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naraburns  nihil supernum  1yr ago (text post)   3365 thread views

Small-Scale Question Sunday for January 1, 2023

Happy New Year!

Do you have a dumb question that you're kind of embarrassed to ask in the main thread? Is there something you're just not sure about?

This is your opportunity to ask questions. No question too simple or too silly.

Culture war topics are accepted, and proposals for a better intro post are appreciated.

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I had to visit the emergency room earlier this year for a nose bleed. At the time I was discharged (October 2022) I paid a 200$ bill to the hospital, foolishly believing that this was the entire cost of the visit. I subsequently received a 357$ physicians statement. This little episode in medical billing really irritated me since I felt that the hospital had hidden the actual cost of their services and because the amount was absurd for the services rendered (10 minutes for a physicians assistant to apply some topical TCX). As a result I have been thinking of not paying it and am trying to understand if recent changes to that the credit reporting agencies have made may allow me to get away with this without damaging my >800 credit score.

In particular it sounds like medical debts < 500$ will no longer impact a credit score starting in 2023 https://www.equifax.com/personal/education/credit/score/can-medical-debt-impact-credit-scores/ and I am trying to determine if this determination is made based on the date of the service(s) (october 2022) or the date that a bill is sold to a collections entity, which could occur in late January. I also discovered that paid medical debt collections haven't impacted a consumers credit score since 2022 (https://investor.equifax.com/news-events/press-releases/detail/1222/equifax-experian-and-transunion-support-u-s-consumers), so its my understanding that even if they are able to sell this bill to a collections entity, the worst that could happen is that I would simply have to pay the amount at a later time.

Does anyone know if this analysis is basically correct? Its my understanding that their only other recourse would be to try and sue me which is unlikely to happen over a 357$ bill.

Why would you have to pay it if they don't tell you the cost ahead of time? There's no contract.

Pretty normal to sign a document that says you are financially responsible for accrued charges.

Consider that when you walk into the ED with chest pain you can end up with a million dollar suite of cardiac surgery or thirty cents of tums and everyone has limited idea to predict which it is going to be ahead of time.

Wouldn't it make more sense for the hospitals to charge a flat rate for a given set of symptoms, tell you what that is upfront, and then take on the risk of whatever treatment you end up needing? The only downside is this gives the hospital an incentive to undertreat (although that's probably better than the current incentive to overtreat), but hospitals would have reputations and could potentially be sued for undertreating.

You'd think so and it's a fair question which is why I gave example somewhere else in this soup of comments. Elective procedures, stuff done at an outpatient surgery center, cosmetic things. Low rate of complications, low rate of fuck ups, pretty simple with a lower range of prices. Sure. Places will do that.

Hard to do for symptoms for so many reasons (is that headache a migraine, a stress headache, or a brain bleed? You are complaining about 8 things and the real problem is heart failure etc etc, the pain is referred and it's actually a very different kind of thing).

Once you've figured out what's going on it's feasible for some things, but the American population is really unhealthy and the one person where you open them up, find out it's bowel cancer and not appendicitis costs hundreds of times more than the regular appy.

It's the equivalent of those housing developments where everyone shares water fees but someone has a pool that they keep emptying and refilling every day.

Is this for real? The person billing OP wasn't even a doctor, and no PA, NP, or doctor is getting paid that much for that type of work. Blame the admin and the billing people for the number, the PA has no control over it and is making 1/10 of that sticker price.

Again, as stated elsewhere doctors have been lobbying for their own competition for years, who proceed to do the same job for cheaper, with less training, and do a demonstrably worse job.

I'm always flabbergasted at how little people seem to know about this in relation to how enthusiastic their beliefs are.

Also the NHS is collapsing.

Ah you took this a different angle than everyone which is a better one.

-Restrictions on open immigration are not unique to medicine, no field wants to import competition and generally countries don't want to fuck over their knowledge workers. While the U.S. is notable for you needing to redo residency, that doesn't mean it's actually possible to move over (Canada and Australia will happily take U.S. docs but Germany is incredibly hard) for other reasons.

-Related to that, most countries aren't excited about this because in many countries a lot of people want to move to the U.S. because it's the U.S. or because salaries are higher. If you offered everyone in the NHS the chance to move to the U.S. healthcare in England would collapse instantly. So both the push and pull are blocked.

-Despite this if you wanted to import family medicine doctors (the only area that has true real need) from other countries I don't think anyone would complain, including the family care doctors.

-Training is strictly controlled in the U.S. and is better than elsewhere (mostly by being harder, potentially for no reason) but is also very much so less variable. You picked good countries but you couldn't do this with say India because of the training programs are absolutely U.S. grade and some are incredibly deficient.

