c people nowadays do a lot of research and they don’t buy this justification anymore. I’ve disputed your kind of reasoning in past articles so I’m not going to rehash everything. But I’m going to mention a couple of things. If it’s so hard to be in business then why are you doing this? Second doctors need to step down from the white horse and stop with the superiority aura. As a doctor you don’t study more or harder then someone with a scientific PhD. Yes, there are schools that charge an obscene amount of money, but there are also some universities in the South that charge very low fees. So you guys should also take some responsibility in the school you chose and for paying astronomical fees. How is that the patient’s fault?

        Btw, there are plenty of doctors that really are not that good at all.

        I find this appalling b/c it is. Quite frankly it’s a disgrace! When exactly did health care become a precious commodity? What you’re saying is that only the wealthy should be treated. What should the middle class and the poor do?

        Let’s stop this sensationalist postings about patients wanting free care. People just want a decent price that actually has value, not to pay hundreds of dollars and still get the in and out treatment. As I said before doctors like this could make millions of dollars and still be unsatisfied. If that’s all it motivates you then why not become a broker on wallstreet or better yet go be a plumber?

        • http://medicalpastiche.blogspot.com Peter

          Alina,

          As I mentioned, when money gets paid for an office visit, the money goes towards coders, secretaries, nurses, office rent, insurance, utilities, office supplies, medical licensing, opportunity costs, education, and physician’s time.

          What the patient gets out of this deal is medical care.

          You can call it appalling or a disgrace, or sensationalist. In reality, it’s the cost of seeing your doctor to receive a diagnosis and treatment recommendations. You can argue as much as you want, decrying the fact that you have to pay someone else to receive a service from them, but your arguing will never change the fact that it costs a lot of money to provide medical services.

          Until you can convince the secretary to work for free, the nurse to work for free, the coder to work for free, the office owner to lease the space for free, the power company to provide power for free, the ISP to provide internet for free, the office supplies store to give all the materials away for free, and the medical boards to provide licenses for free, then you really don’t have an argument to demand care for free. On top of that, you need to find a way to magically train a high-school graduate to be a physician without resorting to an arduous 12 year-training path with all the monetary and temporal costs involved.

          Nobody is forcing you to walk into an office and demand medical services. If you don’t want to pay for a physician office visit only because you don’t value any of the components that make up that encounter, then you don’t have much of an argument here.

          • Alina

            Peter – please read what I posted. Really you restated the same things as in your original post and I’ve already responded to that. Is that the best argument you can muster?

            Seriously 12-year of “arduous training?” How you figure? Many people have a bachelor so I wouldn’t even count that, not to mention that I wouldn’t call that “arduous” since at least ½ of it is general education classes and doctors could also major in non-scientific areas. Never really understood what that has to do with medicine. Then you go on to med school for 4 years. The 3 years residency is same as an entry-level job b/c you do get paid for it. As I said before not different than a PhD. Also this doesn’t guarantee that you become a competent doctor.

            Let’s leave aside the shenanigans about patients wanting free care. How is it that you equate not wanting to get ripped off and pay $145 for a 10-min visit with wanting to get free care? How about charging an appropriate fee and actually concentrate more on improving your competence as a physician? You guys, if you’re even a physician, want to get as much as possible, and provide as little as possible. Your rates have nothing to do with cost, same as hospital prices. We’ve heard the same winning there and we’ve also seen data to disprove these “facts.”

          • Brian

            Alina,

            It is perhaps pointless to respond, but I’ll do it nonetheless.
            Your comments in re: the education of physicians belies your ignorance in what is involved in the preparation for and admittance to medical school, the curriculum thereof, and post-graduate medical training, to say nothing of the costs involved. I’ll deal with the last first.

            Medical school is expensive. There isn’t any way around that. Upon graduation, the average medical school debt for the class of 2009 was $156,456, with 58% of graduates having a debt of $150,000 or more. No one is saying it’s the patients’ fault, but it is certainly the reality that prospective physicians face, and to intimate that this is partly because of irresponsibility on the part of the physician in choosing a school is at best laughable, at worst, insulting.

            Second, yes, many people do have bachelor degrees, but I suspect that you’ll find the mean GPA of all bachelor’s degree recipients to be lower than that of medical school students. This is because for med school applicants, their undergraduate GPA is one of the most important factors for admission. Considering that even those who do not have scientific degrees must take med school prerequisite courses (including the dreaded organic chemistry – shudder), it’s not the most difficult thing in the world, but it’s certainly no walk in the park. Oh, and this is while participating in extracurriculars and volunteering (both of which are also weighted in the admissions game).

            Then 4 years of medical school, which is very much different from getting your PhD (by your comments, I suspect you’re not well-acquainted with what is entailed for either degree). Related to the cost issue above, a significant difference is the fact that PhDs, by and large, are actually PAID to go to school vis a vis a stipend.

