Inflation

Massive can of worms here and one that might offend so I will try and be delicate.

There is also the prestige factor of hospitals/academic medicine.

There is an inverse relationship to the prestige of a hospital and how much an attending doctor makes.

For instance a cardiologist at MGH/UCSF/Hopkins/NYPres/Duke etc. will make 1/3 what a cardiologist in the deep south/midwest makes, that number get's even crazier if it's in private practice.

Maybe ~$220-250 at MGH and like $2mm private practice in the south, meanwhile the CEO of MGH is making over $6 million.

Now those academic hospitals are the hardest to get into for residency and to get a job at... so basically 'the best doctors' are making the least amount of money.

This is very nuanced and there are tons of very smart MDs who have seen the writing on the wall so this isn't completely accurate, but on the whole there is a negative correlation between MCAT/STEP scores and income.

This trend has gotten so nuts that in the last couple of years we have seen a number of major hospital MDs unionize. Penn, Seattle, UMich, MGH, etc.
That is really interesting and I didn’t know that.

I was more thinking about how there are parts of a hospital, critical parts, that really don’t make the hospital money – at least relative to other parts. A Behavioral Health Unit or Dialysis Unit, may barely break even, while an endoscopy unit or OR may rake in a large portion of the revenues of a hospital. What an Internist/Hospitalist makes annually vs what a GI Doc getting $300 a colonoscopy and doing 50 a week makes could be a heck of a difference. It’s not clear to me that one is “more important” than the other.

To @SAJ-99 's point, all else being equal, with a loved one’s life on the line, I would want the more educated person, but I suspect a diminishing return and question where that is. Anecdotally, I wonder if we overestimate education's influence on aptitude. On one hand, hospitals are not necessarily going cheaper with employees. The current trend with RNs is more and more facilities are requiring a bachelors degree. And it sort of makes sense. Out of the gate, RNs with BAs are better prepared that those with Associates degrees, but when you control for age and experience, those metrics level out over time.

Then I can see another perspective that makes sense for hospitals to go cheaper. There’s a lot of things that people aren’t allowed to do, that isn’t a function of real sound logic, but of the inertia of credentialling institutions and regulations limiting flexibility. It's almost as if we need new roles in the medical field. If something an RN making $50 an hour is doing could be done by a tech at $25 an hour, it would make sense to transition down to that. There are specific examples though, of massive pushback against that change in the name of keeping those $50 an hour jobs. And of course.

More than anything, as is the case with nearly all jobs – the vast majority of proficiency comes from on-the-job experience. Education is at least in part, a hoop medical professionals jump through to get that opportunity. What I wonder, and what others in the medical field I have spoken to have stated, is that whether the hoop is far too expensive and long relative to its value to the opportunity. I know that is way oversimplified as another truth is that those on-the-job learning venues have a shortage of their own.

All that said, I don’t even know what the the main drivers are of increased medical costs. People way smarter than me write books about the subject that disagree with one another. At the end of the day, a lot of medicine is so Goddamn miraculous that it borders on priceless. When a few years back, my daughter spent the better part of a month in the hospital after nearly dying from a burst appendix we mistook for a stomach bug, I would’ve gone bankrupt to save her life and it would have been worth it. It only ended up costing a couple hundred thousand dollars, and what they did was a miracle and well worth it though the money I paid was only a portion of the bill, and the whole bill got paid from money from somewhere in the black hole (to me) of the insurance industry.
 
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That is really interesting and I didn’t know that.


All that said, I don’t even know what the the main drivers are of increased medical costs.
A certain hospital system I’m familiar with pays the CEO north of $20 million and continually does multi million $ renovations focused on “patient experience” (aesthetics) and not patient outcome. That’s probably not the whole story but certainly it has something to do with it.
 
It is not complicated. Study the rest of the world.

Healthcare as a right pays for itself by increased worker productivity.

The Healthcare insurance industry charges about 35% of total costs with no increase in healthcare output. In fact it has become a big negative.
 
On one hand, hospitals are not necessarily going cheaper with employees.
First, good post. I think you have summarized the problem. However, this above is incorrect. Hospitals are definitely going cheaper with employees. More NPs, PAs, and less Drs. To your point, are the outcomes the same or worse? I don't know of a hospital that measures that. Probably is one, but I don't know. It would be easy to measure how many burst appendixes are misdiagnosed and end up back in the ER. Do they want to know those stats?

