Author Topic: $900 medical bill for a consultation - is this outrageous?  (Read 28977 times)

stlbrah

  • Bristles
  • ***
  • Posts: 430
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #50 on: August 07, 2015, 11:44:37 AM »
900 isn't that unbelievable. I had a 30 minute consultation, that ended in the doctor recommending to take cipro for some ecoli poisoning. I decline being an athlete and not wanting to ruin my ligaments with an extremely dangerous drug just for food poisoning.

I ended up waiting out that food poisoning, but the bill was about $2200, insurance covered $1300 of it.

Bob W

  • Magnum Stache
  • ******
  • Posts: 2947
  • Age: 60
  • Location: Missouri
  • Live on minimum wage, earn on maximum
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #51 on: August 07, 2015, 11:49:30 AM »
Several years ago I was totally self pay.   

In the exam room the physician had an assistant bring in a portable EKG machine when I told them of my middle of the chest pains.

When I asked how much that machine cost to use they both looked at each other dumbfounded.  No one had ever asked that question and they didn't even know how to find the answer.   

I quickly left the clinic after declining. 

Now bare in mind that I was a home builder at the time.  I could tell you the cost of every single item in the homes I built.  I could tell you the average pay rate for 10 different contractor specialties.    In a home building project there are probably over 100 people involved and thousands of parts and materials.  There are dozens of different tools and machines used.  There is an hourly rate for back hoes, cranes, graders etc..  It isn't rocket science but it is somewhat complex. 

The current so called business model for medical care is obviously broken. 

And it really has become incumbent upon consumers to be assertive and set the boundaries.

One good thing about the ACA is that deductibles are now sky high and many people are opting for Bronze level plans.  This puts the spending decisions in the hands of the consumer.   So people are opting not to pay out of pocket for dubious services.   

I can't wait until there is a mandate that all rates are made public for each service.   Most people would be blown away seeing 10K+ price differences for a particular service on hospitals less than 10 miles apart.

I'm not a Physician but my daughter is --- I think what she would say is "take two Tylenol and call me in the morning"

At least that is what she always tells me.  lol

Bourbon

  • Stubble
  • **
  • Posts: 234
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #52 on: August 07, 2015, 12:17:34 PM »
Sounds like you have a High Deductible plan, so you pay for everything up front until you hit deductible.  You get the benefit of the rates the insurer negotiated up front, but in this case it appears they only got you a $74 discount, or a little over 7%.  In general the billed amounts are inflated and the contracted rates cut them so you can see the "savings".  Could be a bad contract or may be a non-par provider.

As mentioned I would look into the participating status of the second physician.  Presumably you made sure the first doctor was in network with Cigna, but no guarantee the second one is.  Should be able to look this up online on their website or call and ask.  I know that sometimes you may go to a participating hospital and are then seen by a physician who is not in-network(usually pathology, anesthesiology, radiology, ER docs, assistant surgeons) and the plans will treat them as in network and pay more on the bill.  Would probably have to call Cigna and complain that you had no choice in this doc.  Still may not get you anywhere.

Other option is that he may have billed incorrectly, higher level of service etc.  Unfortunately most EOB's don't include the actual code billed by the provider(the 99XXX codes that Hamster mentioned).  You may be able to call and get this code and then do some research. 


goatmom

  • Bristles
  • ***
  • Posts: 291
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #53 on: August 07, 2015, 12:38:58 PM »
Well, also remember that if that first doctor was a fellow and the second doctor was the attending - the first was one is making peanuts and the second one is most likely getting paid a salary.  So, he too probably has no idea how much it costs either.  Healthcare costs are crazy.  It is a mess.  I am in the middle of it and have no clue how to fix it. 

You people ride your bikes everywhere to save money and the environment while able bodied young men and women take medicaid taxis to where I work on the goverment's dime.  Sometimes on a nice day, I suggest that they should walk home instead of calling for a return cab ride.  They look at me like I am crazy.  I wonder how much medicaid spends on cab rides for people that could walk!  I would never dream of calling a cab.  My bike is parked out front.  There is waste everywhere.  Probably need people like MMM to revamp the whole system.

BCBiker

  • Stubble
  • **
  • Posts: 187
  • Location: Colorado
    • Business Casual Biker - Health, Wealth, and Mental Stealth BTYB Bicycle Commuting
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #54 on: August 07, 2015, 12:50:27 PM »
Just to throw in another wrinkle in US healthcare that hasn't been covered...


Insurance pays what they negotiate with the clinic or hospital. Private pay is whatever you are billed or whatever you negotiate. But the government payments are not negotiated and are not based on cost, it is based on what the government decides to pay. So for much of government covered healthcare (which is a large percentage of healthcare) the cost to the clinic or hospital is higher than the government pays. So in order to continue to function, the facility bills higher for everyone else to cover the shortage from the government.


I'm not here to argue this is right, just the way the system works (or doesn't work). Your bill is higher because patients with government coverage don't cover what it costs the facility to employ the doctor and pay everyone involved. How much higher I don't know, but higher.

That is a common myth. Medicare reimburses just fine; hospitals would function perfectly good and docs would all make reasonable salaries if all patients were Medicare patients. I hate that this myth gets propagated! 

Medicaid can be crappy reimbursement depending on the state.
Any references/links to support this?

Which part is a myth? Medicare reimbursement is well below commercial insurance. That is a fact. medicare physician reimbursement is 20% lower, on average, than private insurance.

Most hospitals would not function if they were 100% Medicare unless they cut costs significantly.

There is so much waste that there is plenty of opportunity for the U.S. Medical system to become sustainable if all insurance reimbursed at the same rate as Medicare, but if that reimbursement was the norm today, the hospital I work at would become insolvent, and I am assuming most others would as well, considering ours is in relatively good shape financially.

The Medicare and Medicaid populations are a significant source of hospital revenues. Sure, the occasional 50-year old has a heart attack or breaks a leg. But the biggest volume of care goes to the elderly, disabled, and the indigent. And tack on the fact that about half of births are paid for by Medicaid. So I don't buy at all that Medicare is insufficient for covering the hospital's actual costs. Hospitals, even non-profit hospitals, are incredibly profitable. If you go through many parts of Florida with lots of seniors you see hospitals advertising how great they are. And the concentration of hospitals is high in Florida--because of the demand from seniors. If you were losing money to provide your service, would you advertise to get even more customers? Certainly particular hospitals would need to cut back on waste and inefficiency if they were only getting the Medicare rate for services. Maybe that $5 million CEO salary would get cut down. And we'd have fewer unnecessary NICUs, etc.
In terms of current state (our current wasteful healthcare organizations, drug costs inflated far above the rest of the world, etc), Medicare really is not sufficient if you look at actual numbers.

The median operating margin for 200-bed hospitals and above was slightly negative (-0.7%) last year[2009 from an older story]. That means the money that was brought in from patients fell short of what they needed to spend on staff, equipment, buildings and other items.

In 2013, average operating margin for all US hospitals/health systems was 3.1%. So, if all insurance switched to medicare reimbursement today, you can be sure they would almost all be negative. In the long-term there is certainly opportunity to reduce their costs. The rest of the world does it. But medicare reimburses very poorly compared to private insurance. There are certainly exceptions - hospitalis making 25% margins. But many of them are more selective in ways that change their payor mix so they get more private insurance.

I absolutely agree that if we fix the way healthcare is provided in the US, medicare rates would be fine. But for now, if all insurance billed at medicare rates, the system would go bankrupt.

Finally, in terms of the bolded part... NICU meaning newborn ICU? or neuro ICU? If neonatal, that is a  funny thing to pull out in a discussion of Medicare, which pays for probably zero percent of neonatal ICU care. In most cases newborn ICUs generate money for hospitals, mostly through privately insured patients, although medicaid covers a large portion of NICU patients as well. Although the cases of micropremies who have bad outcomes may be the dominant headline, the vast majority of NICU premies go on to live full, normal lives. Improvements in neonatal care are actually a very good return on investment compared to much of what we do in hospitals.