            WRT residency, you should know that not every residency is 3 years long. Some specialties require 6-7 years of residency training, often followed by a subspecialty fellowship. Currently, the mean stipend for first-year post-graduate training is $48,460/yr. Assuming an 80-hour work week, with (let’s be generous) two unpaid vacation weeks, this works out to $12.12/hr. Entry-level, indeed, especially considering the volume of knowledge and skill already accumulated, and the debt incurred as a result.

            I get where you’re coming from, but let’s not brandish our ignorance like so many torches and pitchforks.

          • http://medicalpastiche.blogspot.com Peter

            Alina,

            I need to reiterate: the money that gets paid for an office visit goes towards the underlying costs of providing medical services to you, which includes all of the supporting personnel, all of the office costs, all of the medical training costs, all of the medical record costs, and all of the liability costs. You have yet again waved your hand and said that the above costs are insignificant compared with the greed of doctors to pinch every penny from a patient. Not only is this incredibly offensive but it is also blatantly wrong.

          • Paul Watson

            Brian and Peter,

            all you are doing is defending an indefensible status quo. As a country we need to start investing much more in education and training to bring down personal costs, and we need much greater economies in infrastructure overheads and the huge overtreatment problem.

    • r watkins

      10 minutes is a 99201 visit for an established patient, for which most payers fork out $20 max. If your insurer is really paying $145 they’re really outside the norm, and can’t be used in any way as a typical example.

      • Alina

        Sorry but the price I posted is the norm – at least in a couple of areas I’ve lived in. Which insurance companies are paying only $20? I have never seen this kind price – ever. Even Medicaid pays more than this.

        I don’t know who does your contract negotiation but if that’s all you’re getting from the insurance companies you are definitely underpaid compared to your peers… even if you are in the lowest paid area.

        • rwatkins

          You’re claiming that insurers in your area pay $145 for a 99201, the lowest level of service (typically 10 minutes or less)? That would mean they’re paying over $500 for the standard 99214. I find that hard to believe.

          • gzuckier

            I’ll disagree with both of you; around here it’s about $50 for a 99201 and about $100 for a 99214.

  • http://Www.twitter.com/alicearobertson Alice

    Wondering….how much would a surgeon charge me to bring all their equipment to my home and do some minor surgery and clean up? I think it would be more than $500?

  • Alice

    Tim how do you pay for Medicare with no free market?

    • http://www.PhysicalTherapyDiagnosis.com Tim Richardson

      Alice,
      The same way every other rich, industrialized nation (except the United States for young, non-retired, non-disabled people) on earth pays – redistributed wealth via government taxation.

      Tim

      • http://Www.twitter.com/alicearobertson Alice

        Tim how do these countries get rich? Is it from taxation? Who do you tax if business is curtailed? As we have seen in Germamy, the UK, Cuba and others redistribution of the wealth works in the short term, not the long term. It is like using all those charge cards that offer teaser rates, then you rack up oodles of debt you can’t pay back. In Europe there are huge budget cuts, retirement ages being prolonged, and Fidel screaming for help, etc., etc. And, sadly, the budget cuts means the quality of medical care goes down.

        • http://www.PhysicalTherapyDiagnosis.com Tim Richardson

          Alice,

          I agree with you with one caveat – Germany. They are the world’s second leading export nation and they have the strongest economy in Europe. They have high taxation and employee protection laws (eg: six months maternity or paternity leave, etc.). They practically invented the welfare state but they spend less than 11% of GDP on healthcare. Government pays for over three quarters of healthcare and over 85% of the population is covered. BTW, Germany has many of the same problems as the USA, eg: immigration, aging and obesity of the population, and a large land mass with a fragmented density map.

          Germany does one thing that the USA does not do – limits the supply and type of physicians based on need (aka: central planning). We do this for hospitals but not for individuals or small practices.

          What if we say that we only need 500 new orthopedic surgeons next year? Do you think Medicare per beneficiary rates of TKR and THR will continue to rise in high cost areas like McAllen, Provo and Bradenton?

          No. Rates will fall and with it overall Medicare spending.

          Tim

          • ninguem

            And Germany is seeing the same problems, the same cost inflation, increased cost passed onto the individual.

            http://www.howtogermany.com/pages/healthinsurance.html

            And the same concern over different healthcare for the haves and the have-nots.

            The term “two-tiered medicine” translates to “zwei-klassen medizin” in German. Google the term and see it discussed in their press.

            In French it’s “Médecine à deux vitesses” to see the same problem in France.

            “Médecin refusent CMU” Doctors refuse CMU “couverture maladie universelle”, their Medicaid.

            “médecins refusent les patients pauvres” Doctors refuse poor patients.

            Google the terms to see the same problem there. Heck, reading the French docs complain about their paperwork hassles with their Medicaid, payments delayed, denied, for legitimate services provided in good faith, it sounds just like USA docs.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    Along with running a cash business comes a lowering of your overhead. You need fewer employees, you get paid up front, your costs go down. Most practitioners in areas heavily resided in by seniors are fearful of going that route. Younger adults remain outraged at having to pay a $20 or $25 co pay to see a highly trained professional even though buying a round of drinks or picking up two packs of cigarettes is something they may not complain about.
    My plumber came over yesterday to fix the water measuring device and flapper in the tank of our toilet. He was there 11 minutes. One of my older adult kids wrote him out a check for $249. The part cost $12.99 in Home Depot but the salesperson said the installation on low flow toilets is tricky call a plumber. At that hourly rate he makes far more than my colleagues in GI doing fiberoptic procedures or my colleagues in interventional cardiology placing stents in critical situations.
    As physicians we face a 23% reduction in Medicare fee reimbursement this morning. A direct pay system makes lots of sense.