More than anything, as is the case with nearly all jobs – the vast majority of proficiency comes from on-the-job experience. Education is at least in part, a hoop medical professionals jump through to get that opportunity. What I wonder, and what others in the medical field I have spoken to have stated, is that whether the hoop is far too expensive and long relative to its value to the opportunity.
This was sort of my point, less training and experience doesn't result in better results regardless of the job. I don't care if it is building a house, operating on a broken bone, or digging a hole. Experience is the key. Drs have to do a residency that builds that experience- mostly through being overworked in a low paying job while being trained by experienced Drs. That should command a $ premium in salary. I can't say if the value is worth it. I guess it depends on the person and the area of specialization. Surgery, and Ortho in particular, largely has paying customers, so they make the Hospital money. ER and Psyche has a high proportion of non-paying customers. Hence the wait. For Hospital admin, this turns ER into a loss leader in a medical business that is volume based. Seeing more patients at a loss doesn't equal a profit. So the hospital cuts costs.

Your story is all too familiar. Either you avoid seeking an opinion because of the wait or you do and get told it is a minor problem, only to find out it isn't. Patients have to know the system. ER can run a lot of stuff without a prior insurance approval. Other specialties and Urgent Cares can't.

The system is broken, but I don't see any path to fixing it without it becoming a two-tiered system - some base level of care from the government and a second level of care from those with private insurance. Of course, this isn't fair.
 
That is really interesting and I didn’t know that.

I was more thinking about how there are parts of a hospital, critical parts, that really don’t make the hospital money – at least relative to other parts. A Behavioral Health Unit or Dialysis Unit, may barely break even, while an endoscopy unit or OR may rake in a large portion of the revenues of a hospital. What an Internist/Hospitalist makes annually vs what a GI Doc getting $300 a colonoscopy and doing 50 a week makes could be a heck of a difference. It’s not clear to me that one is “more important” than the other.

To @SAJ-99 's point, all else being equal, with a loved one’s life on the line, I would want the more educated person, but I suspect a diminishing return and question where that is. Anecdotally, I wonder if we overestimate education's influence on aptitude. On one hand, hospitals are not necessarily going cheaper with employees. The current trend with RNs is more and more facilities are requiring a bachelors degree. And it sort of makes sense. Out of the gate, RNs with BAs are better prepared that those with Associates degrees, but when you control for age and experience, those metrics level out over time.

Then I can see another perspective that makes sense for hospitals to go cheaper. There’s a lot of things that people aren’t allowed to do, that isn’t a function of real sound logic, but of the inertia of credentialling institutions and regulations limiting flexibility. It's almost as if we need new roles in the medical field. If something an RN making $50 an hour is doing could be done by a tech at $25 an hour, it would make sense to transition down to that. There are specific examples though, of massive pushback against that change in the name of keeping those $50 an hour jobs. And of course.

More than anything, as is the case with nearly all jobs – the vast majority of proficiency comes from on-the-job experience. Education is at least in part, a hoop medical professionals jump through to get that opportunity. What I wonder, and what others in the medical field I have spoken to have stated, is that whether the hoop is far too expensive and long relative to its value to the opportunity. I know that is way oversimplified as another truth is that those on-the-job learning venues have a shortage of their own.

All that said, I don’t even know what the the main drivers are of increased medical costs. People way smarter than me write books about the subject that disagree with one another. At the end of the day, a lot of medicine is so Goddamn miraculous that it borders on priceless. When a few years back, my daughter spent the better part of a month in the hospital after nearly dying from a burst appendix we mistook for a stomach bug, I would’ve gone bankrupt to save her life and it would have been worth it. It only ended up costing a couple hundred thousand dollars, and what they did was a miracle and well worth it though the money I paid was only a portion of the bill, and the whole bill got paid from money from somewhere in the black hole (to me) of the insurance industry.
I mean if it’s a teaching hospital then the vast majority of the Doctoring is done by residents and fellows (post grads) I’m not sure the national average but it’s probably a high ratio of post grad v. attending. Post grads salaries are paid by the federal government via Medicare, in fact a hospital takes a cut of their pay. Fed might give a hospital $150k per trainee but the trainee gets only $65k in salary. Now the “value” of the post grads in terms of billing starts low, but in the final year or two of training it’s virtually the same as an attending. (Depends on speciality and hospital)

But TLDR hospitals get a huge staffing subsidy from the fed.
 
First, good post. I think you have summarized the problem. However, this above is incorrect. Hospitals are definitely going cheaper with employees. More NPs, PAs, and less Drs. To your point, are the outcomes the same or worse? I don't know of a hospital that measures that. Probably is one, but I don't know. It would be easy to measure how many burst appendixes are misdiagnosed and end up back in the ER. Do they want to know those stats?
A recent study released showed better outcomes for MD attended v NP. This study was published before Christmas in JAMA…. The journal of the American Medical Association.



