about medical practices that can’t pay enough to keep their employees…

After last week’s letter from a medical practice manager struggling to hire staff and unable to pay more because of tightly regimented insurance company payments, I received this letter offering a different view that I wanted to share here.

Hi LW #2,

As a fellow small medical practice owner, I feel your pain. The feedback about PTO and other suggestions is fine, but I think most commenters (possibly even Alison included) aren’t aware of the root issue.

I run a similarly sized practice to yours. We are known for our amazing culture. I always have more people who want to work here than I can hire or have need for. I have had people move across the country to work here, unasked. There is no problem signing people on.

Our challenge? Retaining staff, because we can’t afford to pay them. We have the exact same problem: our pay ceiling is capped because of reimbursement and the fee-for-service nature of health care. Our staff are crestfallen when they have to resign, but it’s necessary for them to do what’s best for their families. I’m constantly consulting with the staff to tweak our employee offerings: more benefits and less pay, more pay and less benefits, etc. etc. But at the end of the day, we can only offer so much pay + benefits combined. More PTO is fine, but more PTO costs money!

We are able to keep as many people as we have because of our culture. Our staff in two-income families are willing and able to take a lower pay for improved work-life balance and employee experience. But not everyone has that financial privilege.

Insurance rates haven’t budged in over a decade, or they’ve gone down. I ran an inflation calculator this past week. Since I first opened the practice nine years ago, there has been an effective 20% cut in reimbursement. Twenty percent loss of revenues, in less than a decade. Cost of living has gone up and up (and skyrocketed during COVID). Health care workers need higher compensation in order to feed their families, but where does that money come from?

The math just. does. not. work. It is mathematically impossible for a health care practice to take year-over-year cuts (that are outside our control) while maintaining employee compensation levels, let alone increasing. Treatment times may be shortened, as you described, but that’s a huge quality and clinical efficacy hit. In some cases, a shortened treatment might as well be no treatment at all. There are qualitative minimums to clinical care.

We made the decision to go private pay only this year, as a result of this. Our specialty is such that this is doable, we offer a service for which enough people can afford to pay out-of-pocket. This isn’t possible for many kinds of medical care, though. Practices with expensive equipment or involved procedures won’t be able to service anyone but the 0.01% as a private pay clinic.

There is a reason small private practices (and hell, small and mid-tier hospital systems) are all selling and being absorbed by massive entities. I don’t know how long the rest of us who operate these kinds of practices will be able to survive. We are probably the ones who make the best damn buggy whips — but it’s still a buggy whip, and there’s no place for that in today’s market.

The advice from readers (and Alison) is fine, but as someone who has been grappling with everything you expressed, this is NOT because you are failing or missing the mark as a business owner. Sure, maybe you can level up some elements of culture or flexibility or something. But that is only going to get you so far, and you will still have the same struggles.

I don’t have an answer, and I’m sorry to sound so grim. You aren’t alone.

{ 488 comments… read them below }

    1. Cheese Toast*

      Yup, this was my takeaway as well. The root cause is inadequate reimbursement from privatized insurance. Burn it all down.

      1. tw1968*

        Agreed! If they’re seeing insurance repay LESS and every single person who has insurance pays MORE that covers LESS each year, I think we see where the problem lies. Too much greed from insurance companies.

        1. MiloSpiral*

          Yes, yes, yes. This is exactly what was screaming at me from this letter. The longer I read, the angrier I got at the system of privatized insurance. It is inhumane and driven by greed. Burn. It. Down.

      2. Anat*

        Well, is Medicaid / Medicare paying them at a high enough rate to survive? I often hear complaints about the government paying at an even lower rate than private insurance.

        1. Dittany*

          It absolutely isn’t. Medicaid typically pays at much, much lower rates than commercial insurance, to the point where practices with a Medicaid-heavy patient load often struggle financially.

            1. Cheap Ass Rolex*

              Or even some places that do accept Medicaid patients have a cap on how many new Medicaid patients per day/week/etc can establish with them. The doctors may be willing to help but the practice has decided it has to keep the influx to a trickle so that the majority of their patients are still privately insured.

            2. DataGirl*

              As a parent who has had multiple children in need of psychiatric care for the past 2 decades, I have seen the trend in mental health services skew strongly towards private pay only. Mental health coverage is often a separate policy from medical, that reimburses at much worse rates. Plus the huge amount of paperwork and red tape is often more than a small practice is capable of dealing with. Locally we were lucky enough to find a doctor who did private pay and “only” charged $90 per visit. A couple years ago one of my (young adult) children moved to Chicago and I spent weeks calling every mental health practice I could find, only to have them all say they did not accept our insurance. Being a large city where I’m sure office space and overhead costs doctors more- consequently all the private pay docs were charging upwards of $200/visit. They ended up being able to do telehealth with their previous psychiatrist in our home state but it was brutal.

              In addition to the appalling reimbursement for mental health practioners, there’s a serious shortage of them in the US. A few years ago I read that for every child psychiatrist available there are over 250 kids who need mental health care. Given supply and demand, I really can’t blame doctors for going to private pay and just treating those who can afford it. It’s a horrible situation and I’m sure most doctors would like to help more people, they just can’t.

              1. BatmansShorts*

                Oh dear. I’m sorry to hear about your situation.
                It would probably help, too, if we didn’t saddle down our medical students with a quarter million in student debt. There’s no way to deal with that except to make money. In every other OECD country, medical school is free or reasonable priced.

                1. Platypus Queen*

                  Also, in every other OECD country that I am aware of, medical school is not a post-grad program but a bachelor’s degree, which seriously cuts down on the amount of debt (and time) that future doctors have to incur before they can start doing what they’ve trained for.

                2. Dr Sarah*

                  Sadly not in the UK, where medical school costs are still unmanageably high, though at least not as horrendous as ‘quarter million’ levels.

              2. Olddog*

                I’m a mental health professional and I have fought the trend to go private pay because access to care is important to me, as is having a socioeconomically diverse panel of patients. After 20 years I’m finally on the cusp of going private pay only because it’s not sustainable relying on insurance which doesn’t pay for any of the casemgmt work or communication between different providers that is part of good care

              3. Ginger Baker*

                Yeah we managed to get an insurance covered psychiatrist for my teen because of a mental health inpatient hospitalization. I uhhhh…don’t recommend this but it was effective in getting immediate coverage when previously all covered openings were major waiting lists :/ (Kiddo is in a pretty stable place now, thankfully!)

              4. Baby Bootcamp*

                I’m so sorry that this wasn’t easier for you. I’d like to add to your sadly accurate observations.

                I’m a specialized therapist who works with non verbal kids who have significant behavior problems. I have a solo practice, own my own building, no employees, and am completely hands on.

                Even without significant overhead costs, I don’t accept ANY insurance due to the paperwork and red tape. The “reasonable and customary” rates are–from what I can discern–fanciful and from imaginary origin. Also non-negotiable.

                My Medicaid Patients (when I accepted Medicaid), often had their own specific socioeconomic issues. Notably, unreliable transportation and a casual relationship with calendar/clock. Medicaid did not reimburse for No Shows. When my time is gone, it is gone.

                Although I have a pediatric practice, I had to deal with Medicare once. This experience was so universally obnoxious that when I consulted my professional organization, they advised me “Just drop him. It isn’t worth the headache for a small practice.” Medicare cheerfully informed me that I could see my patient for free. They’d have no objections to that.

                As DataGirl observed, I would love to help more people, but a combination of excessive paperwork and low reimbursement keeps me away from dealing with insurance.

                I have over thirty years of experience successfully treating kids who are determined to grow into AAM subjects: Tantrum throwers. Biters. Genital touchers. Food issues. The usual party favorites. Insurance reimbursement rate for my services is the same as for the newbie who doesn’t take the risks that I do.

                Because there are not many in my field that willingly deal with aggressive kids, therapists can choose NOT to serve this population. My job is challenging enough. If universal healthcare means that I will be thrown into the pit of capricious paperwork, you can bet that I won’t serve them either.

                1. pancakes*

                  I’m not sure why you’d think universal healthcare would bring about “a pit of capricious paperwork” even worse than dealing with multiple private insurance companies involves. You don’t think standardization could be an improvement?

                2. Baby Bootcamp*

                  Thanks pancakes,

                  Perhaps standardization could be be an administrative improvement for some practices that already deal with insurance. Perhaps they can tolerate someone else setting a dollar amount on their worth.

                  However, I’m currently opting out of all insurance payments, it is simply not worth the hassle. So, I’m comparing universal healthcare against…opting out of all of it.

                  Right now, I have the option of “cash on the barrel” (minimal paperwork and a great deal of autonomy), insurance (paperwork, plus being on telephone hold to clarify ongoing issues), and Medicaid/Medicare (Huge bureaucratic mess requiring paperwork plus regular maintenance paperwork supporting the original paperwork. For this, I regularly spend several extra unpaid hours and take a pay cut on the hours that they DO pay for.)

                  The free market allows me to charge less than than DataGirl’s private specialists, but more than the insurance company’s “reasonable and customary” fiction. Maybe Universal healthcare will allow me to continue as I am, on the periphery. In that case, I have no dog in this fight. However, if it functions anything like a mandatory Medicare/Medicaid program (with the accompanying reimbursement cuts and deluge of documentation) then I’m out.

                  My caseload includes children who literally try to disassemble me with their teeth. I am not eager to add additional bureaucracy to my daily schedule. I have already earned my combat pay.

              5. Elle*

                I’ve also been seeing a psychiatrist since I was a kid and your point about the lack of options is so true. When I moved cross country as a teen I had to travel back to my home state twice a year for a five-minute refill appointment because there weren’t many psychiatrists where I had moved. So frustrating.

        2. Me*

          Don’t forget Tricare.

          While I absolutely agree univiersal healthcare is the way to go – seeing the government mismanage their existing insurance programs gives me serious concerns.

            1. PT*

              Like the Atlanta VA, where an elderly veteran was eaten in his bed by ants and no one noticed.

              It made national news.

              1. FedVet*

                No worse than private practice where, say, 74 patients were abandoned to die because of a fire (where they could have been saved), or 15 patients were abandoned in a private mental health facility and left to die, or…

                Outliers do not mean the entire system is broken. And the trick with the VA versus any private practice is that there are consequences for the failure – not just “oops, tee-hee, guess we’ll make a stink for a week and then forget about it.”

                Don’t use the VA to say single payer is bad just because of outliers.

                1. Meep*

                  I can agree with you that the VA is a special case, but it is more that the entire U.S. military is a case of “haha! we screwed up! oh well. let’s punish those dang complainers!”

                  I would love to see the VA or any military-run government entity take accountability for anything. Not only is it horrible to vets who are disabled for their service, but it is also anti-women and anti-LGBTQ+. You cannot convince me otherwise when 80% of women who report (which is only 10% of all military SA victims) rape and sexual assault lose their jobs within 8 months while their rapists walk free. It is impossible to fix the VA without completely razing the entire US military and its toxic culture to the ground.

                2. Meep*

                  I can agree with you that the VA is a special case, but it is more that the entire U.S. military is a case of “haha! we screwed up! oh well. let’s punish those dang complainers!”

                  I would love to see the VA or any military-run government entity take accountability for anything. Not only is it horrible to vets who are disabled for their service, but it is also anti-women and anti-LGBTQ+. You cannot convince me otherwise when 80% of women who report (which is only 10% of all military SA victims) SA lose their jobs within 8 months while their attackers walk free. It is impossible to fix the VA without completely razing the entire US military and its toxic culture to the ground.

                3. kt*

                  100% agree, FedVet. The VA provides high-quality and very very cost-effective care in many situations. The percentage of their $ that goes to overhead is low. The percentage of money going to advertising — like nil. The percentage of money to enrolling and de-enrolling and re-enrolling people — likewise extraordinarily low. Private insurance allocated 30% of their spending to all that before Obamacare-adjacent laws tried to cap that at 80%. Private insurance is a white-collar job-creation and money-extraction program. All those office workers processing paperwork and denying claims.

                  Yes, the VA has high profile failures. And news stations are on point on covering all of them — we’ve got one in my town that covers every VA problem you can imagine, including ones that turn out to be lies. They don’t cover people just… failing to get healthcare and then dying from it.

                  In the end, though, here’s the question: do you want health CARE…..
                  … or do you want health INSURANCE?

                  Pick one when you are having chest pains.

                4. when the wolf comes home*

                  @Meep: the VA isn’t part of the US military. It’s literally not even in the same cabinet department.

              2. This is a name, I guess*

                Have you used the VA for services? If you haven’t, perhaps don’t denigrate it without firsthand experience. ALL American healthcare – Medicare, Medical Assistance, the VA, private insurance – is plagued by administrative nonsense that makes it difficult for patients without good advocacy skills, administrative skills, or technology skills. Veterans who use the VA – by dint of age, demographics, and income bracket – are likelier to lack the skills needed to manage the American healthcare system. If they had private insurance, they would likely struggle too. It just looks different in different symptoms.

                My partner used the VA exclusively when she went back to school. She’s trans and received all of her trans-related healthcare through the VA. She also got decent mental healthcare. She also got emergency care for a concussion.

                We have private insurance now, but it sucks in other ways and it’s super expensive. The VA puts a huge administrative burden on the patient, but it wasn’t that much worse than the vigilance required to navigate private healthcare. It’s just different because it’s centralized.

                1. Lacey*

                  Yeah, I have a friend who works for a VA hospital and her experience really changed my perception of them. They’re all about improving care across the board and in each individual hospital. They have a lot of systems in place that go above and beyond what a regular hospital would do.

                  I know there are some bad VA hospitals, but it does seem like they’re outliers and not the rule.

                2. Miss Betty*

                  I know the VA saved my husband’s life more than once and our local one does everything they can to help the veterans here. Unfortunately they are, like all VAs underfunded and understaffed and they really, really struggle. (My dad was a social worker at the VA for 20 years and frequently talked about how he wished they could do more for the veterans but they just couldn’t get the funding and staff they needed.)

                3. pancakes*

                  I have a good friend who gets care at the VA hospital here in NYC, and I’ve visited him there and picked him up from there multiple times. His doctors are great. His experiences getting prescriptions sent to him at home and calling the nurses with questions now and then, also great.

                4. Hmmm*

                  “Veterans who use the VA – by dint of age, demographics, and income bracket – are likelier to lack the skills needed to manage the American healthcare system.”

                  So it’s not that the system is terrible, it’s that veterans are too old, poor, and stupid to handle it.

                5. Anon VA Employee*

                  I work in the Records Dept at the VA in my area – and I can’t even begging to tell you how hard I and my co-workers work to try and keep up with the flood of work we have, because we are understaffed. The pandemic is not helping either because we’re healthcare so we’re in person (my Dept backs up the staff who handle checking in patients for medical appointments – so, nope I’ve been in person for the whole duration), have masking and vaccine requirements. And guess who spends lots of time being abused for trying to enforce rules and policies that CONGRESS makes?

                  But – I took the job because I believe in the responsibility to serve veterans and help take care of their medical needs. I still do three years later too. But every time I hear about something that went wrong – I know the abuse towards me for daring to work at the VA is coming and I wish I could just crawl into a hole and hide till it blows over.

            2. AlyInSebby*

              For 30 years I have been a veteran using VA Health, mental health and I had the strange luck to have been diagnosed w TMJ while I was active duty, thus I have dental care also.

              As the healthcare/health insurance world has crumbled in the past 30 years and whenever people scream that nationalized health care would be horrific I think “Um, has anyone really looked at how successful VA health care actually is given the clients it serves?”

              No question there are horror stories, I have more than a few. It took 10+ years and referral to outside OB/GYN/Women’s Health to get HRT.

              I’ve been lucky to be in a region where for the most part there are longstanding great programs – Northern Calif/SF Bay Area.

              I have a rule for commenting about the military and VA – if you haven’t served please don’t disparage or comment on esteem or speak for those who have served (unless they’ve asked you to or given reason like an adult child who has navigated the system w their parent or spouse of …).

              What if everyone who serves (and expand into options like some European and other countries in this case bc using to qualify for life long benefits minimum service allotment would likely need to be 4 or more years) in military or other social service/national services qualifies for health care for life.

              Like the New Deal create programs that ‘build’ the long term programs and use those early builders to become managers and administrators to keep systems self creating.

              Please don’t thank me for my service – I get ‘thanked’ w the benefits I’ve earned. And definitely don’t thank someone for their service while voting to lower taxes.

              1. Crazyoboe*

                I agree. I use the Cleveland area VAs and my experience has been pretty positive. Sure, I had to wait 6 weeks for an MRI…but I had that same kind of experience when using private insurance prior to my service. It took 6 weeks to get my gallbladder out when it was causing me severe pain, and that was all private insurance. And then once it was out, the earliest “2 week follow-up” appointment was 4 weeks later. VA has been much better than that for me.

                I think part of the problem is that the population the VA serves tends to downplay their pain as a result of the military mindset. If you say it isn’t that bad, the VA will believe you and make you wait. If you are honest and it is an urgent issue, they will move mountains to get you seen. Being in tears when I called the appointment line got me a phone appointment with my doctor an hour later.

          1. Autumnheart*

            The government would probably mismanage them less if they were staffed by competent professionals with background in the field, instead of political stooges being placed in the highest positions.

            At the minimum we need to eradicate the profit motive behind our healthcare system(s) because that’s where the root lies. Healthcare’s motive should be treating patients, not making money.

            1. employee*

              There are differing levels of government staff. Some are political appointees; others are career civil service. There is competence and incompetence among both types. Many professionals who choose government service earn less than they could in the private sector. Unlike the private sector, there isn’t a profit motive. Instead, there is a strong mission orientation.

            2. when the wolf comes home*

              Political appointees are non-existent once you scratch the surface. It’s all career after that, including folks who are high enough to have bios on the VA website. They’re career, not politically appointed.

              Which is a good thing, since those positions were vacant for most of 4 of the last 5 years.

          2. Drago Cucina*

            Oh Tricare. Love thee. Hate thee. At one hospital my husband worked at they changed their employee health care to something so bad we opted to use just go Tricare instead of using it as our secondary insurance. Now my husband is on Medicare and Tricare for Life. It’s a mess and if he didn’t know how to read and speak the language of doctors and hospitals we would be over paying for services.

            Tricare is in a process of raising the co-pay on any prescriptions not filled by Express Scripts, to force people to use the government contractor. Express Scripts is currently more money than we pay at our local pharmacy.

            1. AnonPi*

              A lot of insurance companies are doing that now. They switched our insurance where I work to a crappy high deductible one, and if you don’t get your maintenance meds thru express scripts insurance won’t pay. Of course they wouldn’t pay until I met my deductible anyways. And they wonder why I get my asthma inhaler at CVS/GoodRX for $30, instead of paying $270 thru express scripts.

            2. Me*

              My sis is trying to find a therapist. Mental healthcare is over loaded but so few therapist take Tricare because it pays so so bad! I even consulted my clinical manager friend and she’s just like yeah, places just don’t take it.

        3. Anonforthis*

          I mentioned this below, but because of a state budget crisis, payments were made incredibly late for medicaid billings for a while. So my Dad and other doctors in the state were essentially not getting paid for Medicaid at all. My mom added it up and it was over 100k (to be clear, not all of that goes directly to my Dad, he needs that to pay his staff and facilities, which he was essentially doing from out of pocket).