    • Paul Watson

      If he charged that much for an 11 min job he was ripping you off even with a minimum rate say for a 30 min visit. But this is one profession where the market does work well – but only if there are enough plumbers competing for business. If there aren’t then of course the market fails for everyone except the lucky plumbers.

      The main reason why a plumber type market can’t work in healthcare is of course because we need intervention to ensure there are enough affordable doctors and resources to fix all types of leaky human beings safely, including those who were born leaky.

  • Alice

    Okay, but why is Medicare spending being reduced? Not enough budgeting money via cuts via the need for more revenue which is via those who actually pay taxes (40% of Americans pay no taxes).

    Tim do you want to pay the tax rates of the average oh let’s say Frenchman. And don’t you just applaud Cameron of the UK in principal…because Krugman the winning economist told us a :VAT and death panels are the answer to Medicare cuts. Etc. People are costly buggers the last six of months..

    Overall…with it’s flaws I have seen no better way than the free market.

    • r watkins

      “40% of Americans pay no taxes”

      Misinformation of the worst sort. Approx. 43% of Americans pay no INCOME tax.

  • Jack

    1. Most people NEVER feel like they are being paid enough. It’s normal.

    2. Until you go through what a doctor goes through to get a degree and work/oncall you really have no idea what that life truly means. I mean this in the nicest way.

    3. Too many middlemen getting rich off healthcare who has nothing to do with providing care.

    • Matt

      Nor does the physician know what it’s like to crawl around under a house fixing rusty, broken, leaking pipes on a freezing cold day. The whole “until you’ve walked a mile” argument goes for about everyone.

      • Jack

        Only difference is that a plumber (most professions) has a choice of not taking the job. A physician who’s call in for an emergency doesn’t. And it comes with all the responsibilities/liabilities.

        • anon

          Very well said Matt .As a plumber, you are providing a vital service and have gone through the rigors of training and hard work as any other professional. I don’t think I would want to live without decent working plumbing .
          Jack, you have the same choice as anyone else to take the job or not. If the plumber doesn’t take the job, what happens? If you as a doctor don’t take the job what happens? You both miss an opportunity in your business? Or you may get fired, if you work for someone else? You both CHOSE your careers, and have the FREEDOM to pursue another career, if you don’t like the one you have. Both of your jobs have responsibilities/ liabilities, as do most jobs. Please stop trying to give the impression that you are the only one with an important job on the planet.

          • Jack

            really? It just goes to show you that most people don’t understand the job of a physician.

            Every job/service is important. Never said they are not.

            Choices are something a physician often do not have. Any one can step into an ER to seek help and the physician becomes completely responsible. There is no choice in the matter. The idiot that drink himself to near death for the 10th time can walk in and demand care for almost anything medical. The law prevents us from turning him/her away. We also assumes responsibility for his care/follow up. Oh, he/she won’t pay a cent but will probably sue for anything he/she can think of.

            Most physicians devoted anywhere from 11-16 years of their lives training to be come a doctor. You think they just drop that sacrificed and start a new career? This isn’t a job you just find on http://www.careers.com and learn on the fly.

            You want to know why health care is ridiculously expensive. Just look at yourselves in the mirror. Same people who wants to pay little taxes for full services and little insurance premium for the most expensive medical care and sue if they don’t get it.
            Yes, that is what is included in your medical bills.

        • Matt

          A physician has a choice on an emergency. He can choose not to work for that hospital. If a plumber works for a captive employer, and they order him to work on this or that job, he’s got no more choice than the physician. And it comes with all the responsibilities/liabilities.

          A physician who works in an ED made choices, and knew the pros and cons when he/she made the deal. Just like any employee.

          • anon

            My thoughts exactly.

          • John Ryan

            “A physician has a choice on an emergency”
            No actually, this is not correct. As a member of the hospital staff, even if I don’t work for the hospital, I must see any patient who is assigned to me when I am “on call”, whether or not they can pay, wish to pay, etc. I cannot refuse to be on call, or refuse any patient. The hospital is under similiar requirements, since this is a federal (unfunded) mandate. So add this to the list above of overhead that medical providers pay routinely, unlike other private businesses.
            Most doctors get enormous satisfaction from their job, and won’t be look to becoming plumbers anytime soon. But the realities of the present threatened payment rollback is that the expenses must be cut proportionately, and since we cannot eliminate mandated free care, staffing and patient services will decline in availability & quality, as the need to see more patients in less time increases. In the present system, you can’t charge more, so you do more, quicker, with less frills.