If you are trying to save ICU health care dollars, it is probably much smarter to look at the other end of the age spectrum.

a commentary on this topic
Quote
NICU costs are relatively small in the big picture of the U.S. health care economy. For instance, in a $2-trillion health care economy, the total economic costs of preterm birth has been estimated to be $26 billion (between 1 and 2 percent of total health care expenditures)

I have no doubts that if all people in the US became Medicare patients (Medicare for all or 'dare I say' single-payer) hospitals would all operate just fine.  The concept of thinking that private insurance companies prop up hospitals so that they can afford to pay for Medicare patients is ludicrous. Many if not most hospitals are raking it in with 100s of millions of dollars in excess profits.  HCA remains incredibly profitable and non-profits are growing at unprecedented rates due to the need to reinvest excess capital (profits). Sure there are little hospitals in Redneck, MS that are not making it because they don't have the volumes or because they have to pay doctors a ton to drag them out there. The 2-3% operating margin is commonly quoted by hospital execs even if their specific hospital happens to be operating at a 10-50% margin!

Everyone here seems to agree that the whole system is big, bloated, and inefficient.  Part of what allows it to be this way is the lack of consistency and transparency of cost. Hospitals have been exaggerating costs to persuade insurers that they need to increase reimbursements and then self-pay/uninsured get stuck with the fake charges hospitals have created for the insurers. This is the best resource on how this process has went on: http://time.com/198/bitter-pill-why-medical-bills-are-killing-us/ .

There are no great answers and a ton of myths out there in the popular media, propagated by special interests.  Hospital organizations want everyone to believe that they are barely making it despite their obvious growth and excesses.  Hospital execs often make 2-5 times the most highly paid doctor despite the doc working like a dog while the exec is scooting out every afternoon at 2:00 after putting in a long hard 4 hours of work.  I could rant on this subject forever. I apologize for going on this long.

forummm

  • Walrus Stache
  • *******
  • Posts: 7396
  • Senior Mustachian
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #55 on: August 07, 2015, 01:25:48 PM »
I have no doubts that if all people in the US became Medicare patients (Medicare for all or 'dare I say' single-payer) hospitals would all operate just fine.  The concept of thinking that private insurance companies prop up hospitals so that they can afford to pay for Medicare patients is ludicrous. Many if not most hospitals are raking it in with 100s of millions of dollars in excess profits.  HCA remains incredibly profitable and non-profits are growing at unprecedented rates due to the need to reinvest excess capital (profits). Sure there are little hospitals in Redneck, MS that are not making it because they don't have the volumes or because they have to pay doctors a ton to drag them out there. The 2-3% operating margin is commonly quoted by hospital execs even if their specific hospital happens to be operating at a 10-50% margin!

Everyone here seems to agree that the whole system is big, bloated, and inefficient.  Part of what allows it to be this way is the lack of consistency and transparency of cost. Hospitals have been exaggerating costs to persuade insurers that they need to increase reimbursements and then self-pay/uninsured get stuck with the fake charges hospitals have created for the insurers. This is the best resource on how this process has went on: http://time.com/198/bitter-pill-why-medical-bills-are-killing-us/ .

There are no great answers and a ton of myths out there in the popular media, propagated by special interests.  Hospital organizations want everyone to believe that they are barely making it despite their obvious growth and excesses.  Hospital execs often make 2-5 times the most highly paid doctor despite the doc working like a dog while the exec is scooting out every afternoon at 2:00 after putting in a long hard 4 hours of work.  I could rant on this subject forever. I apologize for going on this long.

Re the bolded, the bigger issue is that the state didn't expand Medicaid, so the hospitals are still eating a lot of uncompensated care.

justajane

  • Handlebar Stache
  • *****
  • Posts: 2147
  • Location: Midwest
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #56 on: August 07, 2015, 05:21:58 PM »
We've had a high deductible, and paying so much really takes some time to get used to. But remember that with other plans, the costs are just hidden. We've calculated that, even with a family of five, there's no way that we can't come out ahead with a high deductible plan. Mind you, not all HDP healthcare plans are created equal, but in many cases they are a better deal.

We've reached our deductible two years in a row. It's $3,000. Ouch! But what are you going to do? I'm not going to avoid sending my kid to the ER when he busts his chin open just because I have to pay the entire 1K. And you needed to find out what was happening with your child. We can make informed choices about what we pay for and what we don't, but overall, I'm not going to skimp on healthcare just because I haven't reached my deductible yet.

And when we do reach it, like the past two years, we use the hell out of it. Dermatologists, urologists (hello, vasectomy!), etc. When you can, plan your health care around big bills.

Sorry this happened to you, but look at it this way, you're that much closer to reaching your deductible, at which point health care will cost much, much less.

And the more times you write checks to hospitals for large amounts (we have written checks for over 4K), the less it will hurt. At least that has been my experience. It's just a cost of living -- like food and housing and transportation.

Workinghard

  • Pencil Stache
  • ****
  • Posts: 637
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #57 on: August 07, 2015, 06:20:42 PM »
Just to throw in another wrinkle in US healthcare that hasn't been covered...


Insurance pays what they negotiate with the clinic or hospital. Private pay is whatever you are billed or whatever you negotiate. But the government payments are not negotiated and are not based on cost, it is based on what the government decides to pay. So for much of government covered healthcare (which is a large percentage of healthcare) the cost to the clinic or hospital is higher than the government pays. So in order to continue to function, the facility bills higher for everyone else to cover the shortage from the government.


I'm not here to argue this is right, just the way the system works (or doesn't work). Your bill is higher because patients with government coverage don't cover what it costs the facility to employ the doctor and pay everyone involved. How much higher I don't know, but higher.

That is a common myth. Medicare reimburses just fine; hospitals would function perfectly good and docs would all make reasonable salaries if all patients were Medicare patients. I hate that this myth gets propagated! 

Medicaid can be crappy reimbursement depending on the state.
Any references/links to support this?

Which part is a myth? Medicare reimbursement is well below commercial insurance. That is a fact. medicare physician reimbursement is 20% lower, on average, than private insurance.

Most hospitals would not function if they were 100% Medicare unless they cut costs significantly.

There is so much waste that there is plenty of opportunity for the U.S. Medical system to become sustainable if all insurance reimbursed at the same rate as Medicare, but if that reimbursement was the norm today, the hospital I work at would become insolvent, and I am assuming most others would as well, considering ours is in relatively good shape financially.

I can only speak from the home health care environment, but my company accepts very few insurance patients. They WANT Medicare patients. If an insurance patient is taken, it's because the physician also gives us Medicare patients and they do it as a courtesy.


Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #58 on: August 07, 2015, 09:58:34 PM »

I can only speak from the home health care environment, but my company accepts very few insurance patients. They WANT Medicare patients. If an insurance patient is taken, it's because the physician also gives us Medicare patients and they do it as a courtesy.
It is funny how there are some things Medicare will cover that others won't."Hoveround!"

Astatine

  • Magnum Stache
  • ******
  • Posts: 3601
  • Location: Australia
  • Pronouns: they/them
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #59 on: August 08, 2015, 12:18:12 AM »
Sorry can't sympathize much. $900 Is not a lot for a physician who is fellowship trained.

I wonder if that's for real. In Australia it takes 12 years to fully train a specialist MD too. However, a 30 min consultation (private, no government or private insurance involved) is about $250-400 depending on the area (doctors in wealthy suburbs charge more). Our cost of living is even higher than Boston, but Doctors still afford their BMWs and McMansions no worries.

Yep, agreed. I recently had a longish consultation with a surgeon and it was about $300 (less if you take into account the rebate). A fifteen minute consultation with another surgeon was about $180 (again with a Medicare rebate).

In the past month I've had a lot of tests done (I need urgent surgery) and every single time I've made the appointment, I have always been given an upfront quote for the approximate cost. Except for one biopsy & ultrasound which was bulk-billed (ie no cost to me). My blood tests were bulk billed too.

When I have my surgery (going through the private system, not the public system), it will be about 2 hours of surgery with 2 separate surgeons (I'm having 2 procedures done while I'm under). I will probably be a few thousand dollars out of pocket (and I pay approx $1000 per year for hospital insurance). I have complete choice in specialists, GPs and hospitals.