        4. RosaL*

          Most socialized healthcare systems don’t use reimbursements because they don’t outsource – the state healthcare system runs its own clinics hospitals etc so everyone is a direct employee. More like a public school than the medicare system. I had this kind of healthcare in another country and it was excellent, wait times were exponentially lower (I once saw a derm as a new patient in under 2 weeks) and everything ran smoother. Medicare for all would certainly be an improvement from what we have now but it isn’t really a fully public system, just a funding method that would be unlikely to solve this problem (and many others our healthcare system has).

          1. Mannequin*


            I’ve been asking why the US does not have Universal Healthcare for decades, but I don’t think “Medicare for all” is the solution either.

          2. Lilac*

            Australia’s system uses reimbursments. In the last decade the scheduled rate for rebates has not moved due to conscious political decisions but the cost of healthcare has gotten higher. For example, because I’m currently on a low income health care card they bill directly to Medicare. However in a month when I start my job and lose the card, the same appointmemt will be $85 and I’ll only get $39 back. It’s undermining the universal part and it’s horrible to watch it get worse.

        5. Nanani*

          But a real universal healthcare system doesn’t run on reinbursements/paying a set rate. It just.. uses tax money to cover all the health care. No price tags or discounts or insurance involved.
          Don’t mistake bad government run offerings in a private for profit system for what actual universal healthcare looks like
          Source: Literally anywhere in the EU

          1. Me*

            Yes I know what universal healthcare looks like in other countries.

            I also know that given the absolute aversion to universal healthcare by a large portion of the US, we are unlikely to go to that kind of model and more likely to a Medicaid for all.

        6. anon with medicaid*

          Just please don’t blame or take it out on medicaid patients we’re just trying to have medical care that keeps us alive.

        7. TootsNYC*

          I asked my doc how he felt about Medicaid for All, and he said, “I’d be for it if they paid more. They don’t pay enough to keep my lights on, let alone the rent, the support staff, my insurance….”

        8. Ergo DNA*

          Nope! Medicaid in my state does not even pay enough to cover an hourly rate for the treating clinician, forget about benefits! Medicare cuts rates pretty consistently. There was a big cut two or three years ago for rehab (my profession) and an additional one Jan 1st of this year for services provided by therapy assistants.

        1. BatManDan*

          Yup. Fastest way to get less and worse care is to let the government take it over. Their absolute failure with veterans’ medical care is proof that they wouldn’t be able to handle it.

          1. lolly pop*

            We are the government, and unfortunately a large part of America has been trained to view ‘the government’ as an enemy. If we had people in place with a mandate to ensure solid care while managing expenses to benefit the program rather than protect private profits (and keep lobbyist money flowing), America would do just fine with public healthcare.
            Maybe removing political obstacles is the way to go, not continuing the same lame complaints.

          2. Starbuck*

            Or is it the problem that the public option has to compete with the private option in the US, and we have a system set up that heavily weights the playing field in favor of private profits? It seems odd that other countries with more public healthcare do so much better than the US by almost every measure. Something to ponder….

          3. FedVet*

            Hi. Veteran here who also formerly worked for the VA.

            VA health care has actually been better for me than private practice ever was. Yes, the civilian who was appointed as the Secretary of the VA is absolutely failing and causing back-slides in the ability to provide quality care, but the medical practitioners and day-to-day staff who support us with our unique needs *absolutely* blow private practice out of the water.

            Please don’t use the VA as some kind of “gotcha” against the government – actually looking at the overall quality of care and miracles they do with the exceedingly limited resources they have proves the opposite point.

            1. mrs__peel*

              The VA was also way ahead of the curve in getting a good electronic medical record system in place, so that people could be treated in various parts of the country and have their records immediately accessible.

            2. DataGirl*

              I think a lot of it depends on location. My dad is a Vietnam Vet- when he lived in Washington state he had horrible care because there weren’t sufficient providers near him. He moved to Nebraska where there’s a huge VA hospital and he is getting excellent care there.

          4. Berin*

            In peer-reviewed studies, Veteran clinical outcomes tend to be better than private sector; roughly 90% of Veterans would prefer to keep their care within VHA when given the option. A lot of people have had shitty experiences with the VA, and I am definitely not questioning their experience! I’d just note that part of the reason that VA has better health outcomes as a whole is because they are answerable to Congress and by extension, Americans in general. Private hospitals/healthcare do not have that same motivator.

            1. boo*

              My dad was a veteran, volunteered at 17 and served 4 years. He tried to sign up for VA care after he was laid off later in life and was denied because my mom made too much (she was a nurse and not wealthy by any means) and was advised to divorce her to qualify. It is a disgrace

              1. Person from the Resume*

                There is a misunderstanding. The VA doesn’t / can’t provide healthcare for every single veteran. There are eligibility criteria that is super hard to navigate.

                I’m sorry your dad had a bad experience, but it’s not a guarantee for all veterans and the people who determine eligibility are not the people providing the healthcare.

                1. boo*

                  I didn’t misunderstand. I stated he was ineligible. I still say it is a disgraceful way to treat any veteran.

              2. Berin*

                Again, I am absolutely not denying your family’s experience. I am saying that healthcare outcomes are better than in the private sector, and the idea that government-run healthcare is “less and worse” than the private sector is not accurate according to the data, in response to the person who initially disparaged VA care.

                I am sorry that your dad was ineligible for care. The only way that VA will be able to care for all Veterans without any eligibility requirements is if there is substantially more funding, as well as the construction of new VA facilities. Frankly I think VA is a good model for universal healthcare if the country ever goes that route, which would also alleviate the eligibility issue that a lot of Veterans face.

          5. Nanani*

            Please for the love of all cheese look at a country that has an actual universal medical care system (hint: you won’t find it in the US)

            Pretending the government’s entry into a private, for-profit system is the same thing as universal care is abject nonsense.

        2. Jaybee*

          Come on now. We all know why Medicare and Medicaid are underfunded and it’s not because all single-payer systems are doomed to be underfunded.

          1. Avril Ludgateau*

            “This program that we deliberately underfunded is failing because we underfunded it to prove the program is a failure,” basically.

      3. Sue*

        I don’t work in healthcare but I am amazed at the unbelievable amount of paperwork we receive from our insurance company. We have relatively inexpensive medicare supplemental policies and I could fill a filing cabinet drawer with what they sent in the last year. Clearly, a large percentage of insurance costs are not getting to the the actual health care providers.
        I said in the other thread, our Dr is now going to a private pay system but it is ON TOP OF insurance. They are charging $70-$500+ per month just to stay as patients. You buy a plan or you’re out. The system, if not broken completely, is getting there.

        1. Old and Don’t Care*

          The insurance company is almost certainly just complying with Medicare regulations. I get very little mail from my insurance company.

        2. Catthullu*

          That…may not be legal (if you are in the US). If your provider is contracted with your insurance, part of the requirement is that they must accept the insurer’s contracted rate. So, for instance, if your provider charges $100, your insurance has a rate of $50, and you have a $10 co-pay, that $50 (the copay plus the $40 from the insurer) is all they can charge you for; they cannot turn around and ask you to make up the $50 difference. If they are out of network with your insurance, it’s a different story. Our healthcare system is trash, but there’s a very good reason for this particular rule and if they wish to remain contracted with those insurers, they must accept the contracted rate.

          1. Eeyore's Missing Tail*

            I’ve seen more medical clinics doing this. I think they are getting around the contracted rate because by paying the monthly fee, you’re paying to be a client of the clinic, not for any specific exam/test.

            1. Anon Supervisor*

              Yeah, this is a new thing that’s being trickled down from rich people. It’s concierge care/clinics. They charge you a monthly fee and you’re supposed to get a higher, more personalized, level of care.

              1. KaciHall*

                I pay $150/ month for my clinic for my husband, our kid, and myself. It covers any visit, my maintenence meds, and provides referrals (sometimes with discounts) when they CAN’T do something. They don’t take insurance, but I still have that on top of the clinic membership.

                Honestly it’s the best care I’ve gotten in decades, and totally worth the money. But I also know it’s pretty cheap compared to other places.

          2. Marie*

            Sounds like they’re trying to get around laws against balance billing, which is illegal in some but not all states. I can understand the reason for the laws, but man, it is rough to see my therapist’s fee on her website, and then see my EOB that says they paid her half that. I know she agreed to those insurance rates, but I also know she’s worth more than they’re paying her.

        3. Healthcare Manager*

          OP LW#2 here – our silent partner wanted to have the discussion about going “concierge” and charging a fee to be our patient, but a) it borderlines on violating our contracts with insurance, which limits what we can charge the patient (copays, coinsurances, deductibles, *sometimes* fees, under specific circumstances and with specific signed documents), b) didn’t really make sense for our kind of clinic, and c) my boss didn’t want to be “on call” for patients 24/7. I understand why doctors are doing it, but I don’t really find it fair.

      4. MissElizaTudor*

        I fully agree we need universal health care. It doesn’t seem like private insurance reimbursement is the main issue here, though. Medicaid and Medicare are huge single buyers of medical care, so have more power to set their reimbursement rates. As far as I can tell, the literature shows they reimburse at lower rates than private insurance (Medicaid reimburses less than Medicare). So a single payer approach to universal health care might make this issue worse from the provider perspective, although many who support single payer think of that as a positive because it lowers health care cost.

        1. Jaybee*

          Are you actually, legitimately saying that
          1. A true single-payer healthcare system is equivalent to how Medicare and Medicaid function in a private healthcare system?
          2. People looking for single-payer healthcare expect it to reduce costs universally?
          3. Eliminating the private health insurance industry (a vastly profitable industry, despite the fact that it relies entirely on sucking up profits from the healthcare industry) will somehow not result in any additional funds being freed up to go to healthcare workers?

          1. MissElizaTudor*

            I’m not saying any of those things at all. I’m primarily saying that single buyers have a lot of power to set prices, so even though we absolutely need universal health care, a single payer version of that might exacerbate the particular issue being discussed in the post. That doesn’t make it bad, but it does mean it may not solve this particular problem.

            I’m also saying that one of the benefits of single payer is lower health care costs, and one way that is achieved is because the government can negotiate prices, and will negotiate then to be lower. That includes costs for drugs and administrative costs, but also payment to people who work at health care facilities.

            1. MissElizaTudor*

              And by payment to people at medical facilities, I mean the amount they pay for appointments and treatment.

      5. Seanchaigirl*

        You’re singing my song. I’ve worked for healthcare orgs for 15 years and every single one has suffered because of insurance companies. There is zero reason that for profit organizations are allowed to decide what kind of care we get and how much we pay for it, while skimming billions off the healthcare sector every year to benefit shareholders. It’s disgraceful.

      6. No name this time*

        My husband’s best friend from college went to medical school and did a long residency for his specialty practice. After working briefly for a practice where he didn’t get along with the head dr., he joined a group of three other well-respected physicians in a high-end NYC suburb. The family enjoyed the fruits of his work -world class schools and colleges, a stunning home, and beautiful community close to family. As the other partners retired, the friend became the principal in the group with a great reputation in the hospital were they saw patients. It looked like life was good. About 25 years ago, the CPA for the practice started telling our friend that the financial basis for the practice was unsustainable due to increasingly inadequate insurance reimbursment and rising costs of doing business. The CPA warned that if things did not change, our friend would end up in such debt that he would lose his home. After a couple of years of warnings, the friend made a major change. He sold his share of the practice, moved to a rural area in a different state where he had been recruited to start a practice as the only dr in his specialty in a very wide area. For a while it worked, but between even lower reimbursments and whopping increases in malpractice insurance, the friend eventually closed the practice, gave up his license, and retired before he turned 60; carrying malpractice insurance was a requirement to hold the license in his state. Such a shame. He’s the kind of dr. who beieved in listening to his patients and really wanted the best outcomes for them.

        1. pancakes*

          That is a shame in several ways, but I want to add that being able to retire at 60 — and after having had ownership of one’s own practice before that — is a luxury very few Americans will have. People age 62 and up have an average student loan balance of $37,739.13, according to U.S. Department of Education Q4 2020 data, for starters. If your husband’s friend has been getting warnings about the instability of his practice model for the past 25 years, I’m curious to know whether and when he started thinking about trying to change the status quo, or whether his plan all that time was to simply move up his retirement date. Moving to another area was a change in his personal life, of course, but I’m curious about where he stands on the broader status quo.

      7. Ally McBeal*

        And insurance companies arguing with doctors about what qualifies as necessary treatment. I’ve heard the concept of suing them for practicing medicine without a license being tossed around and I hope some creative lawyer somewhere can mount a successful class action lawsuit that takes down the whole system.

      8. Ellie*

        We do have universal healthcare in Australia, and GPs are still complaining regularly about these kinds of issues. The government only reimburses a set figure for a variety of treatments, and only reviews these figures at set intervals. They are constantly running behind inflation. The vast majority of clinics now charge a gap (some don’t for children or concession card holders, some do for everyone), and the ones that don’t try to drive down the time taken on appointments to be as low as possible, for better throughput and to maximise the number of patients they can claim for. It’s a funding issue, fundamentally, I’m not sure that there are any good solutions that are within your control.

        Could you look into fundraising at all? I know its a tricky area for a medical practice, but allowing non-medical related advertising, competitions or selling products for fundraising, etc. might be an option if it was carefully done? Also, maybe offering longer appointment times for patients at an increased rate, for those that can afford it? Its such a hard situation, I’m sorry.

    2. TechWorker*

      I don’t disagree but I think countries with universal healthcare do still have similar (though possibly not *as* bad? Idk?) constraints. If the government sets what they’re willing to pay for service x then the small healthcare provider is potentially still in the same boat. (Though, as there’s vastly less money going to the middle man/insurance company, the problem could be solved that way – perhaps that’s what you mean!)

      1. RagingADHD*

        I would imagine countries with universal healthcare have less wage competition for employees, because the reimbursement rates are the same everywhere. In the privatized market, large corporations can negotiate better with private insurers than small practices can, hence the trend toward large corps absorbing small practices.

        If everyone’s margins are the same, there’s nowhere to go if you want to jump ship, other than to leave healthcare entirely. (Which is happening in a lot of places.)

        1. TechWorker*

          Well they can go and work in the private sector in some places. The U.K. has problems because private nursing and locum nursing (for the NHS but contracted out at a higher rate to cover staffing gaps) pay so much better than standard NHS nursing jobs.

          1. Xenia*

            The US is actually having problems with this now. Nurses are quitting full-time jobs and going to travel nursing because even though they’re contractors with no benefits they’re still being paid much better.

            1. Drago Cucina*

              My husband liked this. He only travelled within a certain range so he would be home on the weekends. One benefit was avoiding some of the hospital politics. My son is currently dating a travelling nurse and she really likes it right now.

        2. an academic*

          Countries with universal healthcare also don’t charge medical students (and to a lesser extent, other health practitioners) insane amounts to get their degrees. In the United States, doctors take on high levels of debt in the expectation that they will earn high salaries later to pay it off.

        3. Nanani*

          You don’t have “reinbursement rates” though??? Universal health care means health care workers work for the government and are paid salaries. None of this nonsense about arguing with insurers for reinbursement.

          1. RagingADHD*

            Healthcare workers in the US aren’t paid directly by the insurer. They are paid by the hospital or practice that employs them, which may be salary or hourly.

            The reimbursement rate refers to the *income* of the practice or hospital, not to the workers.

            1. Nanani*

              Its still not a thing in a real universal healthcare system. The system is funded directly through taxes with none of this insurance rate stuff in the middle.

            2. Anon Supervisor*

              Actually, a lot of providers are reimbursed on the number of RVUs they’re billing insurances for. In other words, their salary is predicated on the number of patients they see and the number of procedures they perform. US Healthcare is a fee-for-service model made popular by the HMO’s that rose up in the late 80’s. That’s why some providers will order a buttload of tests for you so that their practice can bill for those charges. Only in the last 10 years have practices started lobbying Medicare and other large insurance companies to reimbursed based on positive health outcomes (tax credits for keeping patients out of the hospital) and total cost of care (the amount of value patients receive from their care…i.e. hitting that sweet spot between ordering the right amount of tests so that the patient’s problem is actually addressed while keeping in mind that the patient probably has out of pocket costs as well). Private insurances are now paying attention to Care Systems’ cost of care when they’re renegotiating contracts or deciding to funnel their membership to clinics. (21-year Medical Billing Professional)

              1. Anon Supervisor*

                Also, patients should look at health systems with a good total cost of care score as well. Insurance companies will pay a higher rate at those clinics, which is great if you have to pay a percentage out of pocket (you have a high deductible or have to pay a percentage as co-insurance). Odds are you’ll get more personalized and conscientious care as well, as providers at those clinics tend to spend more time with you, have slightly smaller patient loads, and will coordinate care between specialists if you have multiple health concerns.

              2. DJ Abbott*

                Yes. The hospital I worked at paid by RVUs. The doctors’ salary was actually an advance on their total billing for the year and every year there was a settlement where the RVUs were counted by analyzing the billing data and the doctors were paid the difference between their salary advance and the total.
                It was always a concern to set the doctors’ salary high enough to give them fair compensation, but not so high that it would exceed their billing and they would be required to pay some back.
                I worked there for several years and every year corporate tried just a little bit more to squeeze the doctors compensation. They changed from using the CMS RVU table to one of their own, and looked for other ways to pinch pennies on the compensation. As you might expect of a corporation!

          2. doreen*

            Sometimes – there are different types of universal health care and not all of them involve providers working for the government. My understanding is that the Canadian government doesn’t employ most doctors or own most hospitals.

            1. Kate*

              Nope, we don’t!

              First because our health care is administered by the provinces, not the federal government.

              But second, the “Canadian health care system” (which is really a bunch of provincial systems) is more accurately a “single payer health care system”. Doctors aren’t employees of the government, they run their own clinics, etc. and get reimbursed per service according to a fee schedule issued by the only payer.

            2. Canadian Jennifer*

              In Canada, health care is managed at the provincial level, not the federal level. So most healthcare workers are ultimately provincial government employees. I don’t know the specific details of how it works, and it varies based on province, but the healthcare worker is employed by the facility where they work, but the funding to run the facility comes from the provincial government, and the union agreements are with the provincial government. So a provincial government controls staffing levels based on the amount of funding they provide for that type of position with the rate of pay, benefits, etc. being determined by the union agreement.

              Also, the idea of who owns a hospital is breaking my brain a little, as hospitals are a government provided service, not a business. It’s like saying who owns that public school. Officially, the legal designation is probably “crown corporation” which means it’s a publicly owned entity.

      2. Lanlan*

        “(Though, as there’s vastly less money going to the middle man/insurance company, the problem could be solved that way – perhaps that’s what you mean!)”

        I’d like to know how the raw numbers work out when you cut out the insurance company and just go straight to the government handling it. A lot of Medicaid and Medicare is currently managed by insurance companies, not straight-up government health care — when I was on Medicaid I had to carry a plan through Excellus, for example. I want to know how the NHS manages to pay its small practitioners enough to keep them coming back to work instead of going over to the private sector.

        1. TechWorker*

          I am not an expert in this at all so very happy to be contradicted by someone with experience but in some cases, they kinda don’t. In some areas practitioners take both NHS and private patients (and to some extent choose the ratio to best suit a) their income and b) demand – they might not have enough demand to go fully private, or they might *want* to treat NHS patients). There are some areas – physiotherapy for Eg – where you can either pay to see a physio straightaway, or go through the NHS and through their waiting list, but might eventually see the same person. It is a bit of a two tier system, and can work less well for things that are chronic or ‘low importance’ but actually still affecting quality of life – but also no-one is made bankrupt through medical bills so *shrugs* I’ll take it.