          • Matt

            Sorry John, I didn’t fully type out my comment. I meant that a physician does not have to take that bargain initially if they do not want.

            “The hospital is under similiar requirements, since this is a federal (unfunded) mandate. ”

            That’s not a mandate, that’s the requirement for receiving federal dollars. That’s like saying your car payment is an unfunded mandate, and ignoring what you received for agreeing to pay those bills.

          • John Ryan

            Maybe the hospital gets some cash from Medicare, I certainly don’t. I just get the finger from most of the ER patients who I care for for nothing. Not a choice I made.

          • John Ryan

            Oh, and as far as car payments, I’ll turn the analogy around. Our beneficent government is like a guy who buys a car at a massive discount, renegotiates the monthly payments down at will, and, oh yes…you have to give his entire family cars for nothing.

          • http://Www.twitter.com/alicearobertson Alice

            John, you forgot to say they will then regulate you to the point you can no longer employ most of your employees who will then lose jobs and insurance…and maybe their own cars, and if you are fortunate to have money to personally invest you and your close friends can invest in the competitor’s businesses and you can make millions……no, no….don’t call that inside trading….this program is available at Socialist Motors where false advertising and hypocrites are welcome to keep the fictional PR campaign up and running under the guise of being humanitarians who only bought those cars to help all of mankind but keep the best ones for the elite…..um….the Cadillac lovers! :)

          • Matt

            “Maybe the hospital gets some cash from Medicare, I certainly don’t. I just get the finger from most of the ER patients who I care for for nothing. Not a choice I made.”

            Did you not consider the payment when you took the job? Determine the likelihood of getting paid based on past history at that hospital? Even if you were in a totally free market I would think you would look at those sorts of things before taking a job, wouldn’t you?

            If you didn’t, that’s not because you don’t have choices. It’s because you didn’t do your homework or didn’t read your contract closely.

          • John Ryan

            “Did you not consider the payment when you took the job? Determine the likelihood of getting paid based on past history at that hospital? Even if you were in a totally free market I would think you would look at those sorts of things before taking a job, wouldn’t you?”
            Matt, I don’t really understand your point. I thought the discussion was whether the medical care system would be better more like the plumber-homeowner model. You seem to be making the point to suck it up or do something else — you should have known better. These regulations were not in place when I began practice. Additional regulations (courtesy of Rep. Pete Stark) now prevent the hospital from paying me for being on call. Doctors are restricted from organizing to improve pay & working conditions. We are super-regulated. I think that the way to improve the medical system is to directly deal with my customer, not a third party.
            I don’t have any financial arrangement with the hospital(s). I am not their employee. They allow me to see & take care of my patients in their facility, as long as I can meet their criteria, one of which is free care for anyone who shows up when I’m on call. And its no different at any hospital (although some doctors are throwing in the towel and taking salary at the hospital). But due to EMTLA laws, there is no way for the hospital or me to condition care based on ability to pay. Where else is this true? If you go to get food, does every private store have to provide it for free if you don’t have the cash? Of course not, the government subsidizes the stores with food stamps.

  • Alice

    Well…golly….thank ya’ kindly for correcting my faux paus of the “worst” magnitude. How much do you charge by the minute for correcting the obvious?;)

    I am posting on a cellphone and can’t really see what I post…so…sometimes the reader needs a translator.

  • http://www.303plumber.com Denver Drain Cleaner

    Well, it is true that we plumbers do pretty well, but your numbers seem off. My hand surgeon charged $20,000 for a 45-minute surgery to repair my hand. Insurance covered most of it, but I didn’t mind paying my little part since I need my hand so badly.

  • Zandolee

    I hope Max enjoys a 23% cut in healthcare professional service the next time he needs to see a doctor.

    • Max

      I am a physician. I mostly got out and took my GME-funded education with me tucked in my head. Flipped the bird on my way out. I thanked America for paying for it through medicare and took it into another lucrative career.

  • gzuckier

    As it happens, I just came from a large home improvement chain big box store which shall remain nameless, where I purchased a kitchen faucet, and noted the sign next to the display enthusing that professional installation was availble for “only $155!”. I really took a wrong turn somewhere, careerwise.

    • http://www.twitter.com/alicearobertson Alice

      This sounds so lame to break this down, because it’s a bit obvious, but it’s the store that makes that money. You didn’t expect a “real” plumber for that did you?:) Tip of the day….check your local paper and find one from one of those lists………or just go to youtube and teach yourself. We are but mere serfs and have managed to never hire a plumber or electrician…..desperate people do desperate things…..I use youtube to avoid the vet and docs when I can too.

      In one year we managed to run up close to a quarter million dollars with the hospital, but the doctor made little of that. Our surgeon was worth three times what he made….and so it is with plumbers who have overhead like a hospital. They don’t bank that whole amount.

    • http://paynehertz.blogspot.com Payne Hertz

      Do you have any idea what’s involved with changing a faucet? While simple in theory, changing a faucet can be a nightmare in practice, and the store gets most of the money.