The American system makes no sense to me. Even Australia's private health system (as opposed to the heavily subsidised public health system) is cheaper than the US system.

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #60 on: August 08, 2015, 01:52:09 AM »
Sorry can't sympathize much. $900 Is not a lot for a physician who is fellowship trained.

I wonder if that's for real. In Australia it takes 12 years to fully train a specialist MD too. However, a 30 min consultation (private, no government or private insurance involved) is about $250-400 depending on the area (doctors in wealthy suburbs charge more). Our cost of living is even higher than Boston, but Doctors still afford their BMWs and McMansions no worries.

Yep, agreed. I recently had a longish consultation with a surgeon and it was about $300 (less if you take into account the rebate). A fifteen minute consultation with another surgeon was about $180 (again with a Medicare rebate).

In the past month I've had a lot of tests done (I need urgent surgery) and every single time I've made the appointment, I have always been given an upfront quote for the approximate cost. Except for one biopsy & ultrasound which was bulk-billed (ie no cost to me). My blood tests were bulk billed too.

When I have my surgery (going through the private system, not the public system), it will be about 2 hours of surgery with 2 separate surgeons (I'm having 2 procedures done while I'm under). I will probably be a few thousand dollars out of pocket (and I pay approx $1000 per year for hospital insurance). I have complete choice in specialists, GPs and hospitals.

The American system makes no sense to me. Even Australia's private health system (as opposed to the heavily subsidised public health system) is cheaper than the US system.
The U.S. System also doesn't make sense to those of us firmly entrenched in it. It is the result of an accident of history with wage freezes around World War II resulting in employer-sponsored health plans, a hodgepodge of government programs trying to provide a safety net and clumsy attempts at containing cost growth while bowing to a pharmaceutical industry that buys politicians, and massive lobbying by so many parties. Based on all the big money in U.S. Politics, I am doubtful we will have meaningful change until the system either suffers near collapse, or corporate influence on US legislators is somehow curtailed.

I am optimistic in the long term, but pessimistic in the short term.

mskyle

  • Pencil Stache
  • ****
  • Posts: 693
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #61 on: August 08, 2015, 05:27:18 AM »
Sorry can't sympathize much. $900 Is not a lot for a physician who is fellowship trained.

I wonder if that's for real. In Australia it takes 12 years to fully train a specialist MD too. However, a 30 min consultation (private, no government or private insurance involved) is about $250-400 depending on the area (doctors in wealthy suburbs charge more). Our cost of living is even higher than Boston, but Doctors still afford their BMWs and McMansions no worries.

Yep, agreed. I recently had a longish consultation with a surgeon and it was about $300 (less if you take into account the rebate). A fifteen minute consultation with another surgeon was about $180 (again with a Medicare rebate).

In the past month I've had a lot of tests done (I need urgent surgery) and every single time I've made the appointment, I have always been given an upfront quote for the approximate cost. Except for one biopsy & ultrasound which was bulk-billed (ie no cost to me). My blood tests were bulk billed too.

When I have my surgery (going through the private system, not the public system), it will be about 2 hours of surgery with 2 separate surgeons (I'm having 2 procedures done while I'm under). I will probably be a few thousand dollars out of pocket (and I pay approx $1000 per year for hospital insurance). I have complete choice in specialists, GPs and hospitals.

The American system makes no sense to me. Even Australia's private health system (as opposed to the heavily subsidised public health system) is cheaper than the US system.
The U.S. System also doesn't make sense to those of us firmly entrenched in it. It is the result of an accident of history with wage freezes around World War II resulting in employer-sponsored health plans, a hodgepodge of government programs trying to provide a safety net and clumsy attempts at containing cost growth while bowing to a pharmaceutical industry that buys politicians, and massive lobbying by so many parties. Based on all the big money in U.S. Politics, I am doubtful we will have meaningful change until the system either suffers near collapse, or corporate influence on US legislators is somehow curtailed.

I am optimistic in the long term, but pessimistic in the short term.

These are the primary things that keep costs high in the US health care system:
1) expensive medical schools and malpractice insurance, which cause doctors' salaries and operating costs to be very expensive compared to other countries in the developed world (also, doctor salaries are not really tied to the value they provide - overall the course of a career, a good family physician provides a lot more "health" than a good surgeon, but we pay surgeons more)
2) unnecessary treatment, which falls into two categories:
  a) treatments that could have been avoided with better preventive care and social services (this mostly happens to the poor/those on Medicare/Medicaid)
  b) treatments that people with "good insurance" or money to burn get because they only want "the best" (a big part of this is the lack of transparency - no one knows how much anything costs, so someone who will happily coupon-clip or shop at Aldi still goes to the expensive specialist at the fancy hospital for a minor issue)

Either way, the unnecessary care causes an unnecessary shortage of services, which drives up prices. A lot of it is about culture, the culture of medicine and an overall US culture of buy now, pay later - for medical education, and for medical services.

justajane

  • Handlebar Stache
  • *****
  • Posts: 2147
  • Location: Midwest
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #62 on: August 08, 2015, 06:13:27 AM »
mskyle -

I struggle with your 2. b), mainly because I'm curious in an ideal system, presumably one that wouldn't be as exorbitant as ours,  who would determine what is necessary and unnecessary.

A good example would be us last year. A rare but fatal genetic neurodegenerative disease runs in my husband's family. He noticed some things in our 5 year old son that concerned him. So we got a referral to go to a specialized pediatric neurologist. Would this be considered necessary or unnecessary in a lower cost system? It was just a concern, but my husband has spent his adulthood around someone with this disease, so he knows what to look for. I guess I have reservations about a system in which patients with concerns can't seek information from those who know the most.

Who determines what is a minor issue and what is a major issue? Internists are highly trained but in many cases might not know enough about a particular specialty to determine whether something is a minor annoyance or actually something that is a marker for a bigger problem.

I unfortunately learned this year that things that are often diagnosed as minor sprains by general practitioners can actually be bone fractures that require different treatment. This is not to denigrate my internist who is awesome and who I very much trust, but if I fall again in the future, I will go straight to an orthopedist.
« Last Edit: August 08, 2015, 06:16:30 AM by justajane »

Jack

  • Magnum Stache
  • ******
  • Posts: 4734
  • Location: Atlanta, GA
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #63 on: August 08, 2015, 07:43:10 AM »
Which part is a myth? Medicare reimbursement is well below commercial insurance. That is a fact. medicare physician reimbursement is 20% lower, on average, than private insurance.

Most hospitals would not function if they were 100% Medicare unless they cut costs significantly.

There is so much waste that there is plenty of opportunity for the U.S. Medical system to become sustainable if all insurance reimbursed at the same rate as Medicare, but if that reimbursement was the norm today, the hospital I work at would become insolvent, and I am assuming most others would as well, considering ours is in relatively good shape financially.

You're conflating "20% less" with "not enough," but it's really just reducing "outrageous" to "halfway reasonable."

I'm sure this will be a controversial opinion, but when it comes to these ridiculous bullshit medical bills, I see no moral problem with simply refusing to pay. If they're not going to be fair, honest and reasonable, why should I?

The worst that could happen (for amounts not worth suing over) is that they'd report it to your credit -- but even then, medical debt collections don't hurt your score as much as regular collections do, which is a sign that credit bureaus tacitly agree that it's reasonable for a normally-responsible person to not pay.