          1. UKDancer*

            A lot of surgeons and consultants take both NHS and private patients, sometimes at the same hospital. My aunt had a cataract recently and the waiting list for NHS treatment was 12 months I think so she paid and saw the same surgeon privately and had the operation done quickly. Chronic conditions can take a long time to be seen to so if you can afford it, a lot of people pay to have it done privately.

            On the other hand if you have something urgent you can get it done very quickly and without charge at the point of service. My father had an organ transplant and huge amounts of aftercare free of charge.

            I’d say one of the reasons practitioners stay in the NHS is an awful lot of them believe passionately in the NHS as an issue of principle and will defend it ferociously. They may earn less money but a huge number of the people I’ve met through my father’s treatment are passionately committed to the NHS and believe in the system and the need for everyone to receive the same treatment regardless of ability to pay. They may do some work privately to pay the bills but the NHS matters to the people who work in it as an ideological issue. That’s why I admire them so much.

            1. pancakes*

              BBC Radio 4 produced a big series on the history of the founding of the NHS on the occasion of, I think, its 70th anniversary a couple years ago. It was very informative and I found the parts about Aneurin Bevan particularly moving. I’m sure it’s still available online someplace and I’d recommend it to anyone interested in the subject.

              1. Batgirl*

                Thank you for this, I’ve always wanted to know more about Nye Bevan, and how involved he was with the Welsh aid society the NHS was based on.

        2. DJ Abbott*

          There are probably stats out there if you want to do an analysis. Or look at economists like Robert Reich and see if they’ve already put something out.
          I would try googling Medicare for all and see if there are any studies that pop up, or specifically Google for the studies.

      3. ElizabethJane*

        Universal healthcare would also force a massive recalibration in medical billing over all. Things like “insurance only covered 40% of this medication so the patient still owes $60” but the medication in question is an antihistamine. Which happens. I was charged $113 for a single does of my anxiety medication when I gave birth to my daughter even though purchasing my monthly prescription at the pharmacy is $3. I was not allowed to bring my own medication from home. When people say “universal healthcare” they don’t mean “just change who provides insurance” they mean “Burn it all to the ground and start over”

        1. Ex-Teacher*

          This! Most complaints about universal healthcare also forget to take in to account the lowered overhead costs (in both money terms and actual labor completed) which would be introduced in such a system- right now, medical practices have to bill different insurances differently, navigate different coverage/authorization requirements, call many different insurers to secure authorizations, track varying co-pays, and get paid different reimbursements for the same procedures based on which insurance covers a given patient.

          If there were only one insurer to submit to, then all of the above items are simplified- there’s only one set of co-pays to track, one set of coverage guidelines, one set of reimbursement amounts, etc. It literally makes less work for the practice, therefore lowering the overhead for any individual practice (which likely also has the consequence of more small providers in communities, because they don’t need to be part of a major medical group just to survive.) And this is all before we talk about how having the government be the massive force when negotiating prescription drug prices.

          1. Autumnheart*

            Not only that, but it sure would be a lot easier to centralize and standardize health care records so that the health history of each patient was much more accessible, whether they got care where they lived in Ohio, or wound up in an ER for a broken leg in Tahoe.

            A hell of a lot of administrative waste is due to the duplicate efforts of maintaining individual records in multiple individual systems, and even more so because it’s tied to employment, so whenever we switch jobs, or when our employers switch providers, that information all has to be duplicated AGAIN with increased chance of error. Having one single centralized system would eliminate that.

        2. M2*

          Omg thank you! You don’t even want to know how much I was charged for Tylenol (two Tylenol after I gave birth)! It was over $100 even with my insurance for TYLENOL!! They made me take Tylenol because I was allowed pain meds after my c- section.

            1. pancakes*

              They’re not pretending it’s something else, or that it’s a good deal for the patient. They can charge this much, so they do.

          1. Chicanery*

            I was just about to mention my $90 Motrin! I had my own Tylenol in my delivery bag, but no, I had to pay through the nose for the exact same pill but furnished by the birthing center.

        3. DJ Abbott*

          Not having insurance through an employer has made getting my asthma medicine a nightmare. The lowest I ever got a one month supply was for $100 and that was with a really amazing and supportive pharma tech who was a magician at finding coupons.
          The price without discounts for a one month supply is over $300, and that’s for the generic.
          Pandemic unemployment has made this happen to a whole lot of people and I hope it creates enough outcry to make some changes. There should be a law that medicines have to be priced at reasonable and sustainable rates.

          1. Mannequin*

            I was in that same boat for a long time, but I was able to find a patient assistance program through Needymeds that enabled me to get BOTH of my expensive asthma medicines free.

            I had a great doctor who used to give me free samples all the time too, just to make sure I had meds.

        4. Mannequin*

          When I went in about 8 years ago I got yelled at by nurse for bringing all my Rx with me. I’d never been in the hospital before and legitimately didn’t know if I needed to bring them or not, and thought it was better to be safe than sorry.

      4. Jaybee*

        Of course that’s what we mean. Is it not obvious that a system in which an entire for-profit industry relies on siphoning profits from another industry is eventually going to be untenable? The only solution is to kill the parasitic industry.

        This is like seeing fleas on your dog and going “well…flea and tick medication has its own drawbacks…I can’t see how the dog would be any better off without the parasites.”

        1. TechWorker*

          Um ok. I am very much in support of universal healthcare sorry if that wasn’t clear! I just (as other people have also said below) do not think it fixes this problem by itself, medical staff are also underpaid in countries with universal healthcare, and – as in this letter – there are still cases where practices move to being private pay only because they can’t afford or don’t want to take on NHS patients.

          1. pancakes*

            I appreciate the clarification. Some of us in this conversation (me, at least!) believe that people not having access to healthcare is the main problem, and doctors not finding it economical to run their practices the way they’d prefer to is a secondary and much lesser problem.

          2. Green Beans*

            There are also other significant long-term benefits to our healthcare system in terms of advancing medicine that are not seen in single-payer/universal healthcare systems.

            1. pancakes*

              US military spending was $778 billion in 2020. This is nearly 40% of worldwide military spending. It shouldn’t be unthinkable to redirect some of that funding to medical research and development.

      5. Ros*

        I work in a Quebec medical clinic, peripheral to the public healthcare system. What I can say: our doctors and nurses don’t have 200K in student loans to repay, and giving that suing healthcare workers isn’t a huge motivator around here, insurance for liability isn’t as high. Salaries are lower, accordingly, but people start out with needs that aren’t as high (and ‘lower’ is relative – physicians EASILY bring in 150K/year, but not 500K unless they’re specialists or working 80 hour weeks. They can easily become millionaires, but not in 2 years. That kind of lower – they’re still doing fine). The work to process paperwork and deal with insurance is also less.

        In practice: lower expenses, more time actually treating patients. All staff, not just nurses or doctors, make a living wage (competitive for other industries with similar training requirements).

        Also, when you say ‘smaller healthcare practitionners’ – there aren’t any. Clinics aren’t meant to show profit, and hospitals are state-owned and operated (and wonderful, IMO, based on recent experience).

        1. pancakes*

          Not the main point, I realize, but the idea that malpractice insurance rates are driven solely by the public’s appetite for litigation and are untethered to, say, the rate or severity of medical errors or the profitability of the insurance business seems quite oversimplified.

      6. doreen*

        I don’t think the issue is just the money going to the insurance company. There’s also the issue of the providers having the staff to deal with the insurance companies. I have had employer-provided dental insurance for the last 30 plus years – and only last year, for the first time did I see a dentist who participated in my insurance and was accepting new patients. Prior to that , I had always seen a dentist who did not accept my insurance (because when I started going there, I couldn’t find one who was accepting my insurance and new patients) .I paid his bill and he then filed my insurance claim. The insurance reimbursed me their set rates, which were much less than the bill. His staff consisted of himself, two assistants, a receptionist and a single person who handled the billing, payments and filing the insurance claims. My doctor on the other hand, had a much larger staff including a couple of people who did nothing other than handle insurance claims and pre-approvals. From what I understand, most countries with universal healthcare do not have an individualized review of each and every claim/pre-approval – they might review a particular provider if it seems that he or she is ordering more MRIs than would be expected but they don’t review each individual claim or substitute their judgment for the doctor’s and decide an MRI is not needed. That review process costs on both ends- the insurance companies and the provider.

      7. BatmansShorts*

        It can work. The government sets a fair price, neither outrageously high or outrageously low.
        Plus, as you’ve noted, there’s a lot of administrative bloat in the US. There’s still administration, but it’s not as bad as the insurance company having to talk to the care provider to figure out whether the practitioner was in network while the care provider has to figure out how to bill the appropriate code to get the insurance company to pay something, not to mention that negotiation for what that particular insurance company will pay that particular provider for that particular service . . . and we haven’t even talked about the patient yet.
        As a side benefit, there’s a lot less litigation with universal healthcare – no one is suing for medical costs when those are covered by the state.

        1. Baby Bootcamp*

          As a practitioner, I’ve observed that the government has no clue how to set a fair price for my services. Nor do they value my experience in relationship to others in my field. Or the consequences for lack of access to my specialty. Or my time spent jumping through excessive and unnecessary hoops of their own making.

          My response is to refuse dealing with any insurance at all. I would much rather spend my time fixing troubled children than to be on hold, listening to bad music, only to talk to someone who’s been coached to say “no” to callers.

          Yes, we need better access to care. Driving the practitioners away won’t do this.

          1. pancakes*

            You said earlier that you don’t accept insurance. I’m curious whether you believe that will improve access in an accelerationist sense, or whether that decision is one you’ve compartmentalized in relation to improving access?

    3. Catcat*

      That won’t fix the problem on its own – healthcare staff are also underpaid in the UK. But of course universal healthcare is necessary for other reasons, and it could be a fix if the government is willing to invest enough in employees.

      1. After 33 years ...*

        Health care workers are underpaid in Canada as well, particularly those involved with mental health (including psychologists). ‘Universal’ health care (although not dental in my province) helps, but there is still much unevenness involved with insurance.

        1. Nanani*

          Depending on the province, Canada doesn’t actually have universal care. There are a LOT of carveouts like dental, optical, pharma, mobility aids etc., so so still have to have US-style private insurance.

          Europe is a better example of real health care than the hybrid mess we have up here.

      2. Gerry Keay*

        I mean yeah, that’s because the Torries have been gutting funding to the NHS essentially since it started. The issue is underfunding, not the model itself.

    4. Double A*

      Yeah, I don’t understand my family pays $20,000 per year in health insurance premiums (between my employer and our share) and yet the industry can’t afford good salaries. What if we paid that $20,000 in taxes instead? Seems like we’d get a better product.

      We have Kaiser, which I like, but one reason it can be good is because of the efficiencies of an HMO. And it has its downsides, because anything they’re not good at (mental health anyone?) you have to pay out of pocket.

      1. an academic*

        I love Kaiser. My copay was $100 to give birth and $100 when I was in the hospital for a few days for an aphasic episode/suspected stroke. But the care varies a lot between different Kaiser regions, and I’ve never tried for mental health.

        1. Hex Code*

          Can confirm their mental health is not good. Nor are there a lot of options for unusual or complex conditions. They are amazing at getting everyone a flu shot and for instance our pediatrician is great, but they have been unable to help me get to the root of any of my more complex conditions that affect my quality of life.

          1. sub rosa for this*

            Kaiser is great if you fit into one of their neatly defined boxes. If you are any sort of an outlier, God help you.

      2. Filosofickle*

        I avoided HMOs for years, and then I joined Kaiser. Not perfect, but worked great for everything I needed it for and my PCP. was great. Unfortunately I just took a new job that sticks me with another insurer. Today was the first day I’ve needed care and it completely sucks by comparison. I can’t select a provider until I need an appointment, can’t make appointments online, and I’ve already had to make 2 calls to verify coverage for this urgent care visit and I’m still not 100% sure that’s going to shake out. I miss KP.

      3. delta*

        I live in Australia and earn $50,000 a year. My “premium” (the tax directed to my healthcare), was $1000. For the year. No copayments, no deductibles, no hidden fees.

    5. I don’t post often*

      Hmmmm 2+2=7? ACA passed in 2010, so I do not find it at all surprising that doctors haven’t received higher reimbursements while premiums have increased. I am paying roughly the same premium price I was in 2009 BUT my deductible increased from $500 to $7,000. Insurance have to cover more services and more people. The money has to come from somewhere. I’m not at all sure how government involvement would help. The government already provides incentives for people to go into certain medical fields and then work in certain under served areas. But still those areas suffer from lack of care and certainly lack of quality care now. I guess what I’m saying is everyone suddenly having health insurance (or in this case have the government pays for their care) does not equal ability to receive care. (We will leave out ability to receive QUALITY care and just say care.)

      1. Starbuck*

        Insurance company profits have also grown significantly during this time. For-profit entities will of course do whatever they can to soak up excess profit, especially in a market where people are now required to buy their product.

        1. I don’t post often*

          The individual mandate no longer applies but some states do require citizens to purchase (or carry) insurance. Profits of insurance companies doesn’t address the availability of healthcare though. And certainly doesn’t address the availability of quality healthcare

        2. pancakes*


          “The nation’s largest health insurer, UnitedHealth Group, reported $4.9bn in profits in the first quarter of 2021 compared to $3.4bn in the same period in 2020 – a 44% increase. . . . Anthem also beat estimates in its report of $1.67bn in profits in the first three months of 2021, a 9.5% increase from the same period last year. Humana’s net income was $828m in the first quarter, a 75% increase from the same period the year before. CVS Health, which owns the Aetna health insurance provider and drugstores, reported $2.2bn in profits, up from $2bn in the same quarter a year before.”

          I’ll put the link in a separate reply, but in the meantime, this quote is from a May 2021 article, “US health insurers report billions in first quarter as small providers face stress.”

      2. Avril Ludgateau*

        . The money has to come from somewhere.

        Yes, it comes from a much larger pool of subscribers paying premiums.

        ACA is not a public option; it is a pro-insurance company model designed by a majority Republican committee, but that’s a story for another day entirely.

        I guess what I’m saying is everyone suddenly having health insurance (or in this case have the government pays for their care) does not equal ability to receive care. (We will leave out ability to receive QUALITY care and just say care.)

        Now I know you are not arguing that “all men are equal, but some are more equal than others” regarding the entitlement to receive health care. Right?

    6. ThisIsIt*

      universal healthcare will make the situation much worse.
      Here are findings from covid:
      -Private insurers paid nearly double Medicare rates for all hospital services (199% of Medicare rates, on average), ranging from 141% to 259% of Medicare rates across the reviewed studies.

      -The difference between private and Medicare rates was greater for outpatient than inpatient hospital services, which averaged 264% and 189% of Medicare rates overall, respectively.

      -For physician services, private insurance paid 143% of Medicare rates, on average, ranging from 118% to 179% of Medicare rates across studies.

      1. Holey Hobby*

        But everywhere that has universal healthcare, things are much, much better.

        It’s weird, the people jumping in with talking points and bullet-pointed statistics, all ready to hand.

        1. MissElizaTudor*

          It’s better for society as a whole, absolutely. But, depending on what kind of universal health care it is, some kinds of universal health care (like single payer) would likely make this particular situation worse.

          1. pancakes*

            I’m curious to hear your arguments for why this particular situation of insufficient revenues for doctors should take precedence over the also long-standing situation in which a much larger number of people do not have adequate healthcare. Why is the former more important?

      2. Vaca*

        I hate the fact that people equate this country’s inept healthcare system with universal healthcare, well, anywhere else. The US system sucks from top to bottom. We should eliminate all this nonsense. Make a system like there is in Canada or the UK. No insurance, no fees, none of it. You’d eliminate thousands of jobs, of course, people reviewing claims and adjusting them and arguing back and forth. Not a problem in my opinion. Citing things that show Medicare sucks just show that a handicapped, poorly run government program isn’t the same as real universal healthcare.

        1. ThisIsIt*

          Better for individuals but would make the poster’s problem much worse. If people can get higher pay everywhere else.

          1. Autumnheart*

            It wouldn’t make the poster’s problem worse at all, because guess what they wouldn’t have to pay for? Healthcare benefits as part of an employee’s compensation. That could all go into straight pay.

          2. Mannequin*

            I am FAR more concerned that all people can obtain healthcare than that OP can make a profit off of it.

      3. Jaybee*

        I have to assume that if you’re trying to use Medicare and Medicaid as examples of what real universal healthcare would look like, you’re arguing in bad faith. I do not believe you are unaware of other countries besides the US, or that you are unaware of the fact that people with the most money (and therefore a lot of political influence) in the US do not use Medicare or Medicaid, and treat it like a piggy bank to mine for funds for military projects, immigration tracking, and projects that will funnel that money into their pockets via their contracting companies, analytics companies, etc.

      4. MissElizaTudor*

        Universal health care is not synonymous with single payer. There are other ways to achieve it, and countries that have a solid mix of a variety of public and private can achieve universal health care with good outcomes.

      5. delta*

        I think it will suck because the US healthcare system is so broken. Universal healthcare won’t work when you have employers holding all the healthcare strings, or insurance companies that can choose to change premiums and deductabes and charge significantly more that cost, or pharmaceutical companies that can advertise prescriptions on TV and arbitrarily change prices just to make more money. Your whole system needs a hard reset.

    7. Vax’ildan is my disaster bicon*

      Both universal healthcare and universal basic income so that people have more flexibility to do meaningful work that may not be highly paid!

      1. Tired social worker*

        This is what I’ve been shouting from the rooftops!!! We need to change the way we think about work in general.

    8. Phony Genius*

      One of my doctors has said that if universal health care ever becomes a thing in the US, he’ll retire early. He knows that the reimbursements will be too low to survive, and Congress would probably legislate them even lower periodically so that they can offer “tax cuts” to voters.

      1. ThisIsIt*

        California is talking about doubling everyone’s taxes to provide universal health care.
        Which will drive doctors out of state.
        The rich will leave the state, because they can afford to go anywhere.
        Poor will be stuck paying double their current taxes and having no doctors.

        1. Autumnheart*

          No it won’t. And who cares where the rich go? Their money isn’t circulating in the economy. The vast, vast majority of it isn’t even kept in the country, it’s in off-shore tax shelters. The people who drive the economy are the 330 million people who live and work here, not the 500 people who have 60% of the wealth.

          1. ThisIsIt*

            Assembly Constitutional Amendment 11 was introduced last week in the California Legislature to enact significant tax increases to fund universal single-payer health care coverage in California, the Globe reported.

            Single payer is a universal state-run healthcare system financed by taxpayers, that covers the costs of healthcare for all residents by a single public system.

            Also last week, Assembly Bill 1400, the “Guaranteed Health Care for All” state-run healthcare bill, which has been kicking around the Assembly for several years now, was heard and passed in the Assembly Rules Committee, but not without some strong debate and some would say, rule breaking, or at least blurred lines enough to be a highly dubious passage.

            The Tax Foundation reports “this will increase taxes by $12,250 per household, roughly doubling the state’s already high tax collections, to fund a first-in-the-nation single-payer health-care system.”

            Previous statewide single payer healthcare proposals elicited estimates of more than $400 billion to implement. The entire 2022-23 state budget proposal is $286 billion.

