People complain incessantly about the costs of health care. Justifiably, don't get me wrong. They'll say that the $1000 for the ER visit is "ridiculous" or that the $360 paid to the orthopedist is "insane."
So let me ask you, what DO YOU THINK the "right amount" is? And for simplicity's sake, let's make it this:
What do you think your annual gyn exam should cost you, the patient? What services should that cost include? How much should you pay each month for birth control pills?
There is no such thing as "free."
13 Pearls of Wisdom:
I would be willing to pay up to $100 for an exam to include STD/HIV screening, pap, breast exam, and a general physical (which is currently what my appt entails). I also like that we get this survey to fill out before and the doctor goes through each item on it with me.
As for BCP, I currently pay $10/month and think that is more than fair. I probably would pay $20/month tops
But really, what do I know about this??
Very sorry about duplicate comments. Please delete one of them (and this one)
This is such a weird question for me to try to answer because as a Canadian, you almost never find out how much that visit to the ER costs or how much it costs to stay in hospital for a night. All I know are the doctor's fees and a rough idea of the cost of lab tests...
I think an annual gyn exam would cost at least $200, more depending on what lab tests you order. But I think the cost to the patient should be "free".
(I'm assuming we're including the cost of lab services in here, in addition to compensating the doctor for time/supplies).
Birth control pills: right now it's probably around $15 per month, as little as $5/month if you have blue cross or something like that. But I think it should be "free". I think it's a shame that Canada is one of the few countries with socialized medicine that does not cover the cost of prescription meds and dental. What's the point of covering the doctor's visit if the patient can't afford the meds I prescribe. It ends up costing the system more in the long run when the patient can't control their diabetes then has a heart attack and ends up in ICU.
And yes, I realize it's not free. We pay taxes.
We went to the ER last year (in Australia) bc my husband had a high fever, got dehydrated, passed out, and hit his head (face). We got the ER bill a few months later (because it turned out that he had let his student health insurance lapse! ah!!) and the bill was only for $100. I was shocked. This $100 included being in an ER bed for about 4 hours, getting IV fluids & basic analgesia, having some general blood tests, having his face glued back together etc. etc. I couldn't believe it was only $100. But now that i think of it, it seems like it shouldn't be more.
My answer to your question: The service should be provided AT COST (meaning no markups, no profits).
But the answer to your question really depends on how inefficient the system is. If you spend just as much $ on administrative costs/insurance billing as you do on the actual medical care, then it will cost twice as much ($200 instead of $100).
The REAL question is, SHOULD it cost twice as much? Should patients have to pay twice as much due to unnecessary administrative costs? The inefficiencies in our current system are such a waste of money.
With a socialized system, a higher percentage of the money that is spent actually goes towards the patient's care (rather than towards inefficiencies). I'm not saying it's perfect, but it's better in terms of efficiency.
So, if I have to pay $700 per month for my health care fee, I don't care what label you put on it ("taxes" or "health insurance") - I'd rather have the one that gives me the most for my money (i.e. 100% towards health care services rather than 50% towards health care and 50% towards administrative costs, billing, etc.). I'd also rather have the one that puts patients' best interests before corporate profits. That's my take.
Disclaimer: This comment is not directed against anyone here. It is mainly a commentary on the system. I hope nobody takes offense.
I will respond to your question with a question: How much is too much to pay for an IV?
I have a family member who had to pay $17,000 for a single IV. Is THAT too much?
He was never warned of the cost ahead of time. He thought it would be a couple of grand at most for his entire visit. Nope. $17,000 for just the one IV. They just gave him the IV and billed him for it later without any discussion of cost. How’s that for shady? In my opinion, this rivals the credit card companies. (The doctors were probably unaware of the cost, so I don't blame them. But that doesn’t erase the fact that the system is set up to keep the patients in the dark about what their costs will be).
As a physician, how do you deal with the knowledge that a single visit may bankrupt your patient? *Bankrupt*. As in, cause them to lose all of their life savings or cause them to lose their home? Is THAT too much to pay?
Most physicians I've worked with have adopted the "ignorance is bliss" approach. It's not their concern. They assume that if the patient has health insurance, it will all be taken care of. That's not always the case. In many cases, patients wind up paying 30% or 50% of the total cost later.
I understand that in the current system, all of this has nothing to do with you. You’re not the billing person. You don’t even know what the fees are. It’s not like you’re in any place to protest to those in charge. And, as a physician, you're not exactly going to lobby for universal health care when it might lower your own salary among other inconveniences. (I know some physicians might, but most won’t).
Regardless, the patients complain to you about the costs. Here’s why:
To the patients, you represent the physician constituency. Physicians are ultimately the ones responsible for building and maintaining this health care system. They are, as you say, “the boss”. So who else should the patients complain to? You are the one providing the basic service they are being charged for. You are the one who takes the oath. They put their trust in you to look out for their best interests.