-We don't have much of a shortage of doctors in most specialties, we have an allocation problem. Most doctors want to live in a relatively small number of urban areas so those places are flooded and everywhere else is lacking. The reasons for this are complex but increasing supply is unlikely to fix it, but doctors for clamoring for an increase in supply (in the form of residency spots) ANYWAY and have zero control it - blame the government.

-Physician political influence is abysmal right now, we've spent decades propping up our own competition, everyone hates us (because of envy of salaries, political involvement with covid, accusations of racism etc etc) and what lobbying we do do is just left wing politics.

-Physician pay is not unbelievably excessive. The average family care doctor makes 220k. That's a lot of money, but the ceiling is low and it comes with unbelievable sacrifices to that point. When people think of ridiculous pay they think of the orthopedic surgeon making 750k but those guys are less than 1% of doctors, over 90% of doctors are in primary care in some form and those people aren't making the "real" money.

-Medicine in general can be described as a skilled trade, that's what nurses are. Physician work cannot. In the U.S. doctors get training in (and are expected to use these skills) teaching, leadership/management, and research science. Depending on the field soft skills vary from mandatory to almost all of the job (as in Heme/Onc, Psych, and Palliative). On top of that some fields do have the manual skills. That is not an upscale plumber. In the U.S. we've made many attempts to drop in people with less training and skills and they do a demonstrably worse job and unlike in emergency plumbing people actually die.

I'm just curious if you'll tell us about the severity of the nose bleed. I get them occasionally, but I have never had one so bad that required medical attention.

It was really bad (had gone on for about 3 hours). I recently moved to a much drier part of the country. I bought a humidifier and now use Vaseline a couple of time a week. This seems to have fixed the issue.

I live in dry, mile-high Albuquerque, a climate known as “high desert”. Were there no city here, it would be scrub grasslands as far as the eye could see. Relative Humidity is routinely 45%, as low as 30% in summer when temps reach 90F.

I stay hydrated by drinking water the moment I feel the least bit thirsty. This results in lips which never need Chapstick, and mucus membranes which are always moist. However, the nose still occasionally bleeds. I’ve gotten really, really good at avoiding nosebleeds lasting longer than a minute:

  • As soon as it starts, shove the nearest absorbent paper in the sanguine nostril: facial tissue (Kleenex), toilet paper, or paper towel in descending preferability.

  • Grab the nearest drinking water bottle, (unopened) press against nape of neck to chill. If summer, apply to front vessels as well. Water inside will be at most room temperature, usually cooler; shrink blood vessels and chill blood simultaneously. When neck flesh is chilled, apply to lower forehead/eyebrow ridge as well, and maybe sides of nose.

  • If no closed water bottle is nearby, apply cool tap water to neck and forehead, let evaporative cooling chill the flesh instead. Cool water on bridge of nose also.

  • Change out absorbent paper. Breathe out (never in) through both nostrils to help platelets clot via CO2 exposure. Always tilt head forward or upright, never back.

  • Repeat cooling if nosebleed lasts long enough for flesh to warm back up. Repeat nasal tampons until clotted.

scrub grasslands as far as the eye could see

It's fair to not count the Sandia forests, but what about the cottonwoods? "Bosque" might be a bit of an overstatement, but there's at least more than scrub and grass in that narrow strip next to the river.

True, the high desert is punctuated by a seasonal ribbon of water surrounded by gorgeous forest. Agriculture has attracted humans to the Rio Grande valley for millennia. Ancient red rock cliffs and multicolored rockscapes show ancient paths of much deeper waters, and towering mountains — the Sandias, Manzanos, Manzanitos, Sangre de Christos, and the giant cone of Mount Taylor — showcase the stunning variety of plant life our desert can boast.

But, as sure as the Rio Grande’s path down the heart of this vast state to become the border between Texas and Mexico, you can be certain that the mile-high dry air will yield nosebleeds.

  1. You should get insurance, this is what it is for. If you have a plan but it has a super annoying deductible....well yes that's how it works (if you don't and you were cash pay you should call the billing department as the other user pointed out, and then get insurance).

  2. I'm not sure if this will help but you should consider that (while it may appear superficially similar) medicine is not going to be like going to a mechanic. When you go to your dealership the work of analysis and diagnosis is often not paid for, then they'll tell you how much it is to fix the issue and you can take it or leave it. The cost is the labor and parts and replacement and repair. When you go to the emergency room you are paying the staff for the time and resources it takes to figure out what is going on. The treatment is often cheap (medicine, a splint, whatever) but the imaging, labs, and professional fees are time consuming and expensive. As a layman you aren't going to know what is going on under the hood (for instance in this case adults generally don't get nosebleeds that are bad enough to bring them to the hospital, so it could be because it's hella cold and dry outside, or it could be because the patient is having issues with clotting blah blah).