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #64 on: August 08, 2015, 09:45:43 AM »

These are the primary things that keep costs high in the US health care system:
1) expensive medical schools and malpractice insurance, which cause doctors' salaries and operating costs to be very expensive compared to other countries in the developed world (also, doctor salaries are not really tied to the value they provide - overall the course of a career, a good family physician provides a lot more "health" than a good surgeon, but we pay surgeons more)
2) unnecessary treatment, which falls into two categories:
  a) treatments that could have been avoided with better preventive care and social services (this mostly happens to the poor/those on Medicare/Medicaid)
  b) treatments that people with "good insurance" or money to burn get because they only want "the best" (a big part of this is the lack of transparency - no one knows how much anything costs, so someone who will happily coupon-clip or shop at Aldi still goes to the expensive specialist at the fancy hospital for a minor issue)

Either way, the unnecessary care causes an unnecessary shortage of services, which drives up prices. A lot of it is about culture, the culture of medicine and an overall US culture of buy now, pay later - for medical education, and for medical services.
I think both of those are factors, but I don't think they are the primary problem.
1) payment to physicians makes up 8-12% of medical costs in the U.S., from numbers I have heard. Whatever portion of that is for covering student loans or malpractice is a small piece of the total pie.
2) this one is very hard to measure and hard to define. It is very real.

But I think the biggest problem is that our system fails on any of the mechanisms that would make pricing efficient.
Free markets could reach efficient pricing, but healthcare is far from a free market. The consumer doesn't pay directly for most care because of insurance. Pricing is opaque as discussed above. There are no good ways for consumers to determine price or quality before purchasing services. Physicians and hospitals paid on a fee for service basis are incentivized to provide unnecessary care, and to charge as high a price as they can make stick.

The other option of Government controls are not politically an option in America. In fact we have a system where the government actually forces prices up by making it illegal for Medicare to negotiate prices with pharmaceuticals.

It is really perverse that the U.S. Government funds so much of the basic research that pharmaceuticals ultimately use to develop drugs, and even US pharma companies are allowed to charge far more to US consumers than to Canada, Europe, etc. and we are not allowed to reimport drugs we export to Canada where they are sold much more cheaply. That is government and business colluding to transfer taxpayer dollars (Medicare/Medicaid) to corporations. Really quite disgusting.

Aside from all that we have a bloated private insurance system that adds little value, but adds huge costs, in direct administration of insurance and associated costs, as well as onerous documentation requirements and additional staffing costs at medical facilities. You would be amazed how many people our clinic and hospital hire to do nothing but review coding for insurance purposes. That is 100% waste that provides no health benefits.

Merrie

  • Bristles
  • ***
  • Posts: 465
  • Location: Midwest
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #65 on: August 08, 2015, 11:54:45 AM »
We've had a high deductible, and paying so much really takes some time to get used to. But remember that with other plans, the costs are just hidden. We've calculated that, even with a family of five, there's no way that we can't come out ahead with a high deductible plan. Mind you, not all HDP healthcare plans are created equal, but in many cases they are a better deal.

We've reached our deductible two years in a row. It's $3,000. Ouch! But what are you going to do? I'm not going to avoid sending my kid to the ER when he busts his chin open just because I have to pay the entire 1K. And you needed to find out what was happening with your child. We can make informed choices about what we pay for and what we don't, but overall, I'm not going to skimp on healthcare just because I haven't reached my deductible yet.

And when we do reach it, like the past two years, we use the hell out of it. Dermatologists, urologists (hello, vasectomy!), etc. When you can, plan your health care around big bills.

Sorry this happened to you, but look at it this way, you're that much closer to reaching your deductible, at which point health care will cost much, much less.

And the more times you write checks to hospitals for large amounts (we have written checks for over 4K), the less it will hurt. At least that has been my experience. It's just a cost of living -- like food and housing and transportation.

This is something we are still getting used to. I, idiotically, put $200 in my FSA this year because I didn't really expect us to need any particular medical care. I had a couple of fillings in the second week of January, and there went that.

I feel like it leads to a dance of "Is this worth going to the doctor for?" for more minor stuff. We paid $200 between the initial and follow-up visits for an ear infection last year. So we're like, do we want to pay $90 to get told it's just a transient bug, or do we want to wait a day and see how tomorrow is? I think the system may be designed to make people think twice before getting care. I feel like this doesn't happen on Medicaid. I fill a lot of prescriptions from the emergency room for stuff that is really not emergency-room worthy (eye drops and Claritin for seasonal allergies, say).

justajane

  • Handlebar Stache
  • *****
  • Posts: 2147
  • Location: Midwest
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #66 on: August 08, 2015, 12:31:55 PM »
I feel like it leads to a dance of "Is this worth going to the doctor for?" for more minor stuff. We paid $200 between the initial and follow-up visits for an ear infection last year. So we're like, do we want to pay $90 to get told it's just a transient bug, or do we want to wait a day and see how tomorrow is? I think the system may be designed to make people think twice before getting care. I feel like this doesn't happen on Medicaid. I fill a lot of prescriptions from the emergency room for stuff that is really not emergency-room worthy (eye drops and Claritin for seasonal allergies, say).

I'm sure as a pharmacist you notice patterns like that. I frankly don't understand why private insurance would lead to more unnecessary visits or prescriptions. If anything, on its face, it would seem to lead to less. Like you, we think twice about going to the doctor if we haven't reached our deductible. But if there were no real financial costs of going (if I was on Medicaid or we had single payer), one would think that a person wouldn't hesitate. I think that's a good thing ultimately, although obviously using an ER for primary care situations is far more expensive for everyone.

But I try not to judge. I went to the ER one night because I had the most painful ear infection I've ever experienced. I couldn't wait until morning. On the surface, I'm sure some of the staff there probably rolled their eyes that I did such thing. After all, it was only an ear infection. But #1 nothing else was open and I couldn't wait 12 hours based on the pain. #2 it ended up being an aggressive infection for which I had to go to the ER two more times. I ended up getting a cat-scan for fear of meningitis and having to be admitted for two days to manage the pain and to put me on IV antibiotics to fight the growing infection. Over 10K in bills for an ear infection. Yup. I was a drain on the system. At some point in time, we all probably will be. I know a sick kid who bankrupted a Catholic school's insurance, i.e. his bills were so astronomical that the insurance carrier either dropped the school or jacked the prices up so much that they couldn't afford the insurance anymore. This was pre-ACA.

frugaliknowit

  • Handlebar Stache
  • *****
  • Posts: 1671
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #67 on: August 08, 2015, 01:02:30 PM »
The lesson here (tough hug....it's happened to me too!) is ALWAYS ask ahead of time, even if you know you and/or the insurance co. is going to pay it...

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #68 on: August 08, 2015, 04:38:07 PM »
This is a very interesting article on the subject of alternatives to control US healthcare costs. It is 6 years old now, about one person's thoughts on how to bring market forces and transparency in to lower medical costs, while still providing a safety net. The article starts with a discussion of hospital infections that is really a side-issue, but the whole article is a good read.

He  into the issue of moral-hazard and why there are few incentives to control costs either by doctors, consumers, or the government in the current system.

I won't go into his solution much here, because I think he states it better than I will, but if you are interested in alternative ideas for insurance and healthcare financing, it is well-written and thought-provoking.

Astatine

  • Magnum Stache
  • ******
  • Posts: 3601
  • Location: Australia
  • Pronouns: they/them
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #69 on: August 08, 2015, 07:32:27 PM »
But I try not to judge. I went to the ER one night because I had the most painful ear infection I've ever experienced. I couldn't wait until morning. On the surface, I'm sure some of the staff there probably rolled their eyes that I did such thing. After all, it was only an ear infection. But #1 nothing else was open and I couldn't wait 12 hours based on the pain. #2 it ended up being an aggressive infection for which I had to go to the ER two more times. I ended up getting a cat-scan for fear of meningitis and having to be admitted for two days to manage the pain and to put me on IV antibiotics to fight the growing infection. Over 10K in bills for an ear infection. Yup. I was a drain on the system.

Do you mean you were out of pocket $10k? That's crazy. If that happened here, it would be $0 out of pocket if you're admitted into hospital from emergency (I know this from experience - I've had 3 hospital admissions in the past 3 years from emergency).

It's a bit heartbreaking hearing all this. I have an online friend who lives in the US. She had symptoms of a heart attack but didn't go to emergency or call an ambulance, just in case it wasn't a heart attack, because the medical bills would have bankrupted her. Luckily she was fine in the end. But contrast this to my country where it's drilled into everyone that if you have chest pain or other heart attack symptoms, call an ambulance immediately. As long as you have ambulance insurance, you are not out of pocket for the visit to emergency (again, I know this from experience - DH had severe chest pain last year, I called an ambulance, we spent half a day in hospital while he had a bunch of tests and it was $0. He was fine luckily.).