      First, there is transportation time to and from the job site. Figure at least an hour round trip unless you live close to the retail outlet. For an “easy” job, figure at least an hour of sizing up the job, setting out your tools, and then laying in an awkward, painful position to get at the fittings holding the faucet in place, and then reversing the process to finish the installation.

      If the faucet is rusted in place, in can take several hours of back-breaking, frustrating work in cramped and unsanitary conditions to cut the old faucet out. if you’re getting all that for $155.00 including transportation time and the plumber’s pay, you are getting a bargain.

  • http://www.twitter.com/alicearobertson Alice

    Why can’t we put the uninsured on a system like Kaiser? It would cost a tenth of what they set aside to pay for Obamacare. Isn’t Kaiser a part of the free market? Wouldn’t that encourage Kaiser to expand….get rid of the insurance companies everyone seems to hate? Why isn’t this option taken seriously even though it was researched and promoted by some of the top hospitals in the US?

    Sometimes it really isn’t about answers……it’s about what’s in it for whatever elected official to get re-elected, and the next election will bring out the people who stand to gain from voting to keep themselves comfy. The southern border states really suffer from this voting mentality and it makes it very difficult for a candidate who wants smaller government to be elected (that’s why this election was a real victory for conservatives).

    Why can’t the free market be encouraged in healthcare? Surely, there is plenty of room for it? Can’t the government step back and let the free market do what they do, and pay private enterprise to do it better than they possibly can? We would save tons of money…….realizing as long as people are running anything there will be problems…..but when government employees get involved (and we know they are paid much better than private industry) it gets expensive, and rarely runs efficiently. I worked for the government….took the civil service exam only to be surrounded by people who wanted to know who you knew to get in where you were…sigh! The joke was not to work too hard, or come back early from lunch because it would be easier to pass a constitutional amendment than it would be to fire you. Nice job…..if you can get it. I didn’t pay social security either……really nice retirement package and benefits that were much better than what we have now. It’s a great system for those who work in it, but those it serves…..hmmm……..?

  • jim m.d.

    I love this M.D. vs. plumber stuff, because actually I WAS a plumber (or more accurately a union pipefitter) before I was a primary care doc. I did the math a few years ago, financial break even point was when I turned 55. If I had stayed a pipefitter I would now be retired with a generous union pension. But then again, I would not have had the grateful thanks from legions of patients and families, and would not have had the memories of delivering new lives into the world. I can rejoice in the fact that I have made a difference during my career, and that far outweighs the downchecks of being undervalued by my society.

    • http://www.twitter.com/alicearobertson Alice

      Hmmm…….we know a midwife who works for an OB and with bonuses she earned $300,000 last year. She said it’s such a booming practice she gets huge bonus checks from the doctor (who makes money without leaving home……she does the deliveries). I don’t know any plumber who makes that.

      I realize this example may not typical, but I find it very hard to believe an OB makes less than a typical plumber.

      Maybe you should start a doctor’s union inbetween deliveries.

    • Matt

      “and that far outweighs the downchecks of being undervalued by my society.”

      It would seem that the only people undervaluing doctors are themselves. They choose this payment model which pays them all the same regardless of skill.

      If you don’t value yourself higher, why should anyone else?

      • jim m.d.

        Matt:
        Guess you didnt get the gist.
        1) doc dollars earned to age 55 approx.= plumbers lifetime salary
        2) doc salary is determined by something less than free market, plumbers by free market
        3)doc’s memories and image in the mirror; priceless

      • Jack

        Matt,
        I didn’t realize that you have your senator or the Presidents on speed dial.

        I am impressed at your ability to comprehend the current reimbursement system after reading this website. Since doctors CANNOT form a union and only be loosely associated in medical societies, we have very little negotiating power against the GOVERNMENT or BILLION dollar insurance companies. Have you negotiated with the IRS?! Medicare?!

        • Matt

          Do you negotiate with the IRS? That doesn’t make sense. I negotiate with insurers – think they’re less tough than Medicare?

          You’re part of the highest paid profession in the world. If you guys don’t have effective lobbyists, who should you blame?

          Granted, you’re paying for the mistakes of your physician predecessors, but still, you keep signing up for third party reimbursement. Whose fault is that?

          • Jack

            There is not negotiating with Medicare. NONE. Nada, zilch. Either you are in or out and if you are out then you are cannot accept Medicare patient for next 2-3 years PERIOD. No exception! They won’t pay you a penny if you HAVE to see them for EMERGENCIES in any ER in the country.

            Government doesn’t negotiate.

            Matt,
            Tell us which are in USA has a pocket of population that pays cash and I am sure some of the doctors will be happy to move there.
            Medicine is expense to practice. Equipments and staff are expensive to hire. Most practices can’t survive if they don’t take insurance because high percentage of the population has insurance and they will not want to pay out of pocket (even if it’s 20 bucks).

  • jim m.d.