            1. Holey Hobby*

              This is a cut and paste from a PAC-created conservative “news” website. At least cite your sources and attribute your quotes.

              1. pancakes*

                Thank you for checking on that. On some level I find it heartening that people making these arguments are invariably relying on shoddy sources and amateurish scare tactics. It is abundantly clear from reliable and conscientious sources, and has been for years, that the US spends far, far more money on healthcare — and for worse outcomes — than any comparable country.

        2. Willow*

          That is a completely inaccurate description of the CalCare plan. Most of the money would come from funds the federal government already provides. The rest would come from employers, who would pay much less than they do now for healthcare, a 1% payroll tax on those making over $49K (which would come out to much less than people’s current healthcare costs) and an additional tax on those making over $149K. No one would see their taxes double. Poor people wouldn’t see any increase. There are healthcare workers’ unions advocating for this plan. They have significant negotiating power and the plan is designed so that reimbursements cover the actual cost of providing medical services.

          1. Mannequin*

            I’m in CA, I’m poor, and I honestly wouldn’t even CARE if they raised taxes to pay for universal healthcare because that’s the kind of stuff I *want* my taxes going for.

        3. Tea*

          HAHAHA, what?

          As a lifelong Californian, who the fuck cares? We have rich people coming out of our ears here, we have other states advertising that the grass is greener on billboards all over trying to lure away some of the wealthy people living here. Do you think a rich surgeon enjoying the various luxuries and amenities made available to them by living in idk, Beverly Hills is going to find life in another state so much more appetizing? I kind of doubt it – otherwise our overpriced and overheated housing market would have long since cooled the hell down.

          1. Mannequin*

            When I briefly moved OUT of California, renting a U-haul was *dirt cheap*- because so many people move to CA, in droves, that there is always a huge surplus of them here, ready to drive away.

            But when I wanted to move back? That same van cost an arm & a leg, because…so many people move to CA, in droves, that there is always a huge surplus of them here, that never get driven back OUT of CA because so few people LEAVE.

      2. Artemesia*

        And yet French doctors do well, have homes, drive nice cars etc — and everyone gets better care than most people get here.

        1. Tired social worker*

          This is so lost on people. People hear “government funded single payer” and immediately assume that means taking Medicare/Medicaid *as they currently exist* and applying it everywhere, to everyone. It’s part of why I think “Medicare for All” was a poor choice of name for a proposed single-payer plan. It enables a severe lack of imagination as to how we would construct a better system from the root, instead of transplanting a diseased sapling from an already-rotting tree.

      3. NoGaslighting*

        There were plenty of doctors in the UK who said the same thing when the NHS was introduced.

        Or in Australia in the 1980s when its Medicare model was introduced.

        And yet the health care systems survived, service is incomparably better, and doctors still earn high incomes (which they should).

    9. AnonInCanada*

      Be careful what you wish for. Many Canadian provinces also cap fees for services, thus many private practices also have to deal with being unable to fairly pay staff, run fewer hours, or being unable/unwilling to accept new patients. It’s been an ongoing problem in Ontario for decades, and only now (likely due to the pandemic) is some of this being addressed. But not all of it. Sure, universal healthcare beats the alternative, but the proverbial grass isn’t always greener on this side of the fence.

      1. Ex-Teacher*

        >Sure, universal healthcare beats the alternative, but the proverbial grass isn’t always greener on this side of the fence.

        I’d argue that if universal care beats what we have now, then the grass is literally greener. It doesn’t have to be perfect to be better.

        1. Caramel & Cheddar*

          Fellow Canadian, and yes, it’s absolutely greener and it’s weird when we pretend otherwise despite watching our American friends get bankrupted on the regular by the system they have.

          1. Artemesia*

            when my Canadian friend had a baby with a serious heart defect she told me ‘All we had to worry about was Charlie, we didn’t have to worry we were going to lose our house.’ Charlie got the surgery and is now a grown man with a family of his own.

          2. Just @ me next time*

            The Canadian system definitely does better than the American one at preventing people from going into debt over their basic healthcare needs, which is good! But it also absolutely does not solve the challenges of staffing a clinic. I don’t know what province you are in, but BC is an absolute clustercuss.

            1. Caramel & Cheddar*

              I’m in Ontario; it can be hard to find a family doctor, absolutely. But a lot of that has to do with people not wanting to be GPs as well; there aren’t enough to go round regardless of how much clinic staff might be paid.

              1. Just @ me next time*

                What I’ve heard from doctors, at least in BC, is that the reason they don’t want to be GPs is because it doesn’t pay enough to be worth it. Obviously there are some doctors who chose specializations because they’re super into a particular type of medicine. But it sounds like we’d have more GPs if the compensation for them was on par with the other branches of medicine. We also have a lot of GPs here who end up leaving the province to practice elsewhere for better pay. Two GPs in my city just announced they’re closing their family practices and switching to private telehealth in the U.S.

          3. Mannequin*

            I mean, I literally DID go through a bankruptcy to discharge 10’s of thousands in medical debt that I acquired from living in the US with a serious/potentially life threatening chronic illness + absolutely no way whatsoever to get medical insurance + absolutely no way whatsoever to afford the $1000/mo (in 30 years ago money) medications that would 100% have kept me from needing to go the ER to prevent DEATH every single time I got so much as a cold, so living in a system where I wouldn’t have to have worried about that for so many years wouldn’t just be “grass is greener”, it would have been UTOPIA to me, even if it was flawed.

    10. Xantar*

      It’s not quite as simple as just implementing a universal healthcare system. And people who say that a Medicare for all system would lead to underpaying providers are also not quite correct. There’s a reason why people spend entire careers studying this stuff and writing whole papers on it.

      I can’t cover everything, but here are some of the factors going on:

      Medicare and Medicaid do indeed reimburse too little for services. Would that be true if private insurance was abolished and they were the only game in town? Evidence says…maybe. It also depends on how much Congress is willing to fund the programs.

      But also, universal healthcare would mean that people would see a doctor as soon as something is wrong instead of waiting until it gets much worse because they are afraid of paying medical bills. It would mean that Emergency Departments (one of the most expensive ways to get healthcare) wouldn’t see so many uninsured people.

      But also also, you have to address the issue that medical schools artificially constrain the number of students they admit which allows them to charge super high tuition.

      And also also also even systems with universal health care are getting more expensive because modern medicine is able to do more things. Ten years ago, certain kinds of cancer were a death sentence, and therefore treatment for them was not that expensive because there just wasn’t anything you could do. Now there are effective treatments available and most would consider that to be a good thing, but it also means more money. If you’re getting charged more for basic procedures, that’s partially because you’re helping to pay for someone else’s really expensive, life-saving treatment that didn’t use to be available.

      And on and on and on.

      I am absolutely in favor of a universal healthcare system of some kind, but it’s not a magic bullet. Nothing is. We probably need at least six different reforms in many different fields.

      1. Artemesia*

        Yeah the whole system needs to be changed. One factor would be supporting medical students so they can become doctors without high debt. Of course change is not simple but Germans do it better and the French in an entirely different way do it better. The UK’s failing system is a result of not putting adequate resources into it. We could be spending much less per capita than we are now in the US but health care is always costly and the quality of universal care depends on making sure it is adequately resourced. We are spending the money now but now getting the quality or accessibility of care.

      2. Ooff*

        Just want to say I appreciate this balanced perspective. You raised some things I hadn’t thought of. Thanks Xantar.

      3. pancakes*

        This theory of costs going up due to expensive tech doesn’t quite square with a study of NHS costs between 2008 – 2017 I’m looking at. One thing the researchers point toward: “Evidence on the relationship between new technologies and healthcare expenditure is mixed, but the fall in drug costs could reflect low generic prices, and the use of health technology assessment or commercial arrangements to inform pricing of new medicines.” I think what they’re getting at is that one of the reasons the most expensive meds, such as chemo drugs, are as expensive as they are is that pharmaceutical companies are keenly aware of how many people need them. There are ways to curb pharmaceutical profits, but when policy-makers favor privatization and profit-making, those aren’t on the table.

        The study is titled, “Trends in and drivers of healthcare expenditure in the English NHS: a retrospective analysis.”

      4. Green Beans*

        And a big part of why healthcare advances happen is because the USA’s healthcare system allows pharma & biotech companies to taken wildly expensive risks (and to fund academic research when government won’t, but that’s another discussion.)

        If you have a treatable and common disease, universal healthcare is likely to be the best option (and that’s most people.) If you have a rare or untreatable disease (or both), the USA’s healthcare system is playing in your favor. Other countries do good biomedical research, but nothing compares to the powerhouse that is the US system.

        1. pancakes*

          I have lymphedema as a result of having been treated for breast cancer, including having had some of my lymph nodes removed. It’s quite common, I’ll have it for the rest of my life (in other words, untreatable), and my insurance doesn’t cover the compression garments I need for it at all, nor adequate sessions with lymphedema PTs. That isn’t just my plan, it’s everyone’s — have a look at lymphedematreatmentact dot org for more info. I really, really do not appreciate being told that the US healthcare system is somehow “playing in my favor.” And in a broader sense, even if I was able to get good care for all of my own health issues through private insurance, I hate living in a country where people die in their 20s from rationing their insulin, and where some people have to use the ER for any healthcare they need (thereby not getting any preventative care at all), etc. Maybe you’re at ease with that, that’s your choice of course, but those of us who see the barbarism in it are not. I would like to hear more about your workings for “most people” vs. the number of people with conditions that are rare, untreatable, or both that you are comfortable leaving to die needlessly early deaths, and leaving in untreated pain or discomfort. I can’t make out what your threshold is.

    11. Jam Today*

      Medicare pays less than commercial insurance, and has much stricter cost-controls in place.

      The real answer is to upend the RVU system which (at a very simplistic level) assigns the “value” of services by type and specialty. Primary care and internal med make the *least* while specialty care is reimbursed at an extremely high rate. If you want to make money in medicine, go into Orthopedics. (Or cosmetic derm, which is a cash business.) If you want to be broke but retain your soul, be a Family Med doctor. Universal healthcare is great, I support it, but it is not a solution to *reimbursement*, its a solution to lack of coverage.

      Every country with universal healthcare (which is not single payer, by the way, and which is most countries) has cost control measures, and countries with single-payer have set rates that they pay physicians. If those rates don’t keep up with inflation and COLA expectations guess what? You wind up losing doctors and nurses to the exact same burnout issues, as the cost to deliver care goes up while their salary remains flat. The NHS is under extreme strain right now, and his hemorrhaging clinicians due to overwork for inadequate pay; its not a panacaea.

      1. Nightengale*

        Specifically specialists who do procedures
        RVUs favor volume (more visits per unit of time) and procedures

        I’m a developmental pediatrician – we take care of children with autism, ADHD and other developmental disabilities. We don’t do procedures the way many other specialists like cardiology or GI do. We might spend 45 minutes talking about medication, reviewing a child’s school program and therapies, trouble-shooting sleep or behavioral challenges at home, talking with a kid about their diagnoses.. So we see fewer kids in a day than primary care. Fewer patients = fewer RVUs. Where I trained, we shared a floor with the pediatric cardiology department and the running joke was that our department was basically subsidized by theirs.

      2. Nightengale*

        RVUs mostly benefit specialists who do procedures.

        I’m a developmental pediatrician – we take care of children with ADHD, autism and other developmental disabilities. I might spend 45 minutes with a patient and family discussing medications, troubleshooting behavior or sleep challenges, reviewing school and therapy programs, explaining a diagnosis to a teen. So I see far fewer patients in a day than primary care does. Fewer patients = fewer RVUs. And unlike say GI or cardiology, we don’t do procedures, which are coded separately from visits and add to the RVU count. (Where I trained, our department shared a floor with pediatric cardiology and we all joked that their department pretty much subsidized ours)

        (There is also only reimbursement for time actually spent with a patient, not the hour I spent last week on the phone with a pharmacy and insurance trying to find out why a medication that was formulary and authorized wouldn’t go through. Yes I have office staff. No, none of them could have made these calls instead)

    12. Boof*

      Not sure if you mean single payer ie medicaid/medicare vs government provided ie VA, but there’s pros and cons to every approach; neither of which will likely help out the small practices here. Medicaid/medicare is usually the bar by which reimbursement rates are set and is certainly are part of the diminishing returns problem.

      1. Artemesia*

        And yet we are pouring twice as much into medical care as our nearest developed nation does and covering much less of the population. The money is there. The problem is that it is going to obscene profits for some and ridiculous salaries for others while starving those who do the most work to help people keep healthy.

        1. Boof*

          I’m really not advocating that our current system should stay as it is / that there isn’t a way to do universal healthcare that will be better (I’m a doc and I’d actually really like to be able to care for everyone who needs it without causing them financial stress, yes!).
          But I feel like “universal health care” is being put forward as a panacea here when it isn’t; it depends A LOT on how it is executed. I actually like the idea of expanding something like the VA into something like the NHS to provide a basic standard of care for everyone. It’s good for long term diseases and I think pretty cost effective. It’s not as flexible as most non-government systems, though, usually slow, and usually doesn’t have cutting edge things, so there’s a role for insurance or something and private providers for things that need something more.

          1. pancakes*

            Of course much depends on how it’s executed, and who better to inform that process than doctors? Yet there are numerous doctors in these comments who seem to see this as personal business problem rather than a societal problem, where the solution is early retirement or refusing to take insurance rather than helping craft a solution that improves the situation for all of us. I see that the AMA has an info page with lots of interesting-looking links about their efforts to raise Medicaid rates, but that’s something I sought out on my own out of curiosity, not something I see doctors taking to the streets to protest.

    13. Who the eff is Hank?*

      Yes! I am a medical provider in a small practice facing the same issues as OP. Yes yes yes a million times yes, we need universal healthcare.

    14. Artemesia*

      This. American medical care costs per capita what it does in France which has care for all and provides equal if not superior care. The difference is in the cost. There are no insurance companies making billions off the top, doctors make very high salaries BUT not the kinds of money that US specialists take home. Pharma doesn’t drive patients into bankruptcy to provide great investment yields and multi million salaries. Hospital executives don’t make millions. The US system is deeply broken and is designed to vacuum money from the patient’s pockets as well as provide enormous profits for investors; even with insurance middle class families often have their wealthy entirely drained when faced with serious injury or major illness. Bankruptcy is often caused by medical bills WITH insurance. No other developed country has a system where if you get sick and lose your job you don’t get health care or are entirely stripped of your wealth. It can’t be fixed doctor’s office by office.

      1. Not So NewReader*

        ANNND. People like me who will never ever recoup a sense of financial security. after paying off my late husband’s medical bills. It’s the gift that keeps on giving. They don’t want to think about how financial stress tears down health. They don’t even consider the aftermath of what happens to the patient’s surviving family
        members. No different than a chain reaction, the suffering of one individual begets the suffering of the individuals around them.

        Some how my father managed to pay off a quarter of a million in medical debt in the early 80s. He was never the same after that. He lived hand-to-mouth for the next 10 years and then died at age 72. He had been working since age 7, wth. That would be around $750k today. I wonder how many people today could shell out $750k and not notice it was missing. I firmly believe he died from the stress inflicted on him by our so-called medical system.

    15. Just @ me next time*

      I hate to tell you this, but universal healthcare does not solve the fee-for-service problem. I live in British Columbia, Canada, where we theoretically have free healthcare. However, we have tens of thousands of people without access to a primary care physician because family doctors cannot afford to practice here. Family doctors can bill the province just over $30 (CAD) per appointment. Out of that, they not only have to pay themselves, but also all the overhead for running a clinic. Cost of living is already very high in all of the province’s large population centres, plus most doctors have massive student loans from their education. So basically, being a family doctor in my province is not worth it. Most of the new doctors we train move out of province or choose to pursue anything but family medicine.

      The knock-on effect of having tens of thousands of people without family doctors is that walk-in clinics are literally at capacity before they are even open each morning. People who can’t get into a walk-in clinic end up having to go to the emergency room at the hospital, where they wait for hours to get treated for something that wasn’t actually an emergency. Or, people choose not to go to the doctor because of the hassle and get even sicker.

      I am 100% in support of free, universal access to health care. But the issues mentioned in this letter are not unique to America’s for-profit model.

    16. The Dogman*

      Yeah, even after a decade of purposeful under-investment, and conservative corruption and theft, our NHS is still way better than the US system of poverty creating madness!

    17. The teapots are on fire*

      I’d love to see it, and if we do see it, I think we’ll all be very unhappy unless the amount of money we’re collectively spending on premiums now goes right into that healthcare system. Medicare and Medicaid under-reimburse because they have very low funding per patient, and we can’t fund the whole system on that level sustainably.

    18. JelloStapler*

      Exactly, but people will say the government will pay back even less. If we had to stay with what we have (which sucks) I would love to see insurance companies being required to be non-profit with caps on malpractice.

    19. Koala dreams*

      Universal healthcare can have similar problems, especially if the government prioritizes tax cuts over health outcomes. There is also the debate over “new public management” that has been going on since the 1980s. I’m all for universal healthcare, but in many places it’s far from the utopia I see from US commenters online.

      There are some interesting videos online from US expats describing health systems in their new countries. Search for “An American explains health care in (country)” if you are interested in getting a more nuanced view of the issue.

      1. pancakes*

        I think it’s great that they are protesting, though. I would like to see US doctors turn out for protest the way immigration lawyers mobilized at airports in response to our previous president’s refugee ban in 2017. Systemic harm to their profession and their patients is worth protesting.

    20. Sasha*

      From a patient’s perspective, absolutely. From a provider reimbursement perspective, having a single national monopoly employer does not lead to high pay.

      NHS staff pay was frozen for ten years, only being unfrozen follow my the pandemic. Residents had a 20% pay cut imposed (following unsuccessful strike action). Basic pay is £30-50k.

      Staff physicians (and bear in mind our training is much longer, I became a staff physician aged 40), start on £80k, rising to a cap of £110k.

      Nursing salaries start at £25k, rising to £60k for a nurse consultant/senior nursing manager. The average nurse is on £35-40k.

    21. Media Monkey*

      i can (unfortunately) give you a direct comparison of this one.

      i’m in the UK. my dad lived in the US and was diagnosed with pancreatic cancer just after Medicare came in (thankfully). He received a great quality of care in a lovely single room in a hospital that you would have been happy to stay in as a hotel. Due to his experience of my step mum having well over a million dollars in bills when she had a brain tumour (just pre Medicare) he spent the entire time completely stressed and refusing to speak to doctors becuase he thought they were going to bill him for it (on mym step mum’s bill there were multiple 15 minute line items for a doctor sticking his head around the door to ask how she was and then billing for it at $150 for example).

      my mum is currently in an NHS hospital and has just also been diagnosed with pancreatic cancer. She is on a ward with 5 other people in a much less fancy hospital with amazing doctors and nurses who aren’t being paid a fortune but really care about patients – it’s absolutely a vocation. She is also getting amazing care. And she hasn’t had to think for a second how much it costs. of course she has paid taxes and national insurance all her working life.

      i know which one i would choose (and it’s not the fancy single room).

    22. Parenthesis Dude*

      You do realize that private insurance pays significantly more than Medicare/Medicaid and is the only thing keeping most providers in business?

      1. pancakes*

        Do you realize there are things the medical profession can do to increase Medicare and Medicaid fees? The AMA has a working group I’ll link to in a separate reply.