If you have chest pain and go to the ER, and after talking to you they give you tums and tell you to avoid spicy food the bill isn't for the tums it's for making sure you didn't have a heart attack.

You can see my responses below if you are interested in more details but I fundamentally don’t feel any moral obligation to a system where you have in network hospitals with out of network doctors.

Also it’s sort of stunning that americas credit bureaus appear to agree that the system is so exploitative that they simply ignore small

Amounts of medical debt when considering my probability of repaying other debt.

Do you believe health systems should be forced to provide care for someone who has no willingness and/or ability to pay? (They are - if you walk into an emergency room and say I will not pay for any care you provide me they are legally required to give you the same shit as anyone else).

If your response is "you know what I don't want any medical care" then my complaint is withdrawn, but otherwise it sounds like you want to "steal" because you don't like how the process works and don't have a lot of information about healthcare economics.*

*From your other post it sounds like you've been on the receiving end of a practice called surprise billing, which is controversial and legislated against in some jurisdictions but exists for a complicated and justifiable reason but is still annoying, as is usual the problem is health insurance companies being pretty much straight up evil and then blaming everyone else.

As for your frustration with medical debt, if people refuse to pay their medical bills all the hospitals go under and nobody gets medical care. I can understand you're frustrated but these things exist for a reason.

Having read through this whole thread, I wanted to say that I consider myself a strict capitalist in most things, but the whole industry of medical billing is so ridiculous for so many inscrutable reasons with everyone pointing fingers at each other that I find I'm unwilling to make any moral judgements at all for anything any particular patient chooses to do.

It is indeed pretty incredible that the situation is seen as ridiculous universally enough that the credit bureaus are now ignoring medical debt.

I don't know that I'm inclined or qualified to really defend any particular party in this mess. But I do notice that everyone seems to love to make the insurance companies the boogiemen. Aren't they all publicly traded though? If they're wildly profitable, can I invest in them and get some of that sweet healthcare cheat money? If not, well where's all the money going? What if they're just struggling to eke out some tiny profit while being constrained by an ever-changing maze of legislation and trying to juggle the conflicting demands of a dozen different groups, as the sole party with some responsibility to actually make the books balance somehow with the totality of everything that's going on?

Nothing about a market this regulated can really be described as capitalist. I don't understand how hard it is for people to draw the, to me, obvious line between level of regulation and dysfunction. Do people just think it's a coincidence that housing, medicine, schooling and banking are the industries everyone seems to constantly have problems with and costs seem absurd?

I agree, and that's why I don't consider the overall American healthcare market to be meaningfully capitalist from a consumer's viewpoint, and so in that case the morality of a capitalist system does not apply, in so far as owing the person doing a job for you a fair wage for the work that they performed.

Nothing about a market this regulated can really be described as capitalist.

That's only if one believes that capitalism and regulation are somehow opposite to each other.

This so where the scope creep of what counts as "capitalism" makes the conversation impossible. The previous post seemed moderately in favor of "capitalism" so I interpreted as "relatively free markets". If we're going to switch to using the "cabal of capitalists control everything" then the response is "of course that's bad but it's never existed and no one would ever claim to be usually in favor of that".

  1. Everyone has an opinion about healthcare, almost nobody expressing this opinion has the slightest idea what's going on and that often includes people in healthcare, often this is downstream of politics (ex: docs foaming at the mouth at anti-vaxxers, or advocating for "socialized" healthcare without knowing what that means) or arrogance (the "medicine isn't hard or complicated" crowd you see here frequently).

  2. Yes follow the money. Some high resource health systems are doing well, but many health systems are being bailed out or going under. Salaries are decreasing relative to inflation (or just overall), burnout is increasing and we've had a bunch of major major strikes/threats of strikes over poor pay and working conditions (like unsafe nursing staffing ratios). Meanwhile:

"The nation's largest insurers, UnitedHealth Group and Elevance Health, reported profits that were 28 percent and 7 percent higher than the same period last year, respectively. UnitedHealth raked in $5.3 billion, while Elevance took in $1.6 billion.

In contrast, some of the nation's largest health systems, HCA and Tenet, saw their profits fall dramatically compared to the third quarter of 2021. HCA reported $1.13 billion in profits, a decrease of 50 percent. Tenet took in $131 million, which is down 70 percent since last year."