    Alice:
    Read carefully! Never said I was an OB. I said I was a PRIMARY CARE DOC. Yes, some FP docs delivered babies, attended their patients in the ICU, assisted in surgeries, rounded at nursing homes, showed up at all hours in the ED and admitted their own patients. Oh yeah I forgot, office hours. Part of the great unwashed undervalued. If your reporting skills are as good as your reading skills methinks your anecdotes might be a tad inaccurate/or overblown.
    Second: We would LOVE to form a pcp union. Unfortunately, to do so violates anti-trust laws and would land us in the slammer.

  • Alicec

    Okay Jim…here is how a reporter works. I am married to a union pipefitter. I will upload his W2 if you will upload your own. Let us compare…true journalism challenge for you.

    • JustADoc

      What Jim wrote is very easy to comprehend. He even broke it down again. Yes, he makes more this year than a plumber makes this year. However if you run the numbers from age 18 to retirement, the typical average family physician doesn’t actually lifetime cumulative outearn the plumber until sometime in his 50s.

      For Matt’s argument, the government has made it extremely difficult to work in a hospital without taking Medicare. For specialists who need the OR or cath lab or GI lab or etc., it is in fact impossible to not be forced to take uncompensated call.

      • Matt

        “However if you run the numbers from age 18 to retirement”

        Let’s see these numbers you’re speaking of.

        “For Matt’s argument, the government has made it extremely difficult to work in a hospital without taking Medicare”

        I would agree they have. However, I would also agree that as a group physicians have been largely complicit in this.

      • http://Www.twitter.com/alicearobertson Alice

        Sigh……where is your logic and deductive reasoning? If my husband was retired now he would get a couple thousand a month. Are you saying doctors retire and live in poverty? Oh boy….you guys launch so many straw men arguments I am thinking you could go into farming, instead of dreaming of the luxurios life of a plumber or pipe fitter.

  • Alice

    Jim….did you say your mirror image is priceless? Gosh…..I love me, who do you love? Mirror, mirror on the wall whose the fairest of them all?

  • weakanddizzy

    One of the main problems with the free market approach to healthcare is that a free market assumes both parties involved in a transaction have relatively equal ” power”. For example, if I want to buy a car and I don’t really absolutely need one today I can shop ( online, in person, car trader, etc.) for it at my leisure and if I don’t like the price from one dealer I can walk out the door and buy from someone else ( private party, etc.). I can also pick and choose what type of car I want ( luxury vs. stripped down). With respect to healthcare, I could potentially strike the same deal but only for certain services ( botox, cosmetic surgery, bariatric surgery, other elective procedures). How does the free market work if I develop appendicitis and the small town I live in has only two general surgeons and one is out of town on vacation? If we had a truly free market the surgeon could ask me ” Well, how much is your life worth to you?” or better yet “I charge $ 1.00 to open, $ 10.00 to remove your appendix but $ 10,000 to close you up. Do you want me to close or just bandage you up with an open wound and you take your chances ?” I don’t have the answer but I think we need a system that ensures we take care of everyone ( we already do just at wildly different prices to society/ patient), pays the providers a fair fee for their time, training, overhead and expertise ( you will eventually know if it fair or not by shortages or oversupply of certain types of physicians) and eliminates the hordes of middleman/ bureaucrats who profiteer way beyond their contribution to the process of healthcare that we have today.

    • http://fertilityfile.com IVF-MD

      Excellent points. Mr. or Ms. WeakAndDizzy

      May I pose some questions?

      In your examples, you present two different fundamental contrasting examples: One where the consumer has many choices. One where the consumer only has one choice. THAT is the fundamental difference, and again, keep in mind that the free market will result in there being multiple choices for something that is in demand.

      So the answer to what happens if there is only one surgeon available to do an appy is that there wouldn’t be just one surgeon, just as there wouldn’t be just one car dealer nor just one restaurant in a metro area. If there is a market for people who need surgery (and I think you and I would agree that any location that has people would by definition have a demand for surgical services) then competing surgeons would crop up to meet those needs and the market would give incentives for these surgeons to make the experience as reliable, economical and customer-friendly as possible so as to attract business to their own practice.

      For example, what’s to prevent a group of surgeons from offering price transparency, low prices, verifiable track record, great ancillary and customer services. What’s to prevent a middle man from offering patients the potential OPTION to gain value from middleman services? That way, patients can do the legwork on their own of searching out a good doctor OR they could just pay a little extra and let the middleman do the work for them?

      The free market always seeks out the BEST solutions if there is a need. The reason we don’t have more options is because the system we currently have gives little incentive for anybody to do this (and arguably sets up deterrents to dissuade anyone from doing this)

      2. What model do you propose that would be superior to a free market model, one that does not involve theft or forced taking of the fruits of labor from one person to pay for the benefits of another person?