To save some time reading this study, it compared Emergency Departments staffed by MD compared to unsupervised Nurse Practitioners.
 
Got a bill from an anesthesiologist the other day for $500 bucks. He introduced himself, two minutes of small talk and he left. Never saw him again.
Pretty good gig. I'm sure there's more examples as I dig through it. mtmuley
I was over $400 for a doctor to tell me I had an infection in my finger, give me a splint and a prescription for some antibiotics. The majority of the visit was spent waiting on a nurse to bring me the splint and some tape
 
Got a bill from an anesthesiologist the other day for $500 bucks. He introduced himself, two minutes of small talk and he left. Never saw him again.
Pretty good gig. I'm sure there's more examples as I dig through it. mtmuley
As an anesthesiologist, I can guarantee he didn’t just talk to you for two minutes and vanish. An anesthesia professional MUST be in the room the entire time the procedure is going on. In most of the country, it’s a specialized nurse (CRNA) in the room with you and the doctor has their back during key parts such as going to sleep and waking up and also if an unexpected situation occurs. In most of the major Montana cities, the doctor themselves personally deliver anesthesia the entire time. You likely only remember the two minute talk because shortly after, the pre-op nurse gave you sedation that also gives amnesia. But guaranteed,
someone was in the room the whole time even if you don’t remember it. And of something unexpected happens in recovery, guess who rushes in to help out. Just because you don’t see us doesn’t mean we arent aware and ready to spring into action.
 
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As an anesthesiologist, I can guarantee he didn’t just talk to you for two minutes and vanish. An anesthesia professional MUST be in the room the entire time the procedure is going on. In most of the country, it’s a specialized nurse (CRNA) in the room with you and the doctor has their back during key parts such as going to sleep and waking up and also if an unexpected situation occurs. In most of the major Montana cities, the doctor themselves personally deliver anesthesia the entire time. You likely only remember the two minute talk because shortly after, the pre-op nurse gave you sedation that also gives amnesia. But guaranteed,
someone was in the room the whole time even if you don’t remember it. And of something unexpected happens in recovery, guess who rushes in to help out. Just because you don’t see us doesn’t mean we arent aware and ready to spring into action.
There was no anesthesia administered. No procedure. I was alone and awake eating a sandwich after he left. Maybe the sandwich was 500 bucks. mtmuley
 
A certain hospital system I’m familiar with pays the CEO north of $20 million and continually does multi million $ renovations focused on “patient experience” (aesthetics) and not patient outcome. That’s probably not the whole story but certainly it has something to do with it.
A non-profit hospital has to not make a profit for that special status. Administrative salaries help keep that profit at zero.

David
NM
 
There was no anesthesia administered. No procedure. I was alone and awake eating a sandwich after he left. Maybe the sandwich was 500 bucks. mtmuley
If he found something in your record that made him cancel and would warrant further work-up, he could charge a consult fee, which I personally don’t do if I’m canceling the case. But that would also mean he spent a good amount of time investigating your medical record . Of note, I hope you weren’t eating that sandwich before he met you or that may be why the case was canceled- surgery is safer on an empty stomach.
 
If he found something in your record that made him cancel and would warrant further work-up, he could charge a consult fee, which I personally don’t do if I’m canceling the case. But that would also mean he spent a good amount of time investigating your medical record . Of note, I hope you weren’t eating that sandwich before he met you or that may be why the case was canceled- surgery is safer on an empty stomach.
No surgery was scheduled. mtmuley
 
No surgery was scheduled. mtmuley
Ok, then i guess it was a pre-op consult which meant the doctor was double checking the past medical history, your labs, surgical plan, etc. My point is, bills are usually generated for some reason. Otherwise, it’s medical fraud and a good way to lose your medical license.
 
No surgery was scheduled. mtmuley
Were they trying to decide if you needed a bronch?

Talking out my ass but I imagine there are a couple of reasons you might call an anesthesia consult on a medicine floor, also depends on the hospital.
 
All I will say about this is that rare diseases are rarer still if you never learned about them, which is directly related to the time you spent in class and on call in MS and residency. And the ability to diagnose and care for complex diseases. At hospitals with Millions+ so you can see the rare stuff.

If you think about the number of hours even the total kitty medical students of these days spend in MS and residency compared to a NP the difference is astronomical.
 
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