Notably HCA and Tenet are both pretty evil companies (large for profit health systems) that will do WHATEVER to make a buck (and have been in legal trouble over it).

  1. Medical billing isn't "ridiculous" okay well it is, but it makes sense and is a well defined system that a lot of people don't understand... but again people don't understand it but everyone is forced to interact and therefore has opinions. Providers become the punching bag for appropriate medical decisions patients don't understand and administrative/billing decisions that providers have zero control or influence over (having being pushed out of medical leadership and admin for decades, sometimes by complicated government mandate).

  2. Speaking of which why is this shit so expensive? People like to blame salaries and labor shortages but that's a lack of understanding at best and jealousy at worst. Our population is getting less healthy (and other countries are catching up in costs as they become like us) and care is getting more complicated and expensive for good reasons. Additionally regulatory and administrative burden means lots of extra hands sucking at the teat. It's similar to academia (think professor to admin ratios, self-inflicted wounds like DEI staff etc).

"these things exist for a reason"

so what? whether something has a reason doesn't mean the reason is good or justifiable; you don't describe any of those reasons or justifications so there isn't anything to respond to here

trying to portray this as some sort of moral choice binary where you either never seek healthcare or you're stealing if you refuse to pay any bill any random biller in any random medical black box decides to send you empty moralizing and a bad argument

anyone who has legitimately tried to find out what services are going to cost in the medical industry knows how incredibly and intentionally dishonest and obfuscatory it is

As for your frustration with medical debt, if people refuse to pay their medical bills all the hospitals go under and nobody gets medical care.

lots of people refuse to pay their medical bills now (especially the full amount) and yet more healthcare is delivered now than ever before

the user isn't claiming no one should pay medical debts, but that at most people shouldn't pay ones which are the result of asinine practices intentionally designed for this outcome which is asinine

if more people refuse to abide by these asinine practices, then the practices would end not that no one would provide medical care to anyone else anymore as is the case in states and countries which ban this practice

If you have your car repaired and drive off without paying you are going to get reported, and you certainly don't get to come back and demand the next issue be fixed. It's absurd. Even in outpatient land you can't fire a patient (even with just cause like total refusal to pay or blatantly abusive behavior) without jumping through a ton of hoops.

Rural hospitals and suburban/urban hospitals with poor payor mix (in a lot of areas/for a lot of types of care medicare and medicaid pay less than cost) are going under left and right, and other places are closing their EDs in an attempt to stem the bleeding associated with most of the people least likely to pay. It's not getting a terribly large amount of attention outside the field because it's mostly poor whites and the media/left feels awkward about leaving healthcare out to hang after so much superficial support during the pandemic.

This specific practice (this explanation is abbreviated)* is driven by insurance companies refusing to negotiate with physician groups and just say lol I'm going to underpay you, fuck you. When providers try and negotiate the insurance companies label this "surprise billing" and lobby jurisdictions to ban, knowing that the result is professionals have to just not get paid or accept the lowball offer. It's a negotiating tactic. In the last few years providers and low resource health symptoms have seen total crashes in economic health while high resource systems and insurance companies are doing fantastic, but they don't replace the resources that are closing and retiring.

About half of the psychiatrists in the country are able to retire and they are just fucking right off instead of staying and during a time of sky rocketing mental health crisis. We have limited ability to train replacements if we even wanted to (for a number of reasons) and the stopgap (Psych NPs) are uniformly terrible and create more work for the leftover physicians (psychopharmacology is a lot more complicated than most management, as in diagnosis).

*Their are other explanations, you have stroke and the one neurologist on call doesn't take your insurance. Either they let you die, or work for free/try and bill your insurance anyway.

Do you think billing for car repair is in the same zipcode as medical billing? When I ask for how much something is going to cost to a car mechanic, they tell me how much it's going to cost. I don't find out a month later that, actually, a ringer car repair guy which costs $10,000 flew in town overnight and did the work. This isn't an appropriate comparison and it's why your attempt at moralizing in this way falls flat. When a person is complaining about a specific reason why this practice makes nonpayment justifiable, your analogy need to address that specific aspect of the justification.

leaving healthcare out to hang after so much superficial support during the pandemic.

the healthcare sector at every level delivers more care at higher prices and higher pay than ever before

given that context, a claim that people refusing to pay bills in situations the OP described is going to result in no services being offered is a stretch

Are places which ban the above practice more likely to suffer the effects you're talking about? If not, I don't really understand the relevance beyond a general criticism for nonpayment.