      • weakanddizzy

        IVF-MD,
        It is actually Dr. Weakanddizzy. You also raise some excellent points and I’m really not sure right now how to structure a system that is fair to all. I suspect a system of fee for service ( free market not medicare/insurance mandated fees) for outpatient visits and major medical coverage for inpatient services is probably the most reasonable for all involved. One of the major problems that has developed in our society is the expectation that medical insurance should cover ” all costs”. After all most people are paying hundreds of dollars/month for health insurance. Personally I don’t think twice about paying $100-$400 for dental visits or even $200 taking the dog to the vet for his yearly exam/heartworm/flea meds. But because I have medical insurance I always check the office co pay ( mine is $20 for generalist, $30 for specialist). If I was paying hundreds/month for dental or veterinary insurance I might be upset about the fees that I am paying now for those same services. A major barrier to a system of free market prices for medical care is the unspoken assumption of society that physician’s time has already been paid for in their monthly insurance premiums. Now we know that the two are completely unrelated. Concierge MD’s are doing well because a small subset ( 80/20 rule) of their patients are willing to pay ” extra”, in reality free market rates, for physician’s time. I’m not sure this will work for the masses. We already have a multi tier system ( it is covert). I think it will just become more transparent over time. Either that or we will go down the socialized med pathway and will develop a very mediocre system staffed by mediocre doctors. Of course this will not happen overnight, It will take a few generations to pass.

        • Alina

          “Either that or we will go down the socialized med pathway and will develop a very mediocre system staffed by mediocre doctors. Of course this will not happen overnight, It will take a few generations to pass.”

          We already have a lot of mediocre doctors…and I mean mediocre at best. As a patient that is one of the most frustrating things there is. Many MD’s send patients for unecessary tests and push pills without taking the time to truly understand what the problem is. And for this “care” we the patients DO pay a lot of money. It’s not just the copay, it’s also the overall fee that physicians are receiving from the insurance company, which btw, as an employee I’m paying for it one way or anoher (part of it coming from the monthly premium fee). As a society we are paying for a Lamborghini and we’re geting a Yugo.

          Good doctors are really few and far between.

          • weakanddizzy

            Alina,
            Your post validates my reply. There are a lot of ” mediocre doctors” because they live on a” hamster wheel”. They don’t get paid to take time to figure out a problem. They have to ” crank ” the patients through the office to make overhead. I’m not trying to make excuses but doc’s are incentivized on volume not quality. How do you know how much the physician is receiving from the insurance company? Have you seen their contracts? I suspect you actually don’t know how much they receive to see you but you know you pay a lot each month. You have just illustrated my point!!

          • Alina

            “How do you know how much the physician is receiving from the insurance company? Have you seen their contracts? I suspect you actually don’t know how much they receive to see you but you know you pay a lot each month.”

            Actually I do receive the EOB (explanation of benefits) which outlines the following information:
            1) amount doc bills (“rack” rate)
            2) allowable amount (actual fee that insurance contracted with the doc).
            3) actual amount paid – which is never different than the allowable amount.
            4) date when payment was made.
            I’ve seen a lot of comments here that docs are not receiving the entire allowable amount from insurance companies b/c some things are disputed, but in my personal experience with diff. ins. companies I’ve never seen them decline anything.

            The EOB described above has been the standard for many, many years. Do you not have insurance?

            “They have to ” crank ” the patients through the office to make overhead. I’m not trying to make excuses but doc’s are incentivized on volume not quality. You have just illustrated my point!!”

            Not so fast :)

            I agree with the second statement “docs being incentivized on volume not quality.” But this include ALL doctors, right? So my question back to you is why do some doctors chose to do the right thing, while others don’t. I think that being a doctor you can’t be motivated solely by extrinsic values. If that’s the case why not chose another profession that offer the same monetary reward?

            Also a question that I never get an answer to is how can some doctors (PCPs) manage all the cost and still spend a min of 20 min with their patients regardless of their payer (Medicaid included)?

  • http://humanfactorinmedicineandlife.blogspot.com/ S. Irfan Ali, M.D

    When I wrote this article I never realized that there would be so much chatter.

    I wrote this article, not because I think physicians are any different or any better, it is just my point of view.

    I wrote this article “Doctors are in for the money” http://humanfactorinmedicineandlife.blogspot.com/2010/10/doctors-are-in-for-money.html
    regarding all the jobs I have done in my life from Pizza delivery to cleaning bathrooms. I am not sure it proves anything. It just narrates the life I have lived. :)

  • DocsWife

    What’s appalling to me is that some balk at even paying a small co-pay of $10-25 to see a physician, as if that’s too much money.

    For those bewildered by just what your office visit is paying for – I’ll tell you, it isn’t simply the physician’s time, it’s also paying for the overhead for the doctor to have a place to see you, all the equipment needed to see you, the medical supplies involved in your visit, the professional staff employed, the business staff needed, the office supplies, malpractice insurance, business liability, rent, utilities, capital equipment (ie. computers), furniture, software licenses, benefits for staff (insurance, 401(k), etc.), etc.

    We recently did a full analysis of cost ratios in my husband’s practice, to better understand our costs to simply remain open and continue in private practice.

    Our bottom line, absolutely must have in revenue to pay all overhead and staff (before husband can take a paycheck) is $355 an hour. When you add in how much he makes – that adds another $50 an hour (yes, he makes an average of $50 an hour as a specialist), so in total, his practice must see revenue of $405 an hour to pay all bills and for DH to continue his salary.