On the flipside, the governments here actively try to discourage people from using emergency for routine health problems. So there is a 24 hour phone number you can call to get advice on whether you need to go to emergency (I think I've rung 3 times in the past few years, got told don't go for one issue and the other 2 times I was told to go straight to emergency for treatment). There is also an after hours GP service (end up $40 out of pocket) and there are some big GP superclinics that are open every day for about 10 hours+ each day. There are also walk-in nurse clinics where people can go for advice instead of going to emergency. There are usually a few pharmacies open until 11pm as well.  It's actually all pretty good. Sometimes you do need urgent care or urgent advice, but if it's not actually a life-threatening emergency, it should be dealt with by a GP or a nurse. That helps to reduce health system costs.

Bumbling Bee

  • Stubble
  • **
  • Posts: 184
  • Location: New York City
    • Journey of a Thousand Face Punches
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #70 on: August 08, 2015, 07:52:03 PM »
This might be a long shot, but you could try contacting the insurance company and seeing if they can renegotiate a better rate for you. I've been to a lot of specialists this year (all board-certified, affiliated with fancy-schmancy hospitals and universities) and the insurance company negotiated reductions of 20% - 50% from the bill rates.

Taran Wanderer

  • Pencil Stache
  • ****
  • Posts: 574
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #71 on: August 08, 2015, 10:49:28 PM »
$900 for a short consultation does seem ridiculous.

Here are some interesting statistics from a healthcare conference I attended last year, from friends and family, and from my own experience as a volunteer firefighter in our rural county.  I'm not sure what conclusion to draw from except that, yes, healthcare is expensive.

Medicare's average reimbursement rate is current 88% of actual costs. On average, and is expected to drop to 82% of actual costs by 2030.  (Editorial comment:  that's not sustainable...)

Private insurance's (employer healthcare) average reimbursement is 132% of actual costs and is expected to grow to 168% of actual costs by 2030.  (Editorial comment:  how long do you think,corporations will stand for that?)

My sister-in-law recently graduated from medical school with $300,000 in debt. She makes $180K a year as a general practicioner. With 5 years of work and two years of med school prep between undergrad and med school, she was 37 years old before she started her career and then started off a mountain of debt in the hole.  And she's actually a huge cheapskate, much more frugal than I am.

A good friend from college is now a vascular surgeon.  After undergrad, he did not immediately get into med school. He eventually got in, but after 4 years of med school, 3 years of surgical residency, 2 years of research, a few more years of surgical specialty, and a couple of years of fellowship, he ended up finally getting a full fledged job at 38 making about $450K.  But, he had $50K of credit card debt, $300K of deferred med school debt, and zero assets.  And a side and 2 kids.

Both got paid nothing while in med school and maybe $50K for 80 hour weeks as a resident, researcher, fellow, etc.

These people are making big bucks now, but they were either paying for med school with no income or getting paid close to minimum wage throughout the rest of their training, and then they start out in a big financial hole once they reach their first fully compensated position. Would we (doctors, patients, and bill payers) all be better off with a different system in which the most qualified could attend medical school at low cost and then get paid well, but not insanely, throughout their careers?  The barriers to entry (med school costs) are so huge and costly, and therefore the risk is so high, can we blame them for wanting a high return on their investment?

Regarding end of life, approximately 25% of Medicare costs in the USA are spent in the last year of our elders' lives.

Finally, in our county, there are normally 4 or 5 (depending on the season) ambulances on duty 24/7. Over the course of the year, the system averages 5 calls per day.  One ambulance staffed 24 hours a day requires a paramedic and an EMT.  Let's say that team costs $60/hr combined with benefits, or about $1,440 per day.  The ambulance costs $250K to buy and outfit, lasts five years, and it burns a lot of diesel running around a rural county.  Then there are all the consumables - bandages, blood, plasma, needles, tubes, etc.  Pretty easy to get to $2,000 for a 5 minute ambulance ride with those numbers.

There are many parts of healthcare that are just plain expensive, e.g ambulances in our community.  (The same could be said of emergency rooms.). In other areas, our system puts the burden of training costs on people who won't see a return for at least a decade, and maybe more like two decades. This skews the costs. Separately we could talk about lifestyle choices leading to chronic diseases like diabetes and heart disease, but that is a whole 'nother story. All of it makes the whole problem so complex that there is not easy solution. And because the best solution - a more mustachian lifestyle with more walking and biking, fewer cars, less stuff, better end of life planning, and less need for health care - doesn't make more money for many of the vested interests, a real solution is very unlikely.

None of that helps your situation, so all I can say is that I am sorry to hear bout your $900 consult.

College Stash

  • 5 O'Clock Shadow
  • *
  • Posts: 78
  • Age: 24
  • Location: Midwest
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #72 on: August 09, 2015, 12:20:34 AM »
We really need a single payer system...

amyable

  • Bristles
  • ***
  • Posts: 295
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #73 on: August 09, 2015, 06:18:28 AM »
Once, I had a $1000 bill for an abdominal ultrasound--I called the diagnostic center and asked if there was a way to reduce it.  They said if I could pay the entire total at once, they'd knock off $250.  Never hurts to ask!

Merrie

  • Bristles
  • ***
  • Posts: 465
  • Location: Midwest
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #74 on: August 09, 2015, 07:15:42 AM »
Once, I had a $1000 bill for an abdominal ultrasound--I called the diagnostic center and asked if there was a way to reduce it.  They said if I could pay the entire total at once, they'd knock off $250.  Never hurts to ask!

I did that with the hospital bills from my son's birth.

GFPchicken

  • 5 O'Clock Shadow
  • *
  • Posts: 10
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #75 on: August 09, 2015, 02:33:30 PM »
I don't know how expensive other children's hospitals are, but our daughter has been to Boston Children's twice, and it did cost a lot, though she had things done other than a consultation. Basically any time we go to Children's we just figure we'll have to pay our full deductible ($3000). Slash, for each year we figure that *something* will happen and our deductible will be met one way or another.

justajane

  • Handlebar Stache
  • *****
  • Posts: 2147
  • Location: Midwest
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #76 on: August 09, 2015, 03:40:06 PM »
I don't know how expensive other children's hospitals are, but our daughter has been to Boston Children's twice, and it did cost a lot, though she had things done other than a consultation. Basically any time we go to Children's we just figure we'll have to pay our full deductible ($3000). Slash, for each year we figure that *something* will happen and our deductible will be met one way or another.

That's exactly our attitude. With children, especially if you have more than one, something is probably bound to happen each and every year. I have just adjusted my expectations, and that has helped a lot to soften the blow.

Do you mean you were out of pocket $10k? That's crazy. If that happened here, it would be $0 out of pocket if you're admitted into hospital from emergency (I know this from experience - I've had 3 hospital admissions in the past 3 years from emergency).

No, we had already reached our deductible (gave birth earlier in the year), after which we are responsible for 20%. After the negotiated rates kicked in, I believe we paid around $1,000 out of pocket for this unfortunate incident. It still stinks. Last year was a record year for us in medical bills, and believe it or not, I believe we still didn't reach our out of pocket maximum, after which they pay 100%. My husband calculated, and we paid around 8K for health care last year. That included premiums. Ouch! The HSA helps a bit, since it is pre-tax, but still.

bacchi

  • Magnum Stache
  • ******
  • Posts: 4069
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #77 on: August 09, 2015, 05:06:58 PM »
These are the primary things that keep costs high in the US health care system:
1) expensive medical schools and malpractice insurance, which cause doctors' salaries and operating costs to be very expensive compared to other countries in the developed world

The good thing about a federalist system is that states can experiment. Capping insurance payouts, which subsequently reduces malpractice insurance premiums, has not affected medical costs.

http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1635882

Quote
In sum, we find no evidence that Texas’s tort reforms bent the cost curve downward.

As far as expensive medical schools -- true. There's also the matter of an artificial limiting of residencies.