This specific practice (this explanation is abbreviated)*

when a patient criticizes a practice which is intentionally designed to extract more money in dishonest ways from patients, your response is to tell the patient they are morally obligated to either pay whatever bill is sent to them or not seek medical care at all and the real bad guys are those darn insurance companies

an easy response is for patients also not to pay, this is just "the system," tell you to whine into the wind at your congressperson, and blame those darn insurance companies

"we're getting screwed so we're going to screw someone else" doesn't magic some moral obligation on the part of the last screwed anyway

this justification is that you have more negotiating power over patients so you're going to use it to extract more money because you don't have that negotiating power against insurance companies; this aspect of the argument is even more true in the case of the individual patient vis-a-vis anything

you have stroke and the one neurologist on call doesn't take your insurance

okay, so what does this have to do with a physician's assistant in a non-emergency situation?

-Hospitals can't tell you how much things are going to cost because they don't know and insurances won't tell them they how much they'll reimburse. Insurance rules are complex, constantly changing, and do so with no notice, if a place says "it will be 500 dollars after insurance" they have no idea if that's accurate or enough, and that's when needs are static. And that's if you pretend cost of delivering care is static. It isn't. If a surgery costs on the median X a specific instance could be 0.8x (healthy thin young adult, 1.2x (obese 50 year old), or literally 100x (patient has a complication, crashes, ends up in the ICU). Is the hospital supposed to charge everyone 1.5x to cover for the one person who explodes? That's like involuntary insurance. Places will offer elective and simple procedures in a fixed price fashion but they are very very cautious with that.

-Healthcare in the U.S. is collapsing, many disciplines are moving out of public insurance (most OP specialties) or private insurance (psych, in a limited fashion). Hospitals and facilities are going under with enough frequency it is approaching a full blown crisis, but most of us live in big cities with a famous name brand academic hospital that just put up a 500 million dollar building and has a million billboards. Easy to miss the crisis.

-This process is not designed to extract money unnecessarily from patients, the insurance company is refusing to provide the paid for service and instead of refusing to pay the insurance company for sucking balls the patient is fucking a different victim who is also legally prohibited from retaliating. I don't understand how the hospital/practice management group (and keep in mind that no clinician at any point is involved with any of this) is the villain because the insurance company refuses to provide insurance.

-As is usual for legislation, surprise billing stuff has a tendency to be written by corporate interests that have a financial interest in making the stroke attending and the ED fast track PA the same situation on paper.

Hospitals can't tell you how much things are going to cost because they don't know and insurances won't tell them they how much they'll reimburse.

so how is this similar to the car mechanic bill situation?

besides, all sorts of other professions delivering all sorts of other services with non-fixed costs and complications manage to present agreed upon, known costs and estimates up front and don't send a surprise bill with an absurd amount attached

I've received healthcare at countries all over the world; there, despite the complications you describe w/re pricing, they're able to tell me an estimate which aligns with the bill I receive later. Even when there are complications. Even when a mechanic while looking at the drivetrain notices the transmission needs to be replaced. As far as I know, there is a single industry which does this and only in a single country in the world.

-Healthcare in the U.S. is collapsing

I am sure there are parts of the US which really struggle with medical services and have the problems you're describing, but on net no it is not or else it wouldn't be delivering more total healthcare, with higher salaries, and higher prices than ever.

Are places which ban the above practice more likely to suffer the effects you're talking about? If not, I don't really understand the relevance beyond a general criticism for nonpayment.

This process is not designed to extract money unnecessarily from patients

"Unnecessarily" doesn't have much explanatory weight, e.g., I promise to pay any bill I think is "reasonable," and I won't unnecessarily refuse to pay any bill I think it reasonable. This statement doesn't really mean anything.

Nothing about this is strictly "necessary" because if it was then it would be done in places which banned the practice except they don't and medical care is still delivered there. An accurate statement would be that they do it because they're trying to extract more money from the patient or their insurance, they don't have negotiating power with the insurance company, and so they're going to go after the weaker position patient.

I don't understand how the hospital/practice management group (and keep in mind that no clinician at any point is involved with any of this) is the villain because the insurance company refuses to provide insurance.

no one has to be the villain here, but it also doesn't mean by default it's just the patient who has some moral obligation to get screwed and fork over whatever amount some derp bureaucrat decides to send them

As is usual for legislation, surprise billing stuff has a tendency to be written by corporate interests that have a financial interest in making the stroke attending and the ED fast track PA the same situation on paper.

I don't doubt that. Judging by the ACA, insurance company lobbying groups will find a way to make it even worse. If the legislation is similar to efforts in my field, it may help some random person like the OP accidentally in certain situations but will mostly be used by megacorps to put them in better negotiating positions.