    Without DH being compensated a penny, 4 visits per hour needs $88.75 per visit to pay for everything that is overhead in the visit. Including DH being paid as part of your visit brings that up to $101.25 for your visit. Yet folks balk at a co-pay that isn’t even 25% of the total for the services they’re paying for!

    • Alina

      Clearly you don’t understand how the system works.

      As a patient I’m not “only” paying the copay of $10-$25, but I’m also paying a monthly premium which, in my employer’s instance (self-insured), goes towards the remainder of the payment that your husband receives for the visit (the so-called “insurance” payment). The insurance is not paying a penny, but rather acts as the clerk administering my company’s fund.

      Btw, you should know that not everyone has a set copay – many people have a co-insurance which represents a % of the allowable fee for the respective visit. You should also consider that for some people that mere $10-$25 means a lot, despite the fact that is pocket change for you.

      Further it’s not only the fee that’s being charged for a 10-min visit nowadays – in my area this fee is $145 – but most importantly is the lack of competence that is SO prevalent. Where is the value in paying this sort of money and getting nothing in return? In any other circumstances as a consumer I would be getting my money back if the product/service is not up to par. Doctors on the other hand WANT to be paid this type of amount just because they NEED money. So do I, so you think my boss would pay me a few million dollars just because I need it? That’s not how it works in the real world you know.

      Lastly, there are plenty of doctors who manage financially and still manage to be caring and human. So I do have to wonder how others can’t.

      • DocsWife

        You need to find another doctor if you feel you are not receiving adequate care and service, simple as that.

        Not all doctors speed through patients – and even the 10-minute office visit typically will consume 30-minutes of time, 20 of which you do not see – preparing for your visit, documenting after your visit and billing and chasing money if your claim is denied.

        In my husband’s practice (specialty) he typically spends no less than 20-minutes face-to-face with each patient due to the circumstance of their medical conditions – some are upwards of 90-minutes.

        The thing in all your replies thus far, that you utterly fail to appreciate, is the cost of just being open to see you….you see little value in the physician education and knowledge, the environment that must be there to see you, or the professional staff employed for him/her to see you.

        Do you really think that’s free?

        Remember, you get what you pay for!

        • Alina

          “You need to find another doctor if you feel you are not receiving adequate care and service, simple as that.”

          I wish it would be as simple as that, but finding a good doctor is the luck of the straw. How much time off should I take so I can find that diamond in the rough?

          “…preparing for your visit, documenting after your visit and billing and chasing money if your claim is denied.”

          I wish the docs would be prepared, but I find that they’re actually reading through the chart when he/she is with me in the room, so actually that 10 min, becomes more like 5 minutes spent on the issue at hand. Specialists do spend a bit (emphasized a bit) more time, but they also receive significantly more than a PCP.

          As for the claim denial, I have NEVER seen one of my claims denied. Further the claims are always paid on time – within a few days, so I’m not buying the whole claim chasing either.

          “The thing in all your replies thus far, that you utterly fail to appreciate, is the cost of just being open to see you….you see little value in the physician education and knowledge, the environment that must be there to see you, or the professional staff employed for him/her to see you.”

          I see value where it actually exist. Many doctors do not provide much value, if any. I’ve seen some doctors who are very good at what they’re doing and they are also very kind and caring. It’s also been my experience that the ones that are arrogant are also incompetent. Value is when someone provides something for the money you pay. If you go to buy a computer for $3,000 and it brakes down in a month will you consider that you received a valuable item? Would you consider the vendor’s high cost of manufacturing as the value definition or you would look at what you received in return for the money you spent?

          The good doctors are also the ones that I never heard complaining about the “high” cost of doing business and they don’t play politics. How do they manage? Maybe some of you on this site need to find some peers that are successful and ask them to share their practices.

          • Maggie

            The good doctors are also the ones that I never heard complaining about the “high” cost of doing business and they don’t play politics. How do they manage? ,/i>

            Most likely they’re in academic medicine – on salary, so don’t worry about the overhead or risk a paycheck if they fail to meet overhead. Just a thought.

  • http://comsi.com Jeff Brandt

    Our health system is heading for a complete breakdown if reform doesn’t happen. Reform is not going to happen overnight. I spend a lot of time in Argentina and know many doctor there. Most when to school in the USA. You can get the best coverage available for $1400/mon through Swiss Medical which includes dental and meds. If there why not here?
    There are a lot of people making a lot of money but it is not the General Practitioner/PCP. They start for about $75K out of school. Some specialist are overpaid, but I don’t think that is the real root of the problem. This is an issue we need to all work on to improve patient outcomes and reduce cost. It must start with the patient, demand more from your doc and yourself. My cholesterol spike because I was gaining weight. I took responsibility and have lost about 11 lb. in the last 4 months. My doc prescribed an MRI for a condition and I asked if we could wait for a few months and retest. The condition was still their but he decided to use ultrasound to reduce the cost because of my high deductible.

    We need to stick together on this one or we are all in trouble.

    Jeff