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #78 on: August 09, 2015, 05:50:39 PM »
As far as expensive medical schools -- true. There's also the matter of an artificial limiting of residencies.

It would be nice if congress would expand funding for residency positions. They capped it in 1997, and my understanding is that this is the reason there aren't more positions. There has been a bill introduced (2 years ago...) to increase funding for more residency slots...

Jack

  • Magnum Stache
  • ******
  • Posts: 4734
  • Location: Atlanta, GA
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #79 on: August 09, 2015, 09:59:53 PM »
As far as expensive medical schools -- true. There's also the matter of an artificial limiting of residencies.

It would be nice if congress would expand funding for residency positions. They capped it in 1997, and my understanding is that this is the reason there aren't more positions. There has been a bill introduced (2 years ago...) to increase funding for more residency slots...

So explain to me, given the huge proportion of GDP we collectively spend on health care, why can't the industry fund the residency positions itself?

You know, in every other professional career that I know of  -- accounting, engineering, law, etc. -- we have the equivalent of "residencies" too, except we don't need any weird-ass "national matching system." We call it "getting hired at a job and working!" It's not as if engineers spring forth directly from university with a P.E. license and start stamping plans as a principle engineer; we start with an E.I.T and work under supervision. But nevertheless it's still a regular job with (usually) regular hours and regular pay!

I also get the impression that law -- except for "biglaw," whatever the fuck that means -- is the same way.

So why do doctors have to deal with what amounts to some kind of fucked-up abusive boot camp? It's totally unnecessary!

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #80 on: August 10, 2015, 08:55:21 AM »
As far as expensive medical schools -- true. There's also the matter of an artificial limiting of residencies.

It would be nice if congress would expand funding for residency positions. They capped it in 1997, and my understanding is that this is the reason there aren't more positions. There has been a bill introduced (2 years ago...) to increase funding for more residency slots...

So explain to me, given the huge proportion of GDP we collectively spend on health care, why can't the industry fund the residency positions itself?

You know, in every other professional career that I know of  -- accounting, engineering, law, etc. -- we have the equivalent of "residencies" too, except we don't need any weird-ass "national matching system." We call it "getting hired at a job and working!" It's not as if engineers spring forth directly from university with a P.E. license and start stamping plans as a principle engineer; we start with an E.I.T and work under supervision. But nevertheless it's still a regular job with (usually) regular hours and regular pay!

I also get the impression that law -- except for "biglaw," whatever the fuck that means -- is the same way.

So why do doctors have to deal with what amounts to some kind of fucked-up abusive boot camp? It's totally unnecessary!
I think it mostly comes down to 'the industry' being made up of lots of different players who don't necessarily see direct return on investing in training the next generation.

A teaching hospital invests a lot in terms of faculty time and supervision in training residents (who mostly will not stay at that hospital when finished). Insurance certainly won't want to pay extra so that a 'trainee' can be involved in a patient's care. Patients aren't going to pay extra for the benefit of resident teaching.

I am not really sure about your last sentence. Residency was hard, mostly because it was a lot of work, but I learned a ton. Mine certainly wasn't abusive. No way I can think of that I could have been a decent doc without it. A first job is really nothing like residency, unless at your first job you have people directly participating in every single thing you do for 3-5 years, providing didactic teaching for several hours a day, and discussing every interesting case that came up for teaching purposes, every single day. The system is far from perfect, and the match system is weird. But I wouldn't ever want to be treated by a doc who hadn't been through residency.

CommonCents

  • Handlebar Stache
  • *****
  • Posts: 2386
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #81 on: August 10, 2015, 09:57:45 AM »
For all those in other countries bashing the US health care system, please know that we subsidize the cost of your health care by paying for drug research and innovations in medical technology.

btw, "biglaw" is a regular job too (although long hours and high pay, usually with a rough lockstep starting pay of $160k in large cities such as NY, DC, San Fran, Boston, etc).  Biglaw just refers to the largest law companies.  It commonly is used for the companies recruiting at the top 1-14 (and to a degree, those at the entire top tier law schools), regardless of size of company though.  I'd hazard a guess it tends to be law firms with 100+ attorneys.

wienerdog

  • Bristles
  • ***
  • Posts: 479
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #82 on: August 10, 2015, 10:08:43 AM »

I can't wait until there is a mandate that all rates are made public for each service.   Most people would be blown away seeing 10K+ price differences for a particular service on hospitals less than 10 miles apart.


I find it amusing the general population would spend more time researching their newest flat screen TV purchase than a medical procedure.  Of course like you said it isn't open and easy right now.

I'm a red panda

  • Walrus Stache
  • *******
  • Posts: 8010
  • Location: United States
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #83 on: August 10, 2015, 10:18:00 AM »
Quote
I can't wait until there is a mandate that all rates are made public for each service.   Most people would be blown away seeing 10K+ price differences for a particular service on hospitals less than 10 miles apart.

My insurance company actually has an estimator on their website. I used it when I was looking for a hospital for giving birth. Turns out at either in the area, I'm almost certain to hit my out of pocket max, so it's moot.

forummm

  • Walrus Stache
  • *******
  • Posts: 7396
  • Senior Mustachian
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #84 on: August 10, 2015, 12:12:06 PM »
Quote
I can't wait until there is a mandate that all rates are made public for each service.   Most people would be blown away seeing 10K+ price differences for a particular service on hospitals less than 10 miles apart.

My insurance company actually has an estimator on their website. I used it when I was looking for a hospital for giving birth. Turns out at either in the area, I'm almost certain to hit my out of pocket max, so it's moot.

I've used those. And they can be wildly inaccurate. Or the same procedure can be wildly different depending on which facility you get it at. Literally $600 at one place and $18000 at another place a few miles away. Insanity.

Even if you put in the time to find out what things will cost, you still don't really know. I've had things be different than what I was quoted (by human beings looking at the exact procedure codes) by thousands of dollars. YMMV.

goatmom

  • Bristles
  • ***
  • Posts: 291
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #85 on: August 10, 2015, 12:19:33 PM »
A residency however is more like four more (or five or more) years of school than a first job. The programs need teaching staff, need to meet strict requirements, undergo inspections, etc. It is called graduate medical education for a reason.  Seems like they need to provide financial incentives to open more slots.

Jack

  • Magnum Stache
  • ******
  • Posts: 4734
  • Location: Atlanta, GA
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #86 on: August 11, 2015, 06:31:51 AM »
I am not really sure about your last sentence. Residency was hard, mostly because it was a lot of work, but I learned a ton. Mine certainly wasn't abusive. No way I can think of that I could have been a decent doc without it. A first job is really nothing like residency, unless at your first job you have people directly participating in every single thing you do for 3-5 years, providing didactic teaching for several hours a day, and discussing every interesting case that came up for teaching purposes, every single day. The system is far from perfect, and the match system is weird. But I wouldn't ever want to be treated by a doc who hadn't been through residency.

So it's more like an internship then? Well, us engineers have those, too, and we still manage to get employers to provide them voluntarily (even decently-paid ones!) without a "matching" system. I still see no reason why the medical industry couldn't manage the same, except for your argument about "'the industry' being made up of lots of different players who don't necessarily see direct return on investing in training the next generation," which does not even slightly excuse it.

Also, when I commented about residency being abusive, I was mainly referring to things like 24-hour shifts and 80-hour work weeks (which was also the main basis of the exception I noted for biglaw).

goatmom

  • Bristles
  • ***
  • Posts: 291
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #87 on: August 11, 2015, 06:56:25 AM »
Well, the residency topic is off the original topic - but I don't think they are willing to pay residents a decent salary because they are not really worth it.  You are training them.  The 24 hour shifts and 80 hour work weeks?  Those are an improvement over the old days.  There really is lots to learn and if you just did a 40 or 50 hour work week you would never learn as much or get as much experience.  It does not need to be abusive and there are safeguards in place to watch for that.  It is not an easy path - and it doesn't start paying well until you are pretty far down it.  So, by the time you can make real money and those loans start rolling in you can get a bit cranky when people complain about your salary when the CEO of the hospital and his/her staff make more.