    23. PieAdmin*

      The problem is, certain people (too many) will insist that these kinds of problems are somehow caused or made worse by universal healthcare, or that private practices are going out of business because doctors can’t make enough money, or some other bologna that convinces them that universal healthcare is bad. Until the majority understands and gets with the program universal healthcare is never going to happen

    24. Rex's Mom*

      For sure. In that time when the practitioner said their reimbursements have gone down by 20%, my annual premiums have tripled. The insurance companies win. No one else.

  1. Lucious*

    If there is a positive takeaway , this may count as such: honesty is the best policy here. Be the employer / leader who tells the truth upfront to the candidates.

    Don’t be the one who plays games and misleads people to avoid a tough discussion about the economic realities of your specific firm and industry.

  2. Nethwen*

    What can the healthcare consumer do to help, on a practical level?

    I mean, writing your representatives and all that has its place, but for the medical practitioner next door, how can the average person help them stay in business and provide quality care?

      1. ElizabethJane*

        After you’ve gone through them line by line and argued off every single ridiculous charge.

      2. The Dogman*

        Better idea: Compel the corrupt scumbags you call politicians over there to stop being corrupted by pharma and other giant businesses and instead introduce a national tax payer funded healthcare system.

        And really withholding all payments to the medical industry for a month would ruin them and force the creation of an NHS, so my advice is to team up and stop paying.

        If the thieves at the top of the pharma corporations can’t get paid they will find some other sector of the economy to be parasites off the labour of poor people.

      3. Beeker*

        Be very familiar with your insurance policy: don’t go to out of network doctors; don’t get non-covered service; have all of your CORRECT info available EVERY time you go to the doctor; pay your copay at time of service; keep your appointments and be on time.

      4. Beth*

        I mean, sure, dealing with people who can’t or won’t pay bills doesn’t help. But medical billing seems to charge the patient more every year–how often, nowadays, do we see gofundme’s for someone’s insulin, or a news story about how a person with good insurance ended up losing their house and going bankrupt due to medical bills?–and yet this letter is telling us that the amount of money that goes to the medical provider is dropping every year. I don’t think people paying promptly will solve this one. The problem is that what insurance companies will pay out keeps dropping, even as they also keep charging us more and keep pushing higher deductibles on us. It’s a systemic problem.

      1. Texas*

        Except collective action is made up of individuals taking action together, so if all individuals do nothing no collective action will occur.

    1. Librarian of SHIELD*

      I feel like the only real option is to lobby for more regulation of insurance companies. Call/write to your representatives, find organizations that are working toward affordable health care goals and donate or volunteer if you’re able.

    2. Former Gifted Kid*

      Unfortunately, individual and consumer action doesn’t do anything. Solving issues like this is adjacent to what I do for work. Even writing to your representative is an individual action. It is community level action that actually affects change. Are you involved in any sort of community organization? By community organization, I mean anything like a religious place of worship, a service club, a PTA, a business association, a neighborhood association, etc. If you are, in your organization, find out how these issues are affecting both medical practitioners and health care seekers in your community. Find out if there is anything that you can do to alleviate those issues on a local level. Then also advocate as an organization to change things on a state or national level.

      We would all love if a simple action we could do on our own would make a difference, but I think we all inherently know that these problems are bigger than ourselves. It takes a bigger effort to solve these problems.

    3. MD*

      Be nice to our staff, please. Like, super super nice. If you’re scared or frustrated we totally understand, but there’s a world of difference between appropriately expressing that and yelling at the people who are trying to help you. If someone made a difference or something went well make sure they know about it. Most offices have a written praise system- these mean the world to us.

    4. Cold Fish*

      I don’t know how much help but just this morning I was listening to Factually with Adam Conover and the latest episode was an interview with a non-profit called RIP Medical Debt. Very interesting if you want to take a listen. May not help with this situation but it may be a good step for the patients.
      (Note: I have just listened to the podcast and have had no time to look further into RIP Medical Debt so this is in no way an endorsement but I found the similar topics very intriguing)

      1. MissElizaTudor*

        I donate to that org. It’s a good one! They were inspired by Occupy Wall Street actions to help people with medical debt, and they buy up medical debt for pennies on the dollar and then forgive it so people don’t have to pay.

    5. Jean*

      Be polite to office staff. Show up on time for your appointment. If you can’t make your appointment, call at least 24 hours before to inform them. Don’t expect your provider to be a magician or miracle worker. Comply with your treatment plan. There isn’t anything individual consumers can do about the financial wreckage of the system.

    6. Xenia*

      Ask about out-of-pocket/private pay discounts. Sometimes if you pay direct and out of pocket, you can get substantial discounts and the money is going directly to the medical practitioner rather than through your insurance company, and you’re not bound by insurance restrictions. Especially if you know you’ll be having a procedure coming up in the near future and can schedule ahead of time

  3. PayHealthcareWorkers*

    This is a key point. I work with mental health and substance use providers, and it’s even worse in this part of healthcare. In most of healthcare, commercial insurance pays higher rates and essentially subsidizes those on Medicaid. In mental health and substance use, commercial insurance pays only 50-60% of the Medicaid rate, and Medicaid generally only covers 80% of providers costs. The providers I work with serve individuals with serious mental illness and/or substance use disorders – they absolutely cannot shift to a private pay model.

    These providers are so short staffed that they are closing intakes, opening waitlists, and closing programs. They can neither recruit or retain a sufficient workforce. This isn’t an obscure issue – this is why kids are going to the ER at alarming rates, why people who are in crisis can’t get care. Overdose rates are skyrocketing and yet I know many programs that have empty treatment slots that they can’t admit anyone into because they don’t have the staff to care for additional clients. We need our government leaders to step up and provide significant funding to solve this crisis, and I’m just not seeing that happen.

    1. Dana*

      Yes. This. I also work in mental health care and substance abuse treatment and this is a significant issue. Reimbursement rates for home-based mental health care for the most at risk children and families in our community have not had a rate increase in Virginia in 17 years. With inflation, that result in a huge net decrease in the value of the reimbursement. In that same time, they have tightened the restrictions for who can provide the service and mandated that many of the services must be completed by individuals with a masters degree. I’m having trouble staffing because people working at Chick-fil-A make more money when you consider the fact that our staff have to drive to their clients’ homes. And this is not by choice – I literally pay the maximum amount I can pay and still keep the lights on and feed my own kids. Mental health is undervalued and reimbursement rates reflect that to a disturbing degree. It’s not as simple as just giving people more money. We don’t have it to give.

    2. The Dogman*

      “We need our government leaders to step up and provide significant funding to solve this crisis, and I’m just not seeing that happen.”

      That is cos you need to get together with others and force the politicians (or politican’ts really) to sort out an NHS and stop being corrupted by the pharma corps.

      1. cranky*

        Sure, I’ll just attempt to force my politicians to do something they’re strongly opposed to.
        That literally isn’t an actionable item in the short or midterm for individuals. Even in states that are better about funding than Mississippi or Alabama, an individual in the short term isn’t able to do that. I can’t storm the freaking statehouse and demand change and actually have anything good happen.

        1. pancakes*

          No one is suggesting that you storm a statehouse. It would help tremendously if people in states with politicians who are “strongly opposed” to improving healthcare reconsidered whether they’re truly well-served by centering their elections around guns and abortion. These politicians aren’t falling out of the sky as blamelessly as weather.

      2. PayHealthcareWorkers*

        The US does need universal healthcare, but that’s not a panacea on this issue. Mental health and substance use care is overwhelmingly paid for by public health insurance in the US (particularly Medicaid). The providers I work with are all licensed and regulated by the government, and are required to provide certain levels of care, have certain staffing requirements, etc.

        But there is massive stigma against people with serious mental illness and people who use drugs, so we aren’t willing to pay adequately for that care, and many people think these individuals should just be incarcerated. It’s not just about national healthcare when we are happy to pay $100k a year to incarcerate someone but won’t pay the $50k per year it would take for them to be treated in the community.

    3. AMT*

      This is why I went into private practice, and why I’m no longer part of insurance networks at my practice. It’s just not possible to make a decent living working in community mental health or accepting insurance as a private practitioner. These roles are invariably filled by a revolving door of overworked new grads, which isn’t fair to anyone involved. When you can make 2–3+ times what you made in community mental health as a private practitioner, the only reason to stay in community mental health is altruism, which doesn’t pay the bills. If insurance rates don’t increase, mental healthcare will continue to be inaccessible to anyone who doesn’t have excellent out-of-network benefits or cash to spare.

      The frustrating part is that whenever I say this, I get some variant of “aren’t you contributing to the problem by not taking insurance/charging ‘too much’/not working in the kinds of community mental health jobs that almost caused you to leave the field”? As though taking a massive hit to my quality of life in order to enable insurance companies to continue underpaying therapists was a solution!

  4. RosyGlasses*

    I felt this for LW2 as well, having worked in dental practices, and am now in a dental-industry adjacent role (which has capped revenue per client because they are small margin practices, so we run into a similar issue with employee compensation). People thing medical = money, and it can, but there is often a (large) gap between private practices and practices that aim to serve the public, which results in low reimbursements and very tight or negative margins.

    When I worked in dentistry, Medicaid reimbursed a cleaning at barely $20! $20! That barely covers the cost of supplies to complete the cleaning, much less covering the staffing and overhead costs.

    1. Cat Lover*

      Medicaid, whether state or commercial, is the WORST. My company had to drop a major commercial Medicaid plan because they paid so little it was insulting.

      1. RosyGlasses*

        Yeah – the folks that suffer are those that cannot afford to pay out of pocket and are locked in to their state medicaid plans. Between being treated like cattle because the only way practices can survive financially is volume, and treated “less than” because of the stigma of poverty and classism, it perpetuates structures of poverty and racism.

        1. Not So NewReader*

          Thank you! And this is why we are seeing more and more distrust building in some groups. But actually they are correct, you should trust those who can’t be trustworthy.

    2. Dentalman*

      As someone with a spouse in this field, I can echo people thinking they’re rolling in money and are just gouging them. Trust, he has hundreds of thousands in school loans to pay back as well as the roof over the practice’s head.

  5. Cat Lover*

    Yep. I work for a small heathecare company as well and COVID was brutal. We lost 75% of our patient base. And since Insurance takes SO much, it was hard to get back on our feet.

    Many doctor’s, like my moms, have gone to out of pocket/self pay only. Accepting insurance is just too expensive. My company has had to drop contracts of some major insurances due the losses (some insurance companies don’t pay enough per charge for providers to break even, much less make a profit). Other have been absorbed by but hospitals or large healthcare orgs.

    1. This is a name, I guess*

      I have okay health insurance, and I recently started seeing a doctor in a Direct Primary Care Practice for an additional $750/yr. I just feel like you need constant vigilence, unwavering self-advocacy, and perfect administrative skills in order to get adequate care in the US. Not having to use my insurance for most of medical care lessens the administrative burden on my life. I’m fortunate enough that I can take on the expense, but it sucks that I have to.

  6. nooneknowsme*

    This is why I am trying to get out of my current industry. I stumbled into working for a health insurance payor seven years ago as an escape from retail hell. The pay and work/life balance/schedule are an improvement for sure, but I struggle most days to be on board with the work that I do because of the state of the industry/health care. I want to help our practitioners but it’s all about the bottom line and there isn’t much I can do as a single peon in the system. There’s got to be a better way then for a handful of big systems to eventually own everything.

    1. Not So NewReader*

      As in any job we have to be able to sleep at night. If a job keeps us awake, there’s really no point.
      I find it ironic that the health care industry does not make a connection here.

  7. Anonforthis*

    My Dad’s a pediatrician and because of a state budget dispute the state delayed paying out Medicaid billings for months (to all doctors). So what was my Dad supposed to do, deny low income kids medical treatment? Of course he wouldn’t. He had to eat costs and ended up paying his nurses and scribes out of his own salary. My Dad’s an older doctor, close to retirement, so he had the margin to do it. But many of his colleagues are younger, with medical school debt and kids. And they were absolutely crushed. My sister was considering med school and my Dad had a frank talk with her about how rough it had been. And mind you, this was pre-COVID. COVID really destroyed billings for well visits and routine stuff that most pediatricians make most of their money on.

    It’s really bad out there.

    1. JohannaCabal*

      And people outside the medical field don’t realize how expensive med school is and the amount of debt that results.

      It’s understandable why most med students go into specialties instead of family/general practice.

      1. Anonforthis*

        It’s also a lot harder to get your med school paid for. My Dad and a lot of his colleagues basically traded a few years in the military for medical school being completely paid. Those programs are much less common and extremely hard to get into.

      2. Swingbattabatta*

        Cosigned. The medical school debt is crushing us and the insurance companies are squeezing the doctors and providers, which trickles down to short staffing and pressure to churn patients through the system.

    2. Summer Day*

      Yep- Family member is owner of a medical practice. He pays a locum to cover his patients one day a week. Even his good permanent locum doesn’t earn enough to cover their own wages. They want more $$ but he’s paying out of his own income already. To compensate the locum gets all school holidays off which will retain her but it’s tough out there!!

    3. Artemesia*

      When we were foster parents we could not find a single pediatrician who would see our kids who were on medicaid.

      1. Anonforthis*

        My Dad’s current waiting list is close to a year (he’s a developmentalist, so a specialist). He’s putting off retirement in part because of this. When he goes it’ll just get worse.

      2. This is a name, I guess*

        Guess which kind of insurance people with disabilities have? Guess who struggle to find necessary medical care?

        1. Anon4this*

          This is why I stay in a less than ideal marriage to someone with excellent health insurance rather than going on disability/medicare.

    4. Healthcare Manager*

      OP LW#2 Here – a LOT of it seems to come down to student loans when I talk to people. We only just instituted a student loan repayment program. I’m not going to deny the issues we have with privatized health insurance in any way, shape, or form, but coming out of school with $200,000 in debt means that you need a job that will cover not only your living expenses but also $600 in loan repayments each month – and I can’t offer that much thanks to the slim margins of our practice.

  8. hayling*

    The PT practice I used to go to closed a year ago. Medicare reimbursements for PT went down, and most PT has a high number of Medicare patients, so they couldn’t afford to keep the lights on. My PT moved to a hospital-based clinic and fortunately the care has been the same, but I imagine that’s not always the case.

    1. Cat Lover*

      I work for a PT practice- the Medicare reimbursement changes have been BRUTAL. We have been actively lobbying against the cuts.

      1. MAGC*

        I’ve never understood the way Medicare restricts PT, not just in total amount billed per year but also the “must be improving” metric. For a lot of older people, retaining physical ability _is_ an improvement over what they would have without PT, which would be to continue to lose that. It’s very short-sighted to curtail functionality that keeps people healthy and independent, as the costs down the road will increase without that functionality.

        But it does line up with U.S. medical practice, which is to have an ambulance at the bottom of the cliff instead of a fence at the top…

  9. notacompetition*

    This makes me want to scream. So over the past couple decades, insurance companies have been CHARGING MORE for premiums, copays, deductibles, etc., but LESS of that money is going to the actual health care workers WHO PROVIDE THE TREATMENT?!
    That literally makes no sense. That is an industry developed ONLY to extract profit. We need universal health care NOW.

    1. MissGirl*

      It’s not the private insurers; it’s the government set rates. We make negative money on Medicare/Medicaid but a small profit on private. That’s why this provider is only servicing private insurance.

      1. Double A*

        That’s not what this letter says: “Insurance rates haven’t budged in over a decade, or they’ve gone down.”

        1. MissElizaTudor*

          But Medicaid and Medicare pay much less than private insurers do. I’m sure private insurance is part of this phenomenon, but they aren’t the only part, and they do pay more than the non-private insurers.

      2. BuildMeUp*

        I didn’t read that as them only taking private insurance, but that they’re only taking patients who are paying them directly:

        we offer a service for which enough people can afford to pay out-of-pocket

    2. Meep*

      Sadly, the people who need health care the most (rural, uneducated, poverty-stricken swaths of America) are the ones who are least likely to vote for it.

      1. Starbuck*

        82% of the U.S. population lives in urban areas. It’s ridiculous that our system lets rural voters hold us hostage in this way.

        1. Meep*

          I don’t necessarily blame rural voters when 27% of the U.S. population doesn’t have reliable access to electricity. This means lower education rates, higher drug use, higher chances of criminality to survive, etc. And many of those without electricity are those rural voters. We need to stop with the nonsense of taking away money from underperforming schools and work on fixing the communities before we complain about rural voters “holding us hostage.”

          Besides, I have met plenty of urbanites who cut off their nose to spite their face. Trump voters come to mind.

        2. Meep*

          I don’t necessarily blame rural voters when 27% of the U.S. population doesn’t have reliable access to electricity. This means lower education rates, higher drug use, higher chances of criminality to survive, etc. And many of those without electricity are those rural voters. We need to stop with the nonsense of taking away money from underperforming schools and work on fixing the communities before we complain about rural voters “holding us hostage.”

          Besides, I have met plenty of urbanites who cut off their nose to spite their face. Go look at Scottsdale, AZ handled the pandemic. It is one of the richest suburbs in Arizona.

          1. Starbuck*

            Sure, you had mentioned ‘rural’ in your comment above so that’s what I was responding to.

            I’m not blaming rural voters themselves, but our system does overrepresent them electorally, that’s a fact.

            27% seems very high, I wasn’t able to find that myself online. I don’t doubt it’s a lot of people and that we have serious issues to fix, especially for tribal nations – but over a quarter of the U.S. population?

        3. Sindy*

          Who do you think grows your food and provides animal products such as eggs and milk? Do you think food comes from the grocery store? It doesn’t. It is provided by people who should not be talked down to as “hostage takers.”

          Talk about biting the hand that feeds. Good lord.

          1. JelloStapler*

            And they are taken advantage of too- by Monsanto, by Tyson. But so many do not want to ask for help because they see it as, and have been told that it means, they are weak or it’s a handout. Politicians prey on this. So many people who vote against fairer laws and policies and such will not because they think it is socialism or their candidate will help them. When in reality, the politicians really do not care about anything but what their lobbyists want.

          2. Captain Vegetable (Crunch Crunch Crunch)*

            A lot of farm work these days is done by people who can’t vote- visa workers and undocumented workers. Acting as if every person in a rural area is a farmer is quite the stretch.

          3. Starbuck*

            Oh, you missed this part in another comment I already made: I’m not blaming rural voters themselves, but our system does overrepresent them electorally, that’s a fact.

            I live in a rural farming community myself, so I have some idea of the importance of local food.

            I’m also talking about at the state/national level – states like Wyoming and West Virginia are given vastly more sway than their population merits. I’m just arguing for one person = one vote, you know?

            1. Boof*

              The whole point was to keep those sort of minority populations from being drowned out by a simple majority

              1. Starbuck*

                Well no, the point was actually to advantage wealthy white landowners and prevent the poor rabble from actually having much of a say. It’s an antiquated system that is no longer serving us well; see how particular individuals from, say, West Virginia, manage to hold back progress for the majority.

      2. nonegiven*

        You know, I’m not sure about that. OK expanded Medicaid by a very narrow margin, in a state that voted orange in a landslide. Enough of the poor, uneducated, poverty-stricken citizens in the rural areas turned out to be enough in combination with the votes coming from the cities to get it passed.

    3. WindmillArms*

      That was my takeaway too! Patients are paying MORE and healthcare workers are receiving LESS. That means the entity in between them (US health insurers) are taking far too big of a cut.