You are also the one who has the most power to change the system. I doubt Martha in billing would be willing or able to do much about it. No offense to Martha, but I expect more out of you than out of her. Out of all the other people in this system, you are the one who holds the highest level of education. You are supposedly the one with the most knowledge of all things medical. So again, who would you recommend they send their complaint to if not you?
Maybe their complaints are really a cry for help. Are physicians equipped to respond? Or are they just flies caught in this web like the rest of us?
Old MD Girl: Your blog is an excellent read and thought-provoking. I especially appreciate your candor.
Anon#1: The only items that are priced even close to "cost" are those that are sold in a perfectly competitive market. Further, it's nearly impossible to determine what "cost" is. Pretty much everything that is bought or sold is priced based on "willingness to pay," which is why I worded my question the way I did. Invoking righteous indignation about how things are "too expensive" is a bit of a waste of time IMO, especially if you've already paid for them and thus proven you ARE "willing to pay" the exorbitant amount.
Anon#2: It depends on what's in the IV.
Though I do agree with both of you that more transparency is necessary in the billing process in the medical system. Too often patients have no idea what's coming, and then get blindsided by a large bill. And it's true that doctors ignore costs to a great degree. I know I do to a certain extent. Still learning.
Without a great insurance plane (I have major medical) I pay 50 a month for bc and anywhere from 300-600 dollars for a doctors visit. I have yet to go to the emergency room (god forbid) but I would hate to see that bill.
Ideally I would like to go back to when I had awesome insurance through my parents. I paid 20 for bc and around 80-160 for a dr visit (depending on whether it was routine or a problem appointment).
I know everyone has to make their money and the problem isn't the Dr's. It's the insurance companies.
I make less than 12,000 a year and they expect me to cover my medical expenses. The only time I get 80/20 coverage is if I am ever in a horrible accident and require emergency attention. Until then they don't cover my dr's appts, they don't give me prescription coverage, and they don't cover any tests my dr's run.
Understandably, I keep dr visits to the minimum bc I can't afford them.
Oh and state insurance pools are a joke.
My apologies in advance for the length of what follows... I know you are in med school and probably don’t have time to even read this, but this was a good chance for me to clarify my own thoughts on the matter, so I went ahead and wrote it out anyway. I hope you don’t mind or find it too obnoxious. I’m not trying to argue with you. These are just the thoughts that came up as I was thinking about your first reply.
“The only items that are priced even close to "cost" are those that are sold in a perfectly competitive market.”
Right, but it is an ideal to aspire to. Your original question asked what *should* the price be, not what it’s fated to be in the current “market”. I answered “at cost” (no markups, no profits) because that reflects my values and beliefs in regard to profit-making in medicine. (I do not believe that “profit-maximizing-firms” belong in medicine due to the conflict-of-interest that they bring along with them).
“it's nearly impossible to determine what ‘cost’ is.”
I disagree with this. Hospitals and clinics have the ability to calculate both their fixed costs (rent, electricity, fixed bills, etc.) and their variable costs (labor, supplies, etc.) just like any other business entity. They already have the ability to forecast their costs. From there it’s just a matter of dividing the costs among the patients. Pricing based on cost is not nearly as complicated as pricing aimed at profit maximization.
- Anon#1
“Pretty much everything that is bought or sold is priced based on "willingness to pay," which is why I worded my question the way I did.”
I think that prices in medicine are based on the willingness-to-pay of insurance companies and Medicare, not on the willingness-to-pay of patients. Having insurance companies in the mix makes any market analysis of consumer behavior ineffectual, in my opinion.
If you’re looking for actual willingness-to-pay, I think a more pertinent question would be what is the maximum (as opposed to preferred) *out-of-pocket* price that people would be willing to pay *before they decided to forgo the service*. It would be interesting to compare the preventative measures (like pap smears) to the heroic life-saving measures. For example, what is the maximum price someone would be willing to pay if their only alternative was immediate death? What is the price that would make them decide to choose death?
This discussion sheds light on why I believe that the medical system should be set up to serve the public good rather than being set up as a system where firms will aim for profit-maximization. I believe that physicians should be public servants like policeman or firemen. This way, their fundamental mission would be to serve the public good rather than to serve the profit-seeking firms that employ them.
“Invoking righteous indignation about how things are "too expensive" is a bit of a waste of time IMO”
I think you are missing the point. I was not complaining that things are “too expensive”. Rather, I was complaining that things are “too inefficient”. The latter is not a waste of time because if you can find the inefficiencies you can make improvements.