I'm a red panda

  • Walrus Stache
  • *******
  • Posts: 8010
  • Location: United States
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #88 on: August 11, 2015, 07:02:39 AM »
Quote
So it's more like an internship then? Well, us engineers have those, too, and we still manage to get employers to provide them voluntarily (even decently-paid ones!) without a "matching" system. I still see no reason why the medical industry couldn't manage the same, except for your argument about "'the industry' being made up of lots of different players who don't necessarily see direct return on investing in training the next generation," which does not even slightly excuse it.

I don't think residency match is like an engineering internship.

First- I'm pretty sure doctors HAVE to do a residency.  Now granted, they could just say "sucks to be you" and weed out those who can't find one; but I know plenty of people who are successful engineers today who didn't find internships in college.  My university the internship process was basically like interviewing for a summer job.  And internships didn't last for multiple years; they were almost always summer assignments.

Second, at least the internship I did when I was in engineering school- it wasn't serving as training for me.  I had a specific project, I worked.  Basically the company was willing to take the chance on a low skilled temporary employee in exchange for a low wage (which was really high to a college student). But they weren't there to teach me HOW to be an engineer. It did enough to teach me I hate engineering though :)

I'd say residency is a little more like student teaching; except that student teaching you pay to work, you don't get a salary. But a resident IS an MD, and a student teacher is pre-service.

gbbi_977

  • Stubble
  • **
  • Posts: 102
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #89 on: August 11, 2015, 07:03:53 AM »
I just negotiated a $273 bill down to $121, by arguing it should be recoded.

Full story here: http://forum.mrmoneymustache.com/ask-a-mustachian/us-how-to-dispute-a-doctor's-bill/msg730259/#msg730259

affordablehousing

  • Bristles
  • ***
  • Posts: 375
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #90 on: August 11, 2015, 08:11:20 AM »
I think the way to get back at the insurance company (since your year just started) would be to just go back for another couple half hour consults, get the deductible out of the way, and then see every doctor under the sun now that you'd be fully covered. Maybe you can use the head start you got on your deductible with the doctor as a silver lining and decide this is the year you get everything checked out, screened, x-rayed, oscopied, cut off etc. Just kidding, kind of, but if you already have this huge expense, maybe you could lean in and get other stuff taken care of for your family and pay less overall, bite the deductible bullet this year and then not again for a bunch of years.

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #91 on: August 11, 2015, 08:51:33 AM »
I think the way to get back at the insurance company (since your year just started) would be to just go back for another couple half hour consults, get the deductible out of the way, and then see every doctor under the sun now that you'd be fully covered. Maybe you can use the head start you got on your deductible with the doctor as a silver lining and decide this is the year you get everything checked out, screened, x-rayed, oscopied, cut off etc. Just kidding, kind of, but if you already have this huge expense, maybe you could lean in and get other stuff taken care of for your family and pay less overall, bite the deductible bullet this year and then not again for a bunch of years.
This is a good example of the moral hazard explanation of why medicine is so expensive in the US. When insurance pays under a fee for service system, there is no incentive for patients to avoid unnecessary expense, and every (financial) reason for providers to seek out unnecessary charges.

justajane

  • Handlebar Stache
  • *****
  • Posts: 2147
  • Location: Midwest
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #92 on: August 11, 2015, 03:47:16 PM »
I think the way to get back at the insurance company (since your year just started) would be to just go back for another couple half hour consults, get the deductible out of the way, and then see every doctor under the sun now that you'd be fully covered. Maybe you can use the head start you got on your deductible with the doctor as a silver lining and decide this is the year you get everything checked out, screened, x-rayed, oscopied, cut off etc. Just kidding, kind of, but if you already have this huge expense, maybe you could lean in and get other stuff taken care of for your family and pay less overall, bite the deductible bullet this year and then not again for a bunch of years.
This is a good example of the moral hazard explanation of why medicine is so expensive in the US. When insurance pays under a fee for service system, there is no incentive for patients to avoid unnecessary expense, and every (financial) reason for providers to seek out unnecessary charges.

Why are you assuming these things are unnecessary? Hamster was making a joke, but this is exactly what we do. I hardly think me waiting until I reach my deductible to get a certain mole removed is seeking out frivolous health care. It's just smart as a consumer to wait a year if I can to get these necessary treatments done.

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #93 on: August 11, 2015, 05:18:48 PM »
I think the way to get back at the insurance company (since your year just started) would be to just go back for another couple half hour consults, get the deductible out of the way, and then see every doctor under the sun now that you'd be fully covered. Maybe you can use the head start you got on your deductible with the doctor as a silver lining and decide this is the year you get everything checked out, screened, x-rayed, oscopied, cut off etc. Just kidding, kind of, but if you already have this huge expense, maybe you could lean in and get other stuff taken care of for your family and pay less overall, bite the deductible bullet this year and then not again for a bunch of years.
This is a good example of the moral hazard explanation of why medicine is so expensive in the US. When insurance pays under a fee for service system, there is no incentive for patients to avoid unnecessary expense, and every (financial) reason for providers to seek out unnecessary charges.

Why are you assuming these things are unnecessary? Hamster was making a joke, but this is exactly what we do. I hardly think me waiting until I reach my deductible to get a certain mole removed is seeking out frivolous health care. It's just smart as a consumer to wait a year if I can to get these necessary treatments done.
I don't mean unnecessary in any specific case at all. I also agree it is smart to wait til it is covered. I am just saying that in a system where neither the provider nor the consumer are on the hook, nobody has an incentive to keep costs and usage down. Sorry if it came across like I was commenting on any specific person's care. I didn't mean it that way at all.

Bettis

  • Stubble
  • **
  • Posts: 196
  • Location: MA
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #94 on: August 11, 2015, 05:36:08 PM »
OK so the bill came in today and I was charged with a Level IV consult.  I tried googling it and it looks like it is overboard for what we did.  http://emuniversity.com/Level4OfficeConsult.html

"Level 4 Office Consult (99244)

This is the most popular code used to bill for office consults.  Internists selected the 99244 code for 40% of these encounters in 2003.   To get an idea of the frequency of use of this code among sub-specialists, nephrologists used this level of care for a whopping 49% of consults performed in the office during that same year (which added up to 77,556 visits). The 99244 ranked 46th among the most frequently used CPT codes by all physicians in 2003.  The reimbursement for this level of care is approximately $168.00.  Usually the presenting problems are of moderate to high severity.

The documentation for this encounter requires THREE out of THREE of the following :

1)  Comprehensive History
2)  Comprehensive Exam
3)  Moderate Complexity Medical Decision-Making

Or 60 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included."

There were options for hospital consult on that page and we did technically go to a hospital but that happened to be where the specialist was so I don't know if that is still considered hospital or office.  I'm going to call tomorrow to try to get it recoded.  If it works, I assume they send another bill right?  I don't want to give them say $500 to settle and then get a bill saying I owe the same $900 or another $400.  I'm getting cynical in my old age :)

Hamster

  • Pencil Stache
  • ****
  • Posts: 623
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #95 on: August 11, 2015, 08:39:05 PM »
OK so the bill came in today and I was charged with a Level IV consult.  I tried googling it and it looks like it is overboard for what we did.  http://emuniversity.com/Level4OfficeConsult.html

"Level 4 Office Consult (99244)
[snip]
The documentation for this encounter requires THREE out of THREE of the following :

1)  Comprehensive History
2)  Comprehensive Exam
3)  Moderate Complexity Medical Decision-Making

Or 60 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included."

There were options for hospital consult on that page and we did technically go to a hospital but that happened to be where the specialist was so I don't know if that is still considered hospital or office.  I'm going to call tomorrow to try to get it recoded.  If it works, I assume they send another bill right?  I don't want to give them say $500 to settle and then get a bill saying I owe the same $900 or another $400.  I'm getting cynical in my old age :)
99244 is an office consult, meaning outpatient. There is likely a facility fee embedded in it, because the clinic is attached to a fancy facility. If you want you could ask Boston Children's or insurance to break down the amount of the facility fee for you, not that it will make much difference. I don't think you can contest the inclusion of the facility fee at all.