      1. Sloanicota*

        Yeah, I don’t understand it. I pay a fortune for private insurance that I barely use, and that has a high deductible on top of what I already pay per month. I have literally not been to the doctor in years, so this is thousands of dollars in free money for the insurance company in return for mailing me a new card once a year. Why can we not afford to pay reasonable rates to medical providers?

      2. Det. Charles Boyle*

        Yes, the insurance companies and their executive-level employees are making a huge profit. If we eliminated them, all that money could go to actually providing healthcare and paying providers.

        1. ChristineW*

          There’s also the issue that the insurance companies have huge marketing costs: agents, call centers, glossy mailings, ads on TV and the internet, etc., aren’t cheap. The companies spend vast sums on things that have limited or no net benefit to the consumer.

          (This past Medicare season, my father-in-law was deluged with mail and phone calls trying to get him to sign up for a “better” Medicare Advantage plan; every single day the mailman brought new letters and pamphlets and flyers about how good Plan XYZ was and why he should sign up with them. Sadly, FIL died almost three years ago; he has no need for any of these plans ever again, and I cannot convince these companies to *stop* sending mail and calling, since it is quite simply a waste. I thought the 2019 season was an aberration and they were just a little slow updating their databases, but two further seasons have passed with little if any change in the volume of mail. [Yes, Medicare itself is well aware of his passing.])

          1. Not So NewReader*

            I dunno if this is still doable now. Years ago I was getting mail from a bank regarding a family members account. Since I felt that I should not be receiving this mail any more (Long Story), I tried to stop it. And the mail just kept coming. So after several attempts I was able to fill out a form blocking that address from sending me mail. I asked at the post office and they helped me.
            This may or may not help in your setting.

    4. Hippo-nony-potomus*

      I suggest learning a lot more about the way our government has systematically screwed up our health care system before asking for more government interference. I’m not a “free market uber alles” person, but you should have a passing understanding of how Medicaid shifts costs to private insurers, administrative overhead raises costs while reducing payments to actual care providers, and obscure billing rules have screwed up our system.

      1. catsamillion*

        I mean, do you think the healthcare industry is gonna fix itself? The free market has been able to choose to do that this whole time, and they certainly have the $$$ to lobby for a fix. I don’t really need a passing understanding of any of this to know that it’s screwed up and we need to fix it.

        1. Starbuck*

          It’s also pretty clear when you can see all the countries out there that are doing better while spending less money. Obviously there are better options we could try!

    5. UHC now*

      Insurance rates are not going up *enough* to keep up with rising costs of health care which is what not enough people are focusing on. Universal health care will take decades to fix this – I’m in favor of it, but, don’t trust our politicians to get it right. Medical care is only getting more and more specialized and more and more complicated and more and more expensive on all sides. Everyone is feeling the pinch – patients and providers alike.

      1. Dust Bunny*

        Okay, but where is this money going that is the rising cost of healthcare? People aren’t getting paid out of it, apparently. Drug companies seem to be charging more than enough to cover themselves. Insurance is doing all it can to not pay for it.

        1. ABK*

          UHG profits increased 12% in 2021, pharma profits are quite large, provider groups have a fair amount of admin bloat, EMRs are a requirement now, certain types of physician are making BANK, there’s a lot of fraud, abuse & lawsuits which soak up costs. Basically, no entity within the healthcare ecosystem actually wants to lower costs for patients/consumers. We need the government to negotiate on our behalf…but then people complain that medicare/medicaid reimbursement is too low (and the federal government isn’t allowed to negotiate drug prices).

          1. New But Not New*

            The Feds DO negotiate drug prices for veterans. I was a contracting officer that did this, and we were BRUTAL. Vets got rock bottom prices, and the VA mail order pharmacy operation was quite a model of efficiency. Why this isn’t done for Medicare/Medicaid, I’ll never understand.

        2. This is a name, I guess*

          Also, the American healthcare system subsidizes the prices of drugs and medical devices in other wealthy countries. Because counties with socialized medicine have huge government-level bargaining power and price regulations, that artificial hip manufacturer charges Belgians $2000 and Americans $20,000 for the same product. Americans are overcharged to ensure that Belgians (and others) receive a fair price. If the US had socialized healthcare, it would cut corporate profits for things like artificial hips (which is a good thing) and would force medical device and pharma companies to have reasonable expectations for profits.

        3. Not So NewReader*

          Insurance is a pyramid scheme. They have to take in more money than they give out. I remember in the 70’s teachers laughing and saying, “You’re betting that you are going to get really sick and the insurance company is betting that you won’t.”

      2. notacompetition*

        “I’m in favor of it, but, don’t trust our politicians to get it right.”

        So, I think this is also a problem. I’m with you on this, but I’d MUCH rather they/we TRY to get it right than just not doing anything. I’d rather actually start innovating and risk making a mistake instead of bankrupting tons of citizens through the skyrocketing cost of care.

    6. a thought*

      Health insurers are capped at the amount of profit they can take (by federal regulation) – I think the mechanism here is that people go to more appointments (e.g., the number of appointments goes up) so this ends up costing more, while each individual appointment is paid out less.

  10. Spamanda*

    It’s also worth pointing out (to folks who are not in healthcare) that without a licensed provider *on site* there are often things you cannot do or services you cannot provide. Offering more PTO is great, but if you don’t have a clinician for a week it can be very complicated to keep your doors open and have normal appointments. The whole thing is a mess.

    1. MissElizaTudor*

      This is one area where there can be improvement – scope of practice reform. Letting more health care providers do more things without having to be supervised by a physician is a good idea. Obviously if all of the health care providers are out, the office staff can’t do much, but if more kinds of providers could do more, that would help in many situations.

  11. ABK*

    In this letter and the previous, I’m curious, are physicians in the practice feeling the pinch as well? Or are they exempt from payroll challenges?

    I”ll also note, in places with single-payer insurance, physicians aren’t paid as well as they are here. the ROI on medical school in the US is VERY, VERY strong.

      1. Sloanicota*

        Yes, my friends in the UK who became junior doctors don’t have anything like the US medical school debt. They are not well compensated but their education was, I believe, either free or very low cost. I agree though there would be a crunch if we tried to shift our current system – we’d have to forgive the educational debt of a generation of doctors first (which I would support, to be clear).

        1. ABK*

          ROI models take into account training costs. SO lower education costs early in career, but lower salaries for their entire careers vs the US model which has very high training costs early in career but very high salaries throughout their careers. Similarly, if you think about each profession in the US taking out loans equal their first year salary, an engineer might take out 80K in loans, an MBA 100K in loans, a physician 200K in loans. Its a lot of money, but it’s in proportion to their salaries (ROUGHLY, just to show how a lot of medical school debt could be proportional to that of other industries)

          1. Det. Charles Boyle*

            And the 200K in medical school debt is ON TOP of undergraduate debt, so the total could be a lot more. That’s a heavy burden for a young physician.

            1. ABK*

              yeah, it could be, but my point is that what really matters isn’t the number, but the ratio of debt : lifetime earnings

              1. The OG Sleepless*

                Check out veterinary medicine if you want to be well and truly shocked by a debt to income ratio.

            2. Artemesia*

              European doctors don’t have that sort of debt; medical school starts earlier and is subsidized to a much greater extend. Doctors are well paid and live well, but they are not paid the way some US specialists are paid.

    1. buried in med school loans with no end in sight*

      Physicians are absolutely feeling it, and I don’t know when is the last year you looked at solid economic data on the pay for private practice physicians versus rising medical school debt and malpractice insurance costs, but you might want to take a look if you really think all-caps “very very strong” is still an accurate and universal description of the ROI for physicians across the board in this country.

      1. ABK*

        I work in the healthcare industry and am fairly familiar with physician compensation. But regardless of industry, we can’t have a reasonable discussion of employee retainment, incentives and compensation without also talking about the highest paid folks (CEO, owner, physician, etc). Which is what both of these letters are trying to do and I find frustrating. Is the OP feeling the pinch in her wallet too (taking into account training costs and insurance), or just on behalf of her employees?

    2. moona*

      I had the same question. I have a few friends who are doctors, including one who runs his own practice, are they are very (VERY) well off. If retaining office staff is such an issue, why not reduce the salary of the doctors to increase the salary of the (low paid) office staff? $10K a year would be much more important to someone on $30K a year than to someone on $200K+.

      1. Burned out PCP*

        It very much depends on the specialty. Primary care is ridiculously underpaid compared with other specialities but have the same amount of debt coming out of med school. We also have some of the highest rates of burn out and pretty bad work life balance too. It’s not surprising the PCP shortage in the US is continuing to grow.

      2. Dotted & Striped*

        My old office had this EXACT problem. Because they were a nonprofit salaries for the MDs who were running the practice were available on tax returns. MDs frequently were complaining about office staff salaries while delegating tons of work to them. One was making over 350k while they were barely paying their full time admins more than min. Wage ( one was making 15 an hour in 2021 in HCOL) . At least at this practice the doctors did not feel the pinch money wise only the staff. It’s safe to say currently they have no admins at all because people make more in the service industry. 2021 was also their best profit year in recent memory because of a better billing specialist who upped reimbursement.

        1. Mannequin*

          I feel like this goes on a lot more than these medical practices wringing their hands about pay & benefits want to admit.

        2. the cat's ass*

          Yes. I worked in a practice where the docs were tooling around in Ferraris and the staff was eligible for section 8 housing. I wasn’t there long.

    3. Someone On-Line*

      It’s strong for specialist, but not as good for general practitioners. That’s why it’s so hard to get a check up but so easy to get botox.

    4. Anonforthis*

      My Dad is a pediatrician which is a less lucrative field. While my Dad is okay, his colleagues who have large amounts of medical school debt are definitely struggling.

    5. Doctor is In*

      Physician here who runs my own solo practice. I am near retirement and take a low salary so I can offer good pay and benefits to get good employees. They allow me to run a good office. I could make a high salary by becoming employed by our local hospital or government clinic but lose my autonomy and control over how I do things. The big clinics and hospitals make lots of money so they can afford to pay physicians more than they can earn on their own.

  12. just getting by*

    Private/concierge style medical care is the wave of the future in the United States. Whether this will work in the long run or whether it too will turn into an unsustainable model and further strain the insurance/medicare system for those who cannot afford private care, remains to be seen.

    1. WindmillArms*

      I’d say that’s the present, not the future. The US healthcare system is mid-collapse right now, and it’s very easy to see why.

    2. aunttora*

      My GP doctor went concierge and priced herself at $2000/year (in addition to any insurance/co-pays, of course). TWO THOUSAND DOLLARS. I have excellent private insurance for the U.S., but my compensation hasn’t gone up either. I don’t know what to do either.

    3. Nightengale*

      Except for the medical needs of people who can’t afford this, which is the majority

      Signed – pediatrician specializing in the care of children with developmental disabilities, some of whom have families with high incomes and some of whom are in foster care, experience food insecurity, have been unhoused, can’t afford gas or bus fare to GET to medical appointments . . . all of whom deserve care.

  13. mcfizzle*

    My aunt was/is a family practitioner, and chose to shut down and be a SAHM instead.

    Why? Primarily for the crappy pay problems mentioned in this post, as well as all the sue-happy people. My aunt had worked in Michigan for 3 years while her husband was in residency for ER / trauma. EIGHT years later she was subpoenaed back to Michigan. Why? A patient she saw 9 years ago – a single time, for a general physical, had a miscarriage 7 years later. She then sued every doctor she had ever seen in the last 10 years. My aunt was just exhausted.

    While she’s a great mom, what a tremendously stupid loss for everyone. I friggin’ hate “health care” in the US.

    1. RagingADHD*

      That’s one reason why any discussion of healthcare needs to include tort reform and malpractice insurance. And why it is so hard to get any meaningful changes made.

      Healthcare in the US is dictated by insurers — not healthcare insurers for the patient, but malpractice insurers for the providers, and the precautions against malpractice are guided by lawyers and underwriters, not doctors. Doctors overtest, overtreat, and go against their reasonable medical judgment because the malpractice insurer and/or the hospital policies require it. They have to treat every horse like a zebra just in case, which just escalates costs all across the system.

      1. mcfizzle*

        You wrote it perfectly – thank you. The uncle in ER medicine has to take that “every horse could be a zebra” to the nth degree. He’s planning to take an early retirement and go into firefighting (his other passion).

      2. Yorick*

        That’s never been my experience. Pretty much every time I’ve gone to the doctor with an actual problem, they do almost nothing and then charge me hundreds of dollars for not even trying to figure out or fix my problem. Maybe they overtest and overtreat white men?

        1. RagingADHD*

          If it’s unlikely your condition would result in a large award of damages, that probably has a lot to do with it. It’s a terrible system that hurts everyone.

        2. Nopetopus*

          Exactly, my endometriosis went undiagnosed for *years* because nobody wanted to actually test me for anything. I would have loved being overtested and overtreated compared to what I went through.

          1. RagingADHD*

            Yes, it’s awful. And as I mentioned above, part (only part, but real) of the problem is that there’s little to no chance of anyone successfully suing for missed endometriosis, PCOS, fibromyalgia, or other conditions that don’t have an extremely concrete before and after moment, or don’t play well to a jury.

            So the policies and checklists are written to protect against legal risk, rather than to provide the best patient care, and you get all the resources thrown at some conditions to the point of absurdity, while others are ignored.

        3. Not So NewReader*

          The only time I see overtesting and undertreating is for the people who have “good” insurance. I know an individual who is at the doctor’s at least 3 days a week. They have “good” insurance. The doctor promptly tells them of every test or drug under the sun.

          The results are what you would expect.

          1. MsChanandlerBong*

            I have good insurance and get blown off regularly. Maybe it’s because I’m a woman; maybe it’s just because they’re too busy. But I had a heart attack at 37, was “undiagnosed” the next day by a cardiologist who was convinced I was too young for one (even though my dad had his first heart attack at 38), and had to fight for three weeks–racking up three separate stays’ worth of medical bills–to get a cardiac catheterization, which showed that I had a subtotal occlusion in one artyer and an 80% lesion in another. Was also blown off multiple times when I had a ureteral obstruction and ended up with hydronephrosis.

      3. Avril Ludgateau*

        Doctors overtest, overtreat, and go against their reasonable medical judgment because the malpractice insurer and/or the hospital policies require it. They have to treat every horse like a zebra just in case, which just escalates costs all across the system.

        I’m not sure this is true. Ask anybody with a chronic condition – not even the “zebras” but remarkably common things like PCOS, endometriosis, autoimmune disorders like Hashimoto’s, lupus, chronic migraines – and they will tell you how long it took them to be diagnosed and how hard they had/have to push just to get a doctor to order a test, never mind for insurance to approve it.

          1. Paris Geller*

            Yeah, this is on the top of my mind right now because I literally just had some blood work done and some tests scheduled TODAY to see if I have PCOS after SIXTEEN YEARS of trying to get an answer. Literally since I was a teenager!

            1. CostAlltheThings*

              On the flip side, I was diagnosed as a teenager roughly 20 years ago and I’ve had doctors tell me there is no way anyone could really know I had PCOS and endo at 15. Oh it takes years and years of documented symptoms and multiple tests.

              Luckily my doctor took pictures of the multiple cysts and endo during the procedure and thankfully my mom was forward thinking enough to get a copy of my file.

              1. New But Not New*

                In 19 friggin 74, (1974!!!!!!), my PCOS was easily diagnosed by a simple laparoscopy confirming the presence of multiple cysts on my ovaries, after some lab work. I presented with missed and unpredictable periods, at 19. It is malpractice that getting a correct PCOS diagnosis is a problem in this day and age. Unbelievable and inexcusable.

                1. New But Not New*

                  It DID NOT take years and years of symptoms and testing to obtain my diagnosis way back then, any practitioner saying this now is incompetent. This really fries me.

              2. Green Beans*

                I had a cyst burst at 14 and was told I likely had PCOS and got put on birth control to treat it.

      4. Gnome*

        Yes. I had to go to the ER for a skin infection.. I needed IV antibiotics. They kept me hooked up to an IV all night. After the first round of antibiotics. I asked the nurse what it was… It was saline for hydration. The rate it was going at was roughly equivalent to a few sips an hour… I asked point blank if this was so they were “doing something” while we watched the infection for response and she said yes and agreed it would be more practical to just bring me a bottle of water and have me drink it.

        1. pancakes*

          Decades ago, at that. There’s no shortage of analysis on it to read. I wonder how many of the people who nonetheless love this song are watching the new NBC series “Dr. Death,” modeled on Texas neurosurgeon Dr. Christopher Duntsch.

    2. Spicy Tuna*

      A good friend of my went to medical school after about 5 or 6 years working as a paramedic (so she was a little behind the people who go to medical school right after undergrad). She WAS an OB/GYN. She had to drop the OB part of her practice because the malpractice insurance premiums were too high. If anything is wrong with the baby, for any reason at all, the OB gets sued. She was never sued, but she couldn’t pay her mortgage, pay her student loans and pay for life in general while also paying the malpractice premiums.

      1. mcfizzle*

        I should’ve put in my original comment how insane their malpractice premiums were/are, and the *many* other times they’ve been sued or people threaten to sue.

      2. Not So NewReader*

        Years ago, a brain surgeon was talking about his premiums. He was paying $450K per year for malpractice insurance. He said he was shutting down his practice.

        1. New But Not New*

          One of my cardiologists stopped practicing in my state because malpractice premiums were ten times higher than in a bordering state. And the shortage of obstetricians is directly related to skyrocketing malpractice premiums. Don’t know how liability is addressed in countries with national health care, but it can’t possibly be like this.

        2. pancakes*

          This seems way out of whack with what I’m seeing from a quick search. It also seems clear there are many, many neurosurgeons who are still practicing.

    3. Starbuck*

      You probably know this better than I do, with your mom’s experience, but – in a society like ours with such a minimal (or non-existent safety net) of COURSE people are going to be “sue-happy” if they’ve got no other options to live comfortably. When an injury, sudden illness, complication or chronic health issue means you’re now in thousands of dollars of medical debt, some people will try anything/everything.

      1. mcfizzle*

        Starbuck – I don’t disagree. But it’s compounding the problem, and it doesn’t get talked about that much. While I am not advocating for incompetence and it obviously happens (and clearly should be held accountable!), many of the scenarios my family members have faced are ludicrous and without a whiff of actual malpractice.

        1. Starbuck*

          For sure; I’m kind of assuming it’s the lawyers doing a spaghetti-style ‘throw everything at the wall and see what might stick’ in hopes of getting paid. It’s hard not to empathize with the desperation, knowing personally people who’ve spent years trying to get providers to listen to them and get a diagnosis, while bills pile up, their condition worsens, and they’re no longer able to really work or make an income – or the converse, they have to stay with the job that’s killing their health just to keep their insurance. Ugh, the kind of stuff that gets talked about here a bunch, I know.

          But I have totally read about doctors having to deal with really burdensome increases in malpractice insurance because of unfounded suits, which I agree shouldn’t be happening.

          1. New But Not New*

            Not al people filing malpractice claims are financially desperate, some are looking for a windfall. Genuine harm should be covered, but unreasonable expectations are also a problem. No human doctor can guarantee that every baby will be born perfect.

      2. Not So NewReader*

        When people feel cornered they come out fighting.

        We need to create a culture of taking care of one’s self. Adequate hydration, sleep, whole foods. These are the basics. And I would say very few people have all three. Even wealthier people eventually learn you cannot “purchase” more sleep if you suffer from inadequate rest. Some things do not come in a little box or pill.