More comments

Fundamentally, it sounds like you perceive that the problem is that people don’t pay enough for health care (whether that is through private insurance or through Medicaid).

This means that the hospital/physician is trying to take advantage of me because I am easier to negotiate with than my insurance company or the government. In the recent past where they could fuck my credit score they had most of the leverage and this would have worked and people like me would have been responsible for propping up a broken payment system. How is this not absurdly predatory?

Now that this is more difficult perhaps the AMA or the hospital lobby or any number of absurdly powerful interest groups which exist to guarantee the welfare of the healthcare industry, can take action on this instead?

I suppose they might also just increase bills so they always meet the 500$ credit reporting threshold but this will probably take them a few years since it will need to at least look somewhat what organic to avoid being sued by some ambitious attorney general somewhere.

The hospital and provider/provider group are definitely not making decisions based off of some credit reporting threshold, they don't have the time or energy for it and charges and costs are too often pegged to other things. The insurance company might be, can't speak to that.

I also make no claims as to if people aren't paying enough, I just want people to actually pay like they said they would (especially in the case of the ED where 9/10 visits are inappropriate and make things more expensive for the people who actually need the ED resources).

Now is the government or insurance paying enough, that's a separate question. No for some aspects of healthcare, in a very demonstrable sense (that is, if your hospital is being paid mostly by medicaid it WILL go out of business without another funding source like being directly propped up by the state government).

Another different discussion is "are providers overpaid" and while that's a much more nuanced question, in a very practical sense the answer is no - if you want to see a specialist outpatient (especially in something like neurology) you are going to wait two months or have private insurance. The healthcare sector of the economy has been trying to slowly boil docs with decreasing salary for decades and it's starting to boil over and you just wont get good care (or care at all in some fields like psychiatry) if you aren't rich. I'd not be shocked if life saving surgery is simply not available within the next 10-15 years because surgeons will just refuse.

But in this case the issue is that you have a problem with the customer service and overall service offered to you by your insurance company, and you are taking it out on the health system. The problem is the health insurance product you purchased not giving you what you want (because of blah blah negotiating with what's probably a private equity owned practice management group with no clinicians in the leadership structure at all). At no point was anyone directly in healthcare involved in what fucked you except for the person who actually helped with the epistaxis.

Generally speaking health systems are very willing to negate with patients paying out of pocket because the charges are made up as part of some bullshit voodoo dance with insurance and the government. The unwillingness to negotiate def increases the likelihood of that professional fee going to a private equity group (the PA probably got paid like 50 bucks for 30-45 minutes of work that was mostly invisible to you).

I'm going to be a bit fiery here because this comment is top to bottom incorrect. It will never cease to amaze me how strong opinions on healthcare are with no experience, knowledge, or accuracy.

  1. The minimum amount (with room for a lot a lot more) of training for a physician to practice independently in the U.S. is 11 years (4+4+3), there are some exceptions but they are very rare.

  2. The person caring for OP who they are complaining about is a provider (a PA), not a doctor, and has a minimum (and essentially maximum) amount of training of 7 (4+3) years.

  3. Physician lobbying groups have spent the last 15-20 years heavily lobbying for people outside their "club" to able to provide healthcare (providers), because they could charge for it in a supervisory capacity. Now it's biting them in the ass because those providers are lobbying for independent care, providing inferior and infuriating care (often while identifying themselves as doctors) and increasing costs (PA/NP care costs more but it's in stuff that the hospital/ownership group gets to take a bite out of instead of professional fees, for example unnecessary lab testing).

  4. Fixing a nosebleed is harder than you think it is. A lot harder. A school nurse or a person at home can shove a tissue up your nose but that doesn't mean they are thinking about coagulopathy, and considering the risk of TSS, other infection, necrosis, know when to call ENT or to do a further work up and so on. Nasal packing for epistaxis is something requires a surprising amount of considering and critical thought, but you don't know that, the nurse doesn't know that, the PA probably doesn't know it, and an annoyingly large number of EM doctors don't know it. Ask a pediatrician.

  5. Physician professional fees are a small portion of the cost of healthcare.

If I wanted to read 10k (or more) words to learn how to be less wrong about healthcare, where might I start?

(and yes I know you asked for a general primer but the point is to build knowledge of the unexpected complexity).

Here's an example-

https://old.reddit.com/r/Residency/comments/104bwb4/why_was_damar_hamlin_in_the_sicu_after_his/

Why is Damar in a SICU (Surgical Intensive Care Unit) - some people are saying that's best practice, some people are saying that's best quality of care, some people are saying that's because of the resources specifically at UC and some people are saying it is because the case is high profile. And you can find someone saying the opposite for each of those. Everybody knows what they are talking about.