Regarding “invoking righteous indignation”... It’s not as much of a waste of time as you may think. Patients may still be paying the exorbitant amount, but that does not make their demand for change in the system irrelevant. The fact is that consumers do not have to tolerate a laissez-faire system. If their demand for change becomes strong enough, consumers will bypass the current “market” altogether and move the good into a more socialized system. Vocalizing their outrage is the first step in this process. It isn’t a waste of time if it mobilizes action. If patients are unable to garner an adequate response from their physicians, they will turn to their public leaders instead.
“Government-run programs are sooooooo inefficient. It is better to keep things in the free market.” (not your quote, but still pertinent to this discussion)
This goes back to my original post. If you want rally against inefficiency, focus your efforts on the current system. The current system is so inefficient that socializing it would actually *improve* efficiency.
Socializing the system would also have the added benefit of putting physicians and patients on the same team, rather than having them at odds with each other over money.
Regarding the “free market” comment, that is irrelevant to this discussion because medicine in the U.S. is nowhere near a free market, and it never will be. If you have questions about that, you should find a basic economics textbook and look up “market failure” to see why. (This is not aimed at you Old MD Girl because clearly you are already familiar with this).
-Anon#1
If you’re looking for actual willingness-to-pay, I think a more pertinent question would be what is the maximum (as opposed to preferred) *out-of-pocket* price that people would be willing to pay *before they decided to forgo the service*.
Yes.
Sure, things are inefficient. This is BECAUSE people have tried meddled in the system as much as they have. Your solution is to meddle more. You are never going to get me to agree that socializing medicine will increase efficiency. The thing is, people want to "get rid of" market forces in medicine. That is not possible no matter how many rules you apply.
Most people I know in medicine went into it because they desire to help people. If they wanted money, they would have worked for Goldman Sachs. If you price cap physician salaries, which you are alluding to, prepare to see the masses of morons taking care of you. Is that something you really want? Or do you not understand that practicing medicine is hard?
A for cost, in the 90's, an economist (from Harvard of course) went around trying to determine the "cost" of various services and procedures that doctors provide. This is what all of the CPT and ICD-9 codes that are used today are based upon. So, someone has already done what you suggested. And look at where it got us.
Thanks for your responses Old MD Girl. This will be my last reply, as I doubt that any further banter would benefit you, a busy medical student who has enough stress without some random person harassing you on your blog. I fully support you in your blogging endeavors, and I do not want to be the cause of any discouragement thereof.
“Sure, things are inefficient. This is BECAUSE people have tried meddled in the system as much as they have."
No, it’s because our leaders picked the wrong system. The current system rewards entrepreneurship more than it rewards community stewardship.
The system should be set up to reward physicians whose mission is to collaboratively provide the best health care possible for the community as a whole. In the current system, no such incentive exists.
Rewards for profiteering behavior simply should not be in the picture.
“Most people I know in medicine went into it because they desire to help people. If they wanted money, they would have worked for Goldman Sachs. If you price cap physician salaries, which you are alluding to, prepare to see the masses of morons taking care of you. Is that something you really want? Or do you not understand that practicing medicine is hard?”
My post was not aimed at cutting physician salaries. I agree with you that physicians should be very well compensated for what they do. Physician salaries are not the problem. The problem is the system itself.
That being said, I am not concerned about morons taking over in the event of physician salaries being capped at $200,000. Let’s not get sensational. I am confident that plenty of intelligent, well-intentioned, and well-qualified pre-meds would continue to pursue medicine en masse even if that were the case. As a matter-of-fact, I wouldn’t mind if such a cap screened out a few of the profiteering types. Not only would that improve the quality of care for patients overall, it would also be conducive to a better working environment for the more patient-centered physicians such as yourself.
“You are never going to get me to agree that socializing medicine will increase efficiency.”
Okay, I won’t try.
But please do read Atul Gawande’s recent article in The New Yorker: “The Cost Conundrum – What a Texas Town Can Teach Us about Health Care” (link below).
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
This is a GREAT article on the topic of health care cost – one that everyone involved in medicine should read. I would attempt a summary, but that wouldn’t do it justice. Just read it. It touches on almost every topic we’ve been discussing but in much more detail. BTW, its aim is to inform rather than to sell any one type of health care system.
-Anon#1
(I know this post is a month late, but hopefully useful nonetheless)
EMTALA is a double edged sword - it requires hospitals to provide a medical screening exam and stabiilizing treatment (usually in the ER), without any mention of the cost.
This means patients must go in blind, because even those who do know what things cost won't tell you, due to risk of an EMTALA violation.
At the same time, it is an EMTALA violation for a hospital to harass you (through a collections agency, for ex) or ding your credit score for failure to pay your ER bill.
Which is why hospitals often post $50 million worth of 'bad debt' related to care provided without being paid for it. Many hospitals are very pleased to get even 40 cents on the dollar billed. So prices go up to cover for those who don't pay.
Of course, this info comes just from what I have read online (blogs and EMTALA rules)
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