        If we want to reduce what is driving the lawsuits we must reduce the sense of hopelessness and futility that seem embedded in our systems. I should not have to explain to a medical person why a patient with EIGHT broken vertebrae cannot get to a medical test at 8 o’clock at night. That conversation should not have to happen, but yet it did.

        1. New But Not New*

          This is all well and good unless you are born with a genetic condition or suffer trauma.

  14. Fake Old Converse Shoes (not in the US)*

    Thanks for your letter, I really appreciate it.
    Unfortunately, I’m afraid the situation is an awful dead end. You either do nothing and risk losing more employees, or do something that risks losing clients.
    (And for those claiming that Universal Healthcare is the solution… If only. Payments are so delayed that small clinics either close or get outside the system and go full private. On December 2020 I got an email from my dentist saying that they won’t take any new patients and everyone has to pay an extra fee to cover the full PPE they need, because they don’t get paid for that.)

      1. Former manager*

        Medicare cut reimbursement for outpatient care last year. So I had to tell my staff “thanks for all your hard work through the pandemic; your reward is a 3% pay cut.”

      1. WindmillArms*

        Yeah that stood out to me, too. “Universal healthcare is bad because the way my dentist operates (without universal healthcare) is bad”…what?

    1. Irish girl*

      I know someone whose Dentist now practices balance billing. If insurance doesnt cover the full cost, they bill the patient the difference.

    2. Mannequin*

      We can’t afford to go to the dentist anymore since my husband’s insurance changed from HMO to PPO. My teeth are currently trashed and I won’t be surprised if I start losing them.

  15. Sherry*

    I want to know how much money is being lost to administer insurance/bureaucracy/documentation:
    In Canada and the UK how much of reimbursement goes to treatment vs paperwork/oversight?
    We also have a brutal residency system where we underpay people to work 70+ hours a week. We have doctors who graduate with huge loads of debt who have been treated terribly and they expect a big payout after that. This debt also stops people in lower income brackets from becoming doctors.
    And we over educate people. My area in healthcare was trying to get a doctorate just so we could have a “seat at the table” during rounds (eyeroll) because PT did it. There is no evidence that I know off which shows an increase in salary with a doctorate but there is an increase in debt.

    1. 867-5309*

      My mother was an RN with an associates degree and eventually promoted to a floor manager. They asked her to take on another floor that was having trouble, while in another breath bagging on nurses without master’s degrees. She did end up going back to school later in life because she always wanted to teach nursing students but an RN does not need an advanced degree.

      1. Sherry*

        So much of good healthcare comes from experience (and updating skills with new research and training)!

    2. Starbuck*

      Well, one thing you can do is look at insurance industry profits. Billions of dollars, and it’s been going up recently!

    3. Nanani*

      The whole framework of “Reimbursement” is not applicable to universal health care. The whole model of paying insurance then insurance paying the provider does. not. apply.

      Also, in Canada (depending on the province) we don’t actually have a universal care system but a patchwork where some things are free (that is, tax funded) and others are carved out to be covered by US-style private insurance. Which sucks.

    4. I'm A Little Teapot*

      Well, in the US, Anthem Blue Cross is a public company, which means its financials are public information. You can find them and see how much profit they have.

      Even for non-public insurance companies, there may be state required financial filings that are public. In Illinois for example the Department of Insurance requires annual reports and I’m pretty sure those are online.

  16. Lemonbex*

    Health care for profit is immoral. Get rid of the middle-men / insurers who are making the money for being gatekeepers.

  17. WorkForScraps*

    I worked for a small practice with 5 providers many years ago. While the providers had high end cars and lavish homes, many of us employees were food stamp eligible. Sometimes the problem is the sense of entitlement of the providers that they deserve a certain standard of living after their years of schooling, forgetting that they wouldn’t have a practice at all without the support staff keeping the office running.

  18. ElizabethJane*

    Burn the entire healthcare system to the ground.

    And eat the rich, starting with the insurance companies.

    1. mcfizzle*

      While I think I understand your general sentiment, this is pretty over the top. And also lacking any actual helpful steps.

  19. M2*

    This is frustrating because the cost of insurance has gone up for employers and employees but yet the practices are loosing money?!!

    I’ll give another example- My doctor recommended a CT scan and wanted me seen right away so scheduled it at a hospital one town over that was recently taken over by a large well-known medical group. I called their billing office and gave my insurance information information and asked for the price of the CT with my insurance (I have a deductible plan) it was going to cost me $3500 and that didn’t include the radiologists fee which was separate. I would have to call his billing office for that information and to see if he or she was in my network.

    So I called a radiologist group I had used for other scans and their billing office told me and sent in writing (because I’m paranoid) the cost of the CT scan and radiologist etc was $200 with my insurance! So I called my doctor and told them to make me a script and they scheduled a CT the next day at this radiologists office. Same thing being done but two widely different prices! This is totally immoral in my opinion.

    This price different is totally insane and needs to be clear on websites of all medical practices. Most people would not know to do this or know how to do this or have the time (it took me hours to reach people and make sure I got the information also in writing).

    The people making money off all this are the insurance companies and these large hospitals that have huge administration staff. The “non-profit” hospital I spoke about above- the CEO prior to this takeover was making close to $2 million a year the new CEO probably makes a ton more and that doesn’t include all the high level executives making bank too. Not the doctors and nurses (some specialists okay making high 6 or low 7 figures) but people with MBAs running “non-profit” hospitals. It should not be allowed.

  20. Happily Retired*

    My daughter (family medicine) bailed from traditional pay structure, especially once a new corporate group owner cranked up the pressure to cram more patients in and over-document to support higher codes. She is now in a direct primary care model and loves it. Her patients can text 24/7 and get a prompt response, the docs do their own xrays and labs, etc., and they refer on to specialists and admit when needed.

    It’s not a boutique clinic. They serve groups such as restaurant employees and long-term care workers, many of whom have never had health insurance before. Many of their employers pay for it, while other self-employed people use it as well.

    “Direct primary care has been promoted by certain groups of physicians as a means for patients to save money on their primary care services, as well as other ancillary-performed services such as laboratory testing, etc. Often, there are no insurance co-pays, deductibles or co-insurance fees thus avoiding the overhead and complexity of maintaining relationships with insurers. The objective is to provide better free-market competition with access to higher quality care at lower prices.” https://en.wikipedia.org/wiki/Direct_primary_care

    1. pancakes*

      What happens when a patient is diagnosed with cancer, like I was when I was 34? Do they get surgery, chemo, and radiation there in the clinic, or . . . ? The wiki link you gave says these arrangements are often paired with high-deductible plans, “as DPC alone will not cover catastrophic health care such as most surgeries.” I suppose that’s fine for your daughter but I’m wondering how well it works for the patients.

  21. Healthcare worker*

    I just started a travel nursing job. My old hospital was so short staffed. I was working overtime and taking care of double, sometimes triple the amount of patients I’m supposed to be taking care of and we still had to leave beds empty because we didn’t have staff.

    We did not get raises or hazard pay. We got a pizza party.

    So I left, and so did most of my co workers. I’ve always wanted to see the rest of the country and my new salary is more than double what I was making before. I have no regrets.

    1. Squidhead*

      And I’m a nurse who stayed behind. I’m training travel nurses into 13-week contracts at our hospital, trying to help them learn our system so they can function somewhat independently. I’m often the only nurse from my unit who actually works for our hospital. The travelers I train generally (not always) have less mursing experience than I do, don’t know our policies or procedures, don’t know the medical providers, and are getting paid 2-3 times what I am. And then they leave and it starts over. Some…many, even…of them are great nurses, don’t get me wrong, but this is not a system optimized for consistent patient outcomes OR staff retention.

      1. Healthcare worker*

        The system isn’t perfect, but there was no way I could’ve stayed at my old job. Being extremely burnt out and overworked isn’t optimized for anyone either and I had to do what was best for me. I’m in a much better place now.

  22. Smilingswan*

    I work for a DME company providing specialized hospital beds, wound therapy, and braces. I can tell you the above about the reimbursement cuts is 100% accurate.
    Once CMS cut Medicare and Medicaid reimbursements, private insurance companies immediately followed suit. In addition, many Medicaid programs in various states are now being farmed out to private insurance companies as managed Medicaid, which lowers reimbursement even more and further restricts patient care options.
    The system has to change. We need single payer healthcare now. The powder keg is lit for an explosion. We’re running out of time, and people are dying because of this.

    1. mockingbird2081*

      Exactly, Medicare sets the fees. When they change the other insurance companies tend to follow.

    2. DJ Abbott*

      Private insurers are greedy corporations who will take any excuse to lower reimbursement and pocket the money, and any excuse to increase profits in any way they can.
      So they see CMS and Medicaid cuts as the perfect excuse and follow them.

  23. Sariel*

    I very much appreciate Alison posting this. As an outsider, it’s very helpful to know what’s happening from the insider’s point of view. While I don’t have ideas for a magic way to fix the issues, I do have a greater appreciation now for what people are going through. And, more of an idea of why some of my favorite practitioners are no longer with the practice I visit. So, I appreciate having more knowledge and empathy now after reading this.

  24. M2*

    Exactly this! I lived in the UK for awhile and yes to the NHS! It isn’t perfect but it’s a lot better than US healthcare! They won’t oversubscribed or over test you but they also have caps I believe if there is malpractice.

    Here whenever I see my doctor if I mention any issue due to malpractice they tell me I need a ton of different tests and scans. To cover themselves for a lawsuit.

    A friend of mine from the Uk lived here for a year and had insurance but didn’t understand the deductible/ costs right away. Right when she moved here she broke her foot so she called an ambulance (not covered under insurance) and they brought her to the ER. With treatment She got a bill for over $6k with her insurance. I don’t even know if that included the ambulance. She didn’t understand. So I had to explain it. If she went to an urgent care it might have cost her $150-300$ with insurance. She told me she would never ever complain about waiting at the NHS ever again.

    1. londonedit*

      Absolutely all of this. The NHS is far from perfect (mostly thanks to 10 years of deliberate underfunding by a Conservative administration that wants to run the NHS into the ground so it can prove it’s ‘not working’ and sell private contracts to its mates) but good lord I would take the NHS a thousand times over the US healthcare system. In October last year I started having a few health problems; spoke to the GP who arranged blood tests and an in-person follow-up appointment, diagnosed an autoimmune condition, referred me to a consultant, and in the meantime prescribed medication. Saw the consultant 5 weeks after referral, had a follow-up phone call from her 48 hours after my initial appointment/tests and now have a treatment plan in place; had a phone call over Christmas from the GP surgery pharmacist to check I was OK with my new medication dosage and set up a repeat prescription. I get three months’ medication at a time and it costs me a prescription charge of £9.35 a go (if I was on a low income, elderly, pregnant or suffering from certain long-term conditions – or lived in Scotland or Wales – there would be no charge at all). I’m going to have at least 18 months of regular blood tests and specialist appointments and I won’t have to pay for any of it (yes I know I theoretically pay via my tax/NI contributions but here we don’t even think about that because there’s no dedicated NHS charge, it’s just the tax you pay). When my father had a stroke he received world-class care from doctors, nurses, physiotherapists, speech therapists and now has long-term management via his GP surgery (he made a full recovery) – we didn’t and don’t have to worry about bills for any of that. Yes in certain situations it makes sense to ‘go private’ if you can afford it – my mum needed cataract surgery and was told the wait would be 12 months, so she paid for the procedure herself. But she could have waited and received exactly the same standard of care.

  25. Spicy Tuna*

    I live in a large urban area, and the two options for health care here are clinics that cater to Medicaid or private pay. My city is the Medicaid fraud capital of the country (this is 100% on the folks that run the clinics, not the patients) and if you have non-Medicaid insurance, it’s hard to get an appointment (because there is limited opportunity for fraud). The “concierge” or private pay isn’t feasible unless one has a lot of disposable income and excellent health.

    I am self employed and I buy my own health insurance. I have a high deductible health plan, so I really limit doctor’s visits. The ONLY doctor I visit regularly is a dermatologist for an annual skin cancer check (a close friend died from melanoma; it was AWFUL). The derm I had been seeing just went to 100% cash pay, no insurance. She wants $550 for a skin cancer check. No thanks.

  26. Tirv*

    I live in Canada. Be careful what you wish for re universal healthcare run by the govt. ( taxpayers) yes there are a lot of positives but also a lot of negatives. It’s basically rationed healthcare and the doctors are paid per 7 to 10 minute visit with a cap placed on the number of patients they can see in a day. You are allowed to discuss one thing and if you have a couple of health concerns, you must make an different appt on a different day. Waiting for referrals to specialists can take months -some a year, and then the surgery many more months. We are losing GPs as the pay is too low which has resulted in lining up at walk in clinics being the only option for an increasing number of people. My doctor retired and I felt like I won the lottery when after months of hunting, I found a GP who was new to the area and willing to take on new patients. I am so thankful our healthcare is free, but there are still challenges.

    1. Marie*

      If you take out the sentence about this being Canada, I would think you’re talking about America. I haven’t seen a primary care doctor for more than 7 minutes at a time in my entire life, specialist referral wait times are that long, longer, or there simply is no specialist to refer to, and getting multiple or complex symptoms addressed doesn’t happen without repeat appointments and verbal persistence to the point of conflict or aggression.

      Not to shut down your comments, you’re allowed to vent about your health care system, too! I just often find that when Americans point to the ills of socialized medicine as a reason not to adopt that system, they’re often describing things that are routinely happening in our health care system as well.

    2. metadata minion*

      You are describing US healthcare for many people, except you at least don’t go into debt for it.

  27. Tara*

    I work in DME, and like almost every healthcare facility, we can’t retain staff and have been overwhelmed for years. My current office works with kids, and we mostly work with Medicaid. It sucks. They pay the least out of any of the insurance providers we take, and their supply limits are very strict so we have to either eat the cost of extra or deny parents the amount of supply they need to comfortably take care of their kids. We lose money hand over fist here, and I think we’re only still in business because we’re part of a (nonprofit) hospital system that knows we’re the only way they’ll get prompt oxygen/trach/mobility supplies for their patients. Other DME companies are even more overwhelmed than we are and can’t consistently offer same-day delivery or after hours service, but delaying equipment like that means delaying discharge, which adds up in cost for the hospitals quickly. Plus another large subset of our patient base doesn’t get us any reimbursement at all because nonprofit hospitals are legally required to offer up to 100 percent discounts to low-income patients, and the hospital workers make sure people know about that. (Which is good! But we’re talking about money, so.)

    I used to work on the adult patient side of the same company, and Medicare isn’t much better. Full price for a basic oxygen setup is about 410 per month. Medicare pays about 120 per month, and that’s all-inclusive, so then we still have to make weekly oxygen tank/supply deliveries at zero charge. Not sustainable. CPAP therapy is pretty much the only place we make money.

    1. Software Dev*

      Yeah, this seems like the first and easiest fix—up the medicare/medicaid reimbursement rates! Private insurers normally pay 200% of medicaid, so if those rates rose presumably private insurance would need to pay more.

  28. PT*

    When I go to the doctor, the doctor barely listens to me, rushes me out in 5 minutes, charges my insurance $430, my insurance says, “Nah we’re paying you $220. Patient will pay $30 copay.”

    When I take my cat to the veterinarian, they get a good long appointment, the vet listens patiently to my concerns, the office visit fee is $70, and they give me a complimentary La Croix.

    And to add to that, one of my cats usually misbehaves during the exam (biting, scratching, needing to be put in the towel burrito) while I have generally been compliant and nonviolent with my primary care provider. (Pediatricians YMMV.)

    1. Beeker*

      You pay cash at the vet and they don’t have to hire a team of people to code, file, and work your cat’s claim sometimes for years on end because the insurance is legally allowed to deny it for no reason other than “cost cutting measures” for the insurance company. Your vet lso doesn’t have to carry the level of liability insurance a medical doctor does.

    2. Pool Lounger*

      Is your doctor’s office owned by a huge corporation? My family physician opened her own practice because the medical practice she previously worked for wanted doctors to see the most patients possible in a day, meaning rushed appointments like you describe. She hated this and opened her own place, only to have the problems faced by the OP. She has med school debt, had to pay a lot of money to open her own place, and now she has problems paying herself and her coworkers. It seems for family doctors the options are work for a big company that doesn’t care about patients, or open your own shop where you can’t afford to keep the doors open.

  29. WhoKnows*

    LW, can you go read this letter to Congress? Because they say they care about small businesses in the US, and small medical businesses are still small medical businesses! Our insurance system just does not work.

  30. Girasol*

    My (USA) medical bills look like “For your everyday medical service X on date (three months ago,) you owe appalling amount. Negotiation between Big Insurance Co and Giant Medical Group has resulted in humongous discount. Big Insurance has paid large amount. You owe smaller amount.” Thanks to expensive insurance in cooperation with Medicare, that last number is not scary. But the process looks more like a game of darts than it does an itemized bill based on the cost/value of service. How does this process look from the perspective of a small private practice that has less negotiating power with Big Insurance? Do they start by charging an exorbitant amount so they can end up dickered down to an amount that actually covers the cost of service, or what?

    1. Beeker*

      Often what seems like an “exorbitant amount” for a small service is actually the market rate for a service when it is combined with all aspects of that care. Medical practitioners can only bill for certain things, like procedures, medications, and certain professional time (doctors, PAs, Nurse Practitioners in certain instances.) But medications require nurse and pharmacist time and expertise, a tech has to spend time cleaning and setting up the treatment room, a secretary has to make your appointment and enter your info and file your claim. All of these people cost money to employ but whose time and expertise cannot be billed separately. Insurance companies set “allowable” amounts based on their own markers of profitability, competitive rates, patient numbers, regional costs, and physician contracting. It’s not a “just throw out a number and hope it sticks” kind of game.

  31. Beeker*

    Thank you for this. Few people understand how our health system works (or doesn’t work, actually) or how insurance works and want to blame rich doctors for our broken system. I spent many decades in healthcare administration and had to completely walk away. The American medical system is on the brink of collapse and I don’t think most folks understand that or why it’s happening even beyond the challenges of covid. Good luck to you LW and to the original writer looking for advice. And to all of us facing an uncertain future of medical access in the Land of Opportunity :(

  32. Lady Glittersparkles*

    Every once in a while I read something that makes me really want to take my family and get out of US, pronto. The healthcare situation feels so disheartening – I can’t even believe how much more I pay for healthcare now than I did upon entering the workforce, and to hear that apparently none of that money is going to people actually providing the services? I know it’s not perfect anywhere but it has to be better than this, right? I’d guess a lot of the problem stems from the sheer amount of administrative bureaucracy involved in our healthcare landscape.

    Unfortunately, it seems that immigrating is hard, especially if you aren’t young, wealthy, or employed in a very in-demand field.

  33. Who the eff is Hank?*

    I’m a medical provider working in a small clinic. Our patients think we’re making bank because we charge (on paper) $150 an hour. But that’s not what insurance pays out, and we also have to pay for facilities and equipment out of that. After all is said and done, I bring home about $45k a year (pre-tax). I have about $100k in student loan debt from medical school and I also work much more than 40 hours a week (much of my charting is done in the evenings, I am always playing phone tag with insurance companies and my patient’s other doctors).

    There’s a cultural expectation that doctors in the US make a lot of money, but that’s not the reality any longer. A lot of us are struggling.