No way to know unless you work there and were involved and some combination of those answers is probably correct.

Stuff is very resource and facility dependent and a lot of things don't have strong consensus.

I learned how to effectively grade scientific literature by looking for places where you'd see the hordes of "SOMEONE IS SAYING SOMETHING WRONG ON THE INTERNET" types and seeing what they said, and then after years of that picking up the skills myself.

Go to /r/medicine or other similar places, look for the hot button stuff, see what people say and complain about. At first you'll be missing context but you'll pick it up. Bonus points if you also go to the other places with different levels of training like /r/residency.

Be aware of the biases of the various areas though (anything remotely political is DOA on meddit, it's appropriate to hate midlevels but the residency subreddit takes it a little far).

Very common for industry adjacent people to do this, you'll see consultants, tech people, and lawyers pop in with their expertise because they are following or work or because of a partner.

Most of the mistakes people make are pretty basic- assuming it's simple and easy, or because they are falling for one of the agenda pushers (including us).

If you look closely you'll probably see one of those situations where three people with over 20 years of training and who very are on top of it are articulately arguing over if something like if "is a bandaid is actually a good idea or not" and you'll be like Jesus this is a nightmare.

You're incorrectly imagining that competition to the medical industry would take the form of a smaller less trained private healthcare industry that otherwise operates entirely the same as the current dysfunctional system. In reality it could be something like going into a clinic staffed by a couple of people with bachelors degrees who go through a digital flow chart and either refer you to a full hospital if the flow chart says it's beyond their capabilities, with an estimate of how much the hospital will charge so that you can be an informed consumer, or solve issue using a step by step guide that comes up immediately from the flow chart. This whole process could cost nearly nothing compared to going into a hospital and paying hundreds of dollars to waste an MD's time and be perfectly transparent.

And yes, the idea that you need over a decade of training to do the majority of what people are paying for in the healthcare industry is absurd and broken.

And yes, the idea that you need over a decade of training to do the majority of what people are paying for in the healthcare industry is absurd and broken.

Just so so wrong. Even in other countries with faster tracking the thing that gets cut down is undergrad (which is fair but hard to do in America, has its own significant problems, and is logistically unfeasible without completely uprooting our system in a way that isn't happening, and only shaves off two years anyway). We have some good evidence for this in the highly limited care given by providers - the NP lobbying groups best data says that NPs outcomes in simple cases is about equal with physicians outcomes in complicated cases (of course they jazz it up but that's what their data says, never mind the MD studies). Keep in mind that doctors are also the only ones getting that much training, everyone else is considerably less....and it shows. Ask any psychiatrist off the record about how the NPs and PAs are doing and they'll be able to convince you to never send a loved one to either.

As for your other point, flow chart care just doesn't work, no matter how much the MBA types may want it to. Decision support tools are miles off, for some godforsaken reason you can replace artists with an "AI" but the EKG autoread (which is one of the most computationally simple tasks imaginable) would get people killed if put in charge.

In addition to the always underestimated medical complexity, you have the human element - patient entitlement these days is sky high (as exhibited in this thread), people are always demanding things that are not indicated or are outright bad for them (ex: antibiotics for viruses) and your flowchart clinic would be immediately going off the chart or burned down.

That's not taking into the account the unacceptability of failure and legal environment, as soon as someone dies because of an edge case (which happens all the time) flowchart clinic would get sued into oblivion.

If you accepted upfront that 10% of people are going to have an unnecessarily bad outcome and 1% of people are going to die unnecessarily you'd be able to do as you say, but nobody is signing up for that. We (rightly so) value human life too much for that.

If you accepted upfront that 10% of people are going to have an unnecessarily bad outcome and 1% of people are going to die unnecessarily you'd be able to do as you say, but nobody is signing up for that. We (rightly so) value human life too much for that.

Really? What are the numbers under the status quo?

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Ask any psychiatrist off the record about how the NPs and PAs are doing and they'll be able to convince you to never send a loved one to either.

I'm married to one, she disagrees. Most of her beefs have been with the embarrassingly dysfunctional nature of the hospitals she's been in that would never stand if there was real competition. EDs that either have no way of checking how many bed the psych department has open or for some reason refuses to believe either those tools or the doctors who tell them they have no beds. Spending countless hours on hold with pharma companies because for some reason totally inconceivable to me you need multiple doctorates to navigate call trees. The pure waste of it all has had me furious more than a few times.