I am pretty sure they are NOT coding based on time, but rather, based on the other 3 categories, so ignore the face-to-face time portion. That is usually more for mental health visits or other such things that involve lots of counseling or care coordination.

You could call medical records and get a copy of the note first. Then ask to talk to billing, tell them that you are concerned that the level of coding is not justified, and ask them to have the coders review it. Usually when this happens, the bill will be put on hold so you won't get charged late fees.

Wait til you hear from them. If they lower the bill based on what is documented, you probably don't need to call the GI clinic at all.

If they don't lower the bill, it means the documentation justifies the level of the bill. At that point, your option is to look at the note, and see if the documentation actually reflects what they did. This will probably come down to the physical exam - often people insert a templated exam, so it is possible that they didn't do everything that they documented (which is naughty, but not that unusual). That said, without getting into too much detail, you can get about halfway to a 'comprehensive exam' before even laying hands on a patient, by just looking at them and having their vital signs taken. (appears well-nourished, no rash in visible areas, no eye discharge, no nasal discharge, unlabored breathing, etc etc.)

reddityeah

  • 5 O'Clock Shadow
  • *
  • Posts: 13
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #96 on: August 11, 2015, 08:47:19 PM »
OK so the bill came in today and I was charged with a Level IV consult.  I tried googling it and it looks like it is overboard for what we did.  http://emuniversity.com/Level4OfficeConsult.html

"Level 4 Office Consult (99244)

This is the most popular code used to bill for office consults.  Internists selected the 99244 code for 40% of these encounters in 2003.   To get an idea of the frequency of use of this code among sub-specialists, nephrologists used this level of care for a whopping 49% of consults performed in the office during that same year (which added up to 77,556 visits). The 99244 ranked 46th among the most frequently used CPT codes by all physicians in 2003.  The reimbursement for this level of care is approximately $168.00.  Usually the presenting problems are of moderate to high severity.

The documentation for this encounter requires THREE out of THREE of the following :

1)  Comprehensive History
2)  Comprehensive Exam
3)  Moderate Complexity Medical Decision-Making

Or 60 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included."

There were options for hospital consult on that page and we did technically go to a hospital but that happened to be where the specialist was so I don't know if that is still considered hospital or office.  I'm going to call tomorrow to try to get it recoded.  If it works, I assume they send another bill right?  I don't want to give them say $500 to settle and then get a bill saying I owe the same $900 or another $400.  I'm getting cynical in my old age :)

Honestly, the coding is correct based on what you've said, and it seems like you are appropriately charged. And this is not a hospital consult. A hospital consult is when you are admitted to the hospital by the primary team, and the primary team needs a consult from a specialist team. Yours was an office consult. Primary care doc referred you to a specialist.

Cathy

  • Handlebar Stache
  • *****
  • Posts: 1046
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #97 on: August 11, 2015, 10:12:30 PM »
You know, in every other professional career that I know of  -- accounting, engineering, law, etc. -- we have the equivalent of "residencies" too, except we don't need any weird-ass "national matching system." ...

In Canada, the monopoly on the practice of law rests in each province with a provincial body called the "Law Society". In order to join the Law Society of a province, every Society requires that the prospective lawyer spend a certain period of time "articling" under a lawyer or judge, essentially a mandatory apprenticeship, similar to the doctoral residency scheme. This is a matter of provincial law, so the rules are different in every province, but every province has some form of mandatory articling system.

One interesting unrelated quirk is that in BC, the practice of law on a volunteer basis is wholly unregulated. In BC, only the practice of law in exchange for a fee comes within the scope of any regulation.

The Canadian system is fundamentally different from what is used in the US. In the US, the theoretical basis for the regulation of the practice of law is that every court claims to have an inherent authority to regulate who can practice law before it, and the practice of law is thus restricted to the "bar" of that court. (Some states have codified this in statutes, but this is still the theoretical basis.) Courts are not considered to have such a power in Canada, although they do have some powers to regulate the parties who appear before them (e.g. through the contempt power and other sanctions).

In Alberta, judges are not considered to be lawyers and in fact cease to members of the Law Society upon accepting a judgeship. The theoretical basis for that practice is to cement the separation between the Law Societies and the courts. See Legal Profession Act, RSA 2000, c L-8, § 33. (In an earlier draft of this post, I said that was the case in "Canada", but apparently some provinces allow judges to optionally remain as lawyers.)

For further discussion on these matters, see Rhode (2012).

The only part of this post that is relevant to what I quoted is the articling system. I just included the other facts in case they might be interesting.
« Last Edit: August 11, 2015, 11:32:29 PM by Cathy »

Taran Wanderer

  • Pencil Stache
  • ****
  • Posts: 574
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #98 on: August 11, 2015, 10:44:53 PM »
You know, in every other professional career that I know of  -- accounting, engineering, law, etc. -- we have the equivalent of "residencies" too, except we don't need any weird-ass "national matching system." ...

In Canada, the monopoly on the practice of law rests in each province with a provincial body called the "Law Society". In order to join the Law Society of a province, every Society requires that the prospective lawyer spend a certain period of time "articling" under a lawyer or judge, essentially a mandatory apprenticeship, similar to the doctoral residency scheme. This is a matter of provincial law, so the rules are different in every province, but every province has some form of mandatory articling system.

One interesting unrelated quirk is that in BC, the practice of law on a volunteer basis is wholly unregulated. In BC, only the practice of law in exchange for a fee comes within the scope of any regulation.

The Canadian system is fundamentally different from what is used in the US. In the US, every court claims to have an inherent authority to regulate who can practice law before it, and the practice of law is thus restricted to the "bar" of that court. Courts are not considered to have such a power in Canada, although they do have some powers to regulate the parties who appear before them (e.g. through the contempt power and other sanctions).

Another interesting quirk is that in Canada, judges are not considered to be lawyers and in fact must resign from the Law Society before accepting a judgeship. The theoretical basis for that practice is to cement the separation between the Law Societies and the courts.

The only part of this post that is relevant to what I quoted is the articling system. I just included the other facts in case they might be interesting.

Oh my, the foam!!!

Just kidding.  Thanks for the primer on Canadian law.  Always interesting to hear how things are done in other places.  :-)

forummm

  • Walrus Stache
  • *******
  • Posts: 7396
  • Senior Mustachian
Re: $900 medical bill for a consultation - is this outrageous?
« Reply #99 on: August 12, 2015, 05:44:05 AM »
OK so the bill came in today and I was charged with a Level IV consult.  I tried googling it and it looks like it is overboard for what we did.  http://emuniversity.com/Level4OfficeConsult.html

"Level 4 Office Consult (99244)

This is the most popular code used to bill for office consults.  Internists selected the 99244 code for 40% of these encounters in 2003.   To get an idea of the frequency of use of this code among sub-specialists, nephrologists used this level of care for a whopping 49% of consults performed in the office during that same year (which added up to 77,556 visits). The 99244 ranked 46th among the most frequently used CPT codes by all physicians in 2003.  The reimbursement for this level of care is approximately $168.00.  Usually the presenting problems are of moderate to high severity.

The documentation for this encounter requires THREE out of THREE of the following :

1)  Comprehensive History
2)  Comprehensive Exam
3)  Moderate Complexity Medical Decision-Making

Or 60 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included."

There were options for hospital consult on that page and we did technically go to a hospital but that happened to be where the specialist was so I don't know if that is still considered hospital or office.  I'm going to call tomorrow to try to get it recoded.  If it works, I assume they send another bill right?  I don't want to give them say $500 to settle and then get a bill saying I owe the same $900 or another $400.  I'm getting cynical in my old age :)

Honestly, the coding is correct based on what you've said, and it seems like you are appropriately charged. And this is not a hospital consult. A hospital consult is when you are admitted to the hospital by the primary team, and the primary team needs a consult from a specialist team. Yours was an office consult. Primary care doc referred you to a specialist.

This was my reaction too. They just charged a lot (as hospitals do) for visits.