If you accepted upfront that 10% of people are going to have an unnecessarily bad outcome

If by "unnecessarily bad outcomes" you mean their nose bleed takes longer to figure out then sure I think people would be more than happy to deal with that and save hundreds of dollars.

1% of people are going to die unnecessarily

No way this is accurate.

That's not taking into the account the unacceptability of failure and legal environment, as soon as someone dies because of an edge case (which happens all the time) flowchart clinic would get sued into oblivion.

Why yes, we're discussing the legal framework your lobbying group has been enmeshed in creating. "We'll crush your upstarts like the pathetic little bugs they are if they dare" is precisely the thing I'm arguing should be abolished.

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If this is cash pay, call the hospital billing department and ask them to cut it down if you'll pay cash.

If it's insurance, this is stupid but you just have to live with it.

It was insurance, apparently the hospital is in network but the physicians assistant was not so they won’t pay any of it. Also the physicians bill didn’t come from the hospital but from some other entity which refused to negotiate.

I've had this happen. The last town we lived in, the entire ER staff was out-of-network! Do you know if your state has a law against surprise billing? I am really happy that I now live someplace that does.

Surprise billing legislation (while superficially well meaning seeming) is a scam invented by insurance companies as a negotiating tactic, which is part of why its implementation is limited.

Can you point me to any support for this statement, or why this legislation would be undesirable for consumers?

https://old.reddit.com/r/medicine/comments/da5ccm/in_california_a_surprise_billing_law_is/

In general you can dig around on meddit just search for surprise billing.

Superficially this looks more like a problem for docs than for patients (well fuck you guys just take a pay cut) but in general you want doctors to have more leverage and control because while they want money (just like anyone else) they came into the field despite the opportunity costs because they wanted to actually help people. The other interests are just trying to extract value for the least costs (insurance companies, private equity firms that buy physician groups and so on).

Physician power and influence (and self-employment) has been plummeting for awhile now and they essentially minimal influence over care and costs in a lot of settings which generates the stuff that pisses people off.

A doc can provide free care (and many did) if they aren't owned (by a hospital, practice management group etc).

Shorter version: monopolistic competition = bad.

I agree that monopolistic competition is bad, which is why it's terrible that I can have one hospital in my city and their ER doesn't take insurance. What is the average person supposed to do in that situation? They can't shop around; they just have to eat whatever medical bill comes their way, on top of whatever they and their employer pay for insurance.

Emergency medicine is a place where the free market system really breaks down, and we need a different solution from what we have now. I don't know if the surprise billing legislation is the best situation, but what else is being proposed?

Why can't the insurer pay the customer directly?

Surprise billing pops up in two major places- the ED and for consult/pop-in needs.

The later is rarer, less obvious to patients, and harder to fix without big sweeping reform (I NEED EXTRA HANDS IN THIS ROOM RIGHT NOW or "is anyone at work right now who can help answer this question?" are hard problems) attempts at fixing the ED stuff break this process to and discourages those resources from being available. Nobody wants to risk not getting paid so community hospitals have an increasing dearth of specialists and then whole death spiral (for the health system) and poor quality of care things happens.

The issue with the ED is that the structure of American healthcare discourages physician self employment and physician owned practices, so one of the major driving factors here is that private equity groups have bought all of the ED doctors who aren't hospital owned and then start some fuckery with the insurance companies and this is one of the things that shakes out.

Realistically it's still a problem in physician lead healthcare but right now it's those large and connected industries fucking with each other.

Some breakthrough protection would probably help a lot "in case of truly emergent care needs the professional fees need to be covered by insurance but at no more than 110% of the fee schedule for the mean costs of in network professional fees" or something would fix the problem.

I'm sure that would have issues but the point is that the insurance companies aren't interested in fixing the problem they are interested in lobbying so that they don't need to pay for things and someone else gets the blame.

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What is reasoning behind only paying doctors that are in the network?

I truly don’t understand the moralizing, there is no universe where having an in network hospital with an out of network doctor is anything other than an attempt to obfuscate in an attempt to extract a higher price. Also I am surprised that you believe that complaining to congress about exorbitant healthcare costs is anything but a waste of time, the last 30 years of history would seem to contradict you on this.

Upon reflection it’s stunning that americas credit reporting agencies apparently consider healthcare to be so predatory that they don’t think medical debt is predictive of someone’s willingness to repay other kinds of consumer debt.

It doesn’t sound like anybody is trying to raise prices for you. It sounds like there’s inscrutable bureaucratic reasons for the bill getting passed on to you and not the insurer.

Yes, this is frustrating, but if you couldn’t pay a $350 bill you should have picked a different plan.

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