  34. Binkybecker*

    My husband folded his 35 year single doctor practice 18 months ago due to this very reason. He had to join a big group just to continue to make a somewhat livable wage. Declining reimbursements hurts not only the employees, but the employers. Everyone should remember this when they have no choice but to go to a 20 doctor practice associated with a hospital or for profit based organization. It’s reality now.

    1. L. Ron Jeremy*

      Is minimum wage a living wage? I’m sure he making more than a living wage, right? We need to play everyone a thriving wage, so there is money left over after paying for the cost of living.

  35. Leilah*

    This is extremely analogous to what has happened to agriculture as well, essentially make small farms extinct. I have to hold a full time job just to afford the privilege of producing food for people with my second job. The price of our outputs is not under our control at all, just like in this scenario, and the price of our inputs is also not under our control for the most part. This means that there is no where to give. I have farmed for 7 years now and never made one single penny of salary, income or profit. I lose around $50,000/year. It just tears my heart out to think that producing food for people, an absolutely essential part of our society (just like healthcare!) people can’t even hope to make a living any more.

    1. Captain Vegetable (Crunch Crunch Crunch)*

      You of course don’t have to answer any of this if you don’t want to, but I am very interested in knowing more. Where do you live? What do you grow? How many acrs? What’s your full time job? Where/to whom do you sell your products?

      1. Leilah*

        I live in the midwestern USA and am a dairy farmer with only 20 acres to my name, and some other rented land. Even without buying land it took me $300k to start farming. Like the vast majority of all dairy farmers in America my milk is sold wholesale to a cooperative of which I am a member-owner and processes the milk into cheese and butter. The milk price is somewhat federally controlled and somewhat set by the global markets, it’s extremely complex and the bottom line is that I don’t have any ability to control the price paid for my milk and don’t even know how much it will be until the check arrives (several weeks after the milk was already sold). The total milk price has been under $21/cwt for almost a decade, despite the cost of producing that milk being over $20/cwt on average (and more like $30-$40/cwt for a family sized farm). There have been many months where the price was $15 or less. The most recent year dairy farming was profitable was 2014, and that was one brief year. I started out on my own 2015, expecting the markets to continue cycling in a reasonable manner. It did not. Something like a quarter of US dairy farms have given up since then. I stopped using facebook because I couldn’t handle seeing another farm in the same position as me give up and lose their cows every single week.

        Since I started my career goal in 2003, we’ve lost over 50% of US dairy farms. We’re all just riding on equity and bigger and bigger loans hoping maybe one day the market might turn again, because the alternative is butchering the cows we’ve cared for our entire lives. This is all while US and world dairy consumption is going UP, every single year, as is the price consumers pay for dairy in the grocery store. I now wake up at 5.30am, milk and feed the cows which takes two hours, go to work for a large agricultural conglomerate where I do animal nutrition work, start milking and feeding again at 5.30pm and get in the house between 7:30-8pm. You have to milk the cows at 5.30 and 5.30 every single day, 365 days a year. At least one full weekend day is usually devoted to fixing things, running farm errands, moving or vaccinating cows, all the other work that comes with farming. I can’t afford to pay anyone to fill in, so I beg my retired parents to occasional do chores once in awhile so that I can attend a wedding or something. I haven’t had a day off in…I can’t remember? Years. But it’s that or kill the cows. I wouldn’t mind it so much if I didn’t have to do the full-time other job too. I wouldn’t mind it so much if I just broke even, so I didn’t burst into tears anytime something breaks because I can’t afford to fix it. Producing food people want to eat should at least let someone afford to survive, don’t you think? What a mess.

        1. Batgirl*

          I’m so sorry Leilah. I would pay good money for milk from a farmer who loves their cows and I hope this comes about one day.

          1. Leilah*

            Thanks! There are family farms who have done it — please support them! Buy their cheese or butter or milk! If you tell me what state you are in I could even give you recommendations. The problem is that unlike say, fruits and veg, I can’t just sell you raw milk (in most states). I have to build an entire food processing facility in order to sell milk (or cheese or butter) directly to people. I have thought about doing this, and I might still do that someday, but right now it’s really hard to save up enough and take another risk getting a loan for around $250k to build and install a small milk processing plant. So on one hand that model can keep family farms alive, on the other hand the only farms who can afford to take that leap have to be quite financially well-off to begin with. It also adds a whole other layer to running a business when you have to be a mechanic, an animal health expert, milk 365 days a year, and now know how to process food and sell it and market it and advertise it, and so on.

  36. OlympiasEpiriot*

    Obviously, an unsustainable situation such as this cries out for a multi-pronged systemic overhaul.

    (1) Education financing for medical students needs to be provided early and heavily.

    (2) The for-profit insurance has to end.

    Depending on how it is handled, Universal Healthcare may or may not work to support the system we need to make sure we have broad and equitable access to healthcare.

    I don’t know how we are going to get there, but, as someone said above in the comments eating the rich might be part of this. It is immoral how more and more wealth is effectively taken out of circulation by virtue of ending up in the hands of fewer and fewer people during this pandemic. Long before 2020, it already seemed that a bare handful of people were behaving like Smaug sleeping on his pile of gold, hoarding it for no reason whatsoever.

  37. HigherEdAdminista*

    It really feels like in the US we are getting to the breaking point for a larger number of people than ever before, that life has become so expensive and full of red tape that people can’t function. Most of my friends are earning mild class salaries, and they aren’t getting ahead. Rent is going up (almost no one can afford a house unless it is magical unicorn type situation), food costs are going up, and even “cheap” forms of food or entertainment are adding up. It feels like most people I know are looking for some kind of relief and all they get is higher bills and greater expectations.

    I don’t fully have the words to explain this, but it just seems that into year 3 of the pandemic, there has been a shift and a lot of people are starting to want something different out of life and the powers that be are just scrambling to prevent that from happening.

    I’m sure both this LW and the original one had a dream of having their own practices and helping their patients, and being real accessible type doctors. This used to be so common and it worked for people, and now we are driving people out of business because some person who is already rich finds there is money to be made in having 100 random urgent care centers instead.

    1. Paris Geller*

      Yeah, it’s rough out here. I have a master’s degree and a decent, though not amazing, income and things are still a struggle. When I was in grad school I was the typical broke grad student, but I had hoped by now I’d have more of a safety net. I’m better off than many people and I recognize that, but the idea of ever being able to buy a house or have significant savings seems like a far-off dream.

    2. Starbuck*

      “now we are driving people out of business because some person who is already rich finds there is money to be made in having 100 random urgent care centers instead.”

      Yeah, I feel like things are unlikely to get better until we meaningfully wrest away the power and resources that the financial class has hoarded from everyone else.

    3. pancakes*

      Please have a look at wage stagnation over last 40 years or so. The Economic Policy Institute (EPI) has a lot great reports on this. The problem is not red tape.

    1. T. Boone Pickens*

      This is totally spitballing but maybe places that specialize in elective surgery (Lasik, plastic surgery, etc?)

    2. Brownie*

      Plastic/reconstructive surgery. My reconstructive surgeon dropped all contracts with the insurance companies and went to private pay less than a month before my surgery last year. His practice is doing quite well still as the options for his (specialty condition) patients are either pay out of pocket or end up with highly restricted mobility/in a wheelchair/dead from condition complications.

    3. Software Dev*

      A friend of mine pays a private pay only GP, known as direct primary care. Most kinds of doctors /can/ go private pay.

    4. Stevie*

      I’d say mental health therapy (psychology) and psychiatry. I’m going to be blunt here; I’ve never had anything close to an insurance-accepting therapist or psychiatrist who was at all someone I would recommend in my major metro area. I’ve had to go private, and my friends in their major cities have had to also. I submit to insurance after the fact and get basically less than half back. It’s just an awful system for people who need mental health services but can’t afford it.

  38. Paris Geller*

    I appreciate this letter, but man does it make me depressed. I’m paying thousands of dollars every year for healthcare that seems to cover next to nothing and the actual healthcare providers aren’t being paid adequately? Truly I don’t know how we in the US managed to come up with the worst healthcare system but we seemed to have achieved it. It seems our current system is bad for everyone except insurance executives making $$$$$.

  39. Galahad*

    Business Operation Model.
    The second writer wrote about how shorter service times leads to lower care, but that is one option.
    For reference, this is how I observe the business model in canada, for GPs with their own offices. (GPs paid by province for each visit, and they pay their support staff, rent on space, equipment from that revenue).

    1) Group together so you have fewer admin per doctor or per patient, and to also have weekend on call coverage so you get to have time off occassionally.
    2) Have walk in clinic hours in addition to regular patients. Walk ins often are very quick to turn.
    3) Goal for each patient is average 5 minutes per patient, then 1-3 minutes between patients for documentation. Note, this means that you don’t do annual physicals anymore, not just because of guidelines but also because they take more than 5 minutes.

    Split up one visit across multple days so you can bill each individually (won’t be paid for 2 visits on one day for same patient, even if you spent an hour with them, total):
    4) Only address one problem per patient per day. If patient presents with needing test for strep throat and a toenail fungus, make them come back the next day for the toenail issue.
    5) Move new patient intake / screening / meeting to a separate appointment. Actual healthcare visit (prescription renewal, health concern treatment etc) move to another day. If you are good at this, you can split a new patient intake into at least 4 in person visits — meet and greet, visit to get lab requisition, visit to review lab req and treatment plan, follow up to renew meds in 30 days. Even if all that is wanted is simple like BC medication that patient has been taking for years with a different doctor.
    6) Greatly reduce any routine testing that takes time (pap smear, other) by limiting available hours to do these so they are virtually impossible to book, or refer patient to do them through hospital outpatient / quasi hospital clinics instead (women’s health centre).
    7) For serious discussions needed (new diabetes patient?) limit to 15 minutes counselling and then send away for testing, then back to you for counselling, then testing, then counselling to generate more short visits you can bill for.. This is also better because patients can only recall a certain amount of information. Refer to on on-line education and support “clinics” provided by gov’t health for more education for patient about their health issue. (how to take glucose measurements, concerns about health diet, etc). These are cheaper to operate than GP offices as they are usually staffed by experienced RNs and support staff.

    Note — this process means that people that work start to look for semi private practice and are willing to pay $1000/yr to bump up their services to have a “one and done” visit if they are healthy, and working full time.

    Also Note – Dentists / para health (massage, physio, chiro, etc) set own rates, often using a college “recommended pay scale” but can go over it if needed, like private practice. These services are often time based that you can’t cut short like the GP visits per the above model.

    1. consultinerd*

      Yikes. I’m not trying to jump down your throat for sharing what you see as the reality of making the numbers work in your system, but this seems like an absolute nightmare from a patient standpoint. Splitting a 20 minute appointment into 4x5min appointments could mean someone losing a full day of work to travel and wait times.

    2. Chickaletta*

      I had to read your suggestions twice because by the time I got to point 4) I thought you were being sarcastic by listing all the things NOT to do. In fact, most of these things are what the health care system I work for is explicitly trying to avoid because it leads to patient dissatisfaction, adverse outcomes, and overall lower scores on healthcards that are reviewed by the DOH and various oversight organizations, insurers, and lenders.

    3. Dino*

      Please examine the ableism in the “5 minute/patient” model. Some of the sickest, most vulnerable patients are exactly the ones who require more time.

      Our whole lives require more time, because we use paratransit or a relay service, or have to manage a half-dozen chronic conditions meaning more time in line at the pharmacy, in the waiting room, calling their insurance company because of a billing issue. Disabled people have our time stolen through those multiple appointments you mention, only for the ableist system we have to interact with to resent us for costing *them* an extra 5 minutes.

      Anyone from another culture, or without English as a first language, or neurodiverse, or or or or also experience this. Those who already have the worst outcomes and hardest time accessing care are the easiest to just decide not to serve.

    4. OlympiasEpiriot*

      I really hope you are providing a “completely ridiculous worst-case survival” scenario because, if you aren’t, I ALREADY feel like I’ve been turned from a person into an extractable resource in so many parts of my life and this just sounds like a roadmap to more of that.

      My mother didn’t birth me for me to be raw materials for your medico-factory.

    5. delta*

      Oh… oh no. This has to be one of the most unethical lists that I can think of. You are geninely suggesting that a newly diabetic patient should have multiple apointments over days or weeks for a condition that is harrowing, expensive, terrifying and potentially deadly?

      The system is very broken, but this is not the answer.

  40. Carlottamousse*

    My OB runs her own private practice and recently (as of 2022) has instituted an annual administrative service charge applied to all her patients. She wrote a letter explaining the why and what it covers, and to me, it makes complete sense. She is and has been easily accessible by email and phone, without extra charge, for years. To the point she’s burning out writing emails until midnight to her patients (I can attest to this having been the recipient of her emails late into the night). Anyways, as a patient who’s gotten great access to her via email that I really appreciate, and as a lawyer who is used to thinking about charging for one’s time, it makes sense to me that she would implement a fee that would cover her time being accessible to her patients. Our pediatrician’s office, also a private practice but a group practice, has a similar annual administrative charge to all patients, to cover their 24-hr doctor-access phone and filling out forms and email access, etc. Also worth it to us. But it does put an additional burden on patients. If expectations are set and fees explained, this could be something to explore until our healthcare system is revamped (if ever??). These fees are not reimbursable by insurance.

  41. raincoaster*

    If the insurance industry is the problem, then the solution is to eliminate it with universal coverage. We do not have this problem in Canada.

  42. The OG Sleepless*

    Veterinary medicine is direct pay as well, and I feel this in my soul. The only places that can pay staff decently are the high priced corporate practices. So they’re all leaving smaller practices. So we are understaffed. So we are swamped. So people have to wait. So we get nasty Google reviews. So we get more burned out and more people leave. Repeat on infinite loop.

  43. Anonymous Commentator*

    Yes, this makes sense when their is a legit issue that affects cash flow.

    Employers like my old employer are just cheap. They’re making record profits, but are desperate for staff and have begged me twice now in two months to quit my current job and to come back full time. But the offer wasn’t even half of what I make now and I would be on call 7 days a week. And when I pointed out that the union contract stipulates I actually would require a higher hourly rate due to last experience they tried to pretend they had no idea what I meant. No thanks!

  44. Aglaia761*

    This is also the case for DSP’s or Direct service providers. I work with several nonprofits who work with people with IDD (Intellectual or Developmental Disabilities). Due to the nature of fee for service healthcare and government reimbursement rates, their pay is also capped at a minuscule amount with very little room for growth.

    Hundreds of homes and providers have closed and those individuals are being dumped on super overworked DSP’s with no end in sight.

  45. Art3mis*

    I work in health insurance and fully support Medicare for all. It’s not perfect, but it would be better than what we have now.

  46. Rebekah*

    I have to say, while many people are very convinced that universal healthcare is the answer to everything, it does come along with its own host of problems. I’ve lived in both Canada (my home country) and the USA as a medicaid patient, and I would much rather be a medicaid patient in the US than live with the Canadian system. Was it perfect? Very, very far from it. The paperwork was awful, the bureaucracy gave me heart palpitations, but the medical care itself was lovely.

    1. Software Dev*

      This is a complete roll of the dice. Please please stop using anecdotal luck to decide one system is better than the other. I have friends who have experienced amazing medical care in the United States and friends who’ve experienced extraordinarily terrible and abusive medical care in the United States. Neither of these sets of experiences should determines what kind of healthcare system we should have.

      1. Eyeroll*

        They’re allowed to share their anecdotes. You just did. Qualitative and quantitative information has value.

      2. Stevie*

        Agreed. I don’t see the problem in acknowledging the cons of a universal healthcare system, in addition to the pros. It doesn’t mean universal healthcare won’t come out on top when everything is said and done.

    2. Dino*

      For anyone with limited English skills, the forms and bureaucracy are a legitimate barrier to care.

      1. Batgirl*

        My English is great and just hearing the word “forms”, made me change my mind about emigrating to the US. Until that point I just thought funding was merely done differently, maybe not as fairly to all, but with essentially the same aim of getting care to people as efficiently as possible. Apply for the privilege of seeing my own doctor? No thank you.

      2. Green Beans*

        That depends. Where I grew up (in the USA), pretty much everything was offered in English and Spanish. Voting ballots, doctor intake forms, Walmart bathroom signage – everything. There is no reason that any form has to be offered in only English and there are truly bilingual places in the US.

        1. Dino*

          And for the illiterate? Those with learning disabilities? And signing deaf people? Doctors already refuse to provide interpreters for the actual appointment, much less to live transliterate their ridiculously complex forms.

          I’m happy you and those you know are fortunate enough to be literate.

          1. pancakes*

            I think some of this must be regional. Doctors at the cancer center where I was treated and where I still go for my monthly Zoladex injection are most certainly not refusing to provide interpreters. A short excerpt about the services available there from their website, which I’ve seen posted there in various languages for years:

            “Qualified Medical Interpreters for spoken languages

            – Over-the-phone interpretation services in more than 200 languages available 24/7
            – Video remote interpretation services available in 35 languages
            – In-person interpretation services through staff or agency interpreters (requires advanced notification)

            Qualified Sign Language interpreters for Deaf individuals

            – In-person ASL or other Sign Language (requires advanced notification)
            – ASL video remote interpretation available 24/7
            – Tactile interpreters for Deaf-blind individuals (requires advanced notification)”

            Granted this is NYC and there are many languages spoken here, but if they can contract for the provision of these services, others can as well. Yes, there are still too many barriers to care, but the lack of interpreters you describe isn’t a problem everywhere.

  47. James*

    As OP notes, there has been massive consolidation in the healthcare industry and monopolization is a big reason why the little guy can’t get by anymore. This is not only a healthcare issues, but is found across industries these days. The solution is to support anti-monopoly legislation and representatives that will stand up to big business.

    Here is a great example from the healthcare industry and group purchasing organizations: https://pluralistic.net/2021/09/27/lethal-dysfunction/#luxury-bones

  48. TootsNYC*

    My doctor has:
    • added tons of advertising in his waiting room
    • added tons of advertising in his exam rooms
    • added a medical-technician school
    • rented exam rooms to other doctors

    It’s pretty clear he’s in a constant fight to be able to pay his rent (and he has a basement suite; it’s on a main street, but it’s still not the most desirable real estate).

    Meanwhile my premiums have gone up. So I’m guessing the health insurance companies are profiting.

    1. TootsNYC*

      Oh, and every specialist I’ve seen has been automatically saying, “Come back in 6 months,” and it feels like churning. My stye is basically gone, so when I come back in 6 months, it won’t take much time or focus to make sure I’m still healthy, but my ophthalmologist will have another charge to submit.

  49. DiplomaJill*

    Holy sh!t. I had no idea. Making mental note now to pay all the independent physicians we owe, stat! ($20k in medical debt has made me blase on payments … It feels like “what’s the point” since there’s always another hammer to drop … But I can prioritize the little guys.)

  50. Don't be long-suffering*

    I had an operation that takes place over three consecutive days. Very delicate. Surgeon told me he will only do it on Monday and Tuesday, first thing, and he cancels if he can’t get the crew he wants in the OR. Two weeks later another general anesthesia for the follow up. Two office visits before, one office visit after, phone check-ins, in-house lab work. The total amount Medicare paid his practice was $689. I don’t think they made minimum wage among them. I want my surgeon and staff to be compensated fairly, dammit. He sold the practice to the hospital shortly after, of course, which had made out way better, at least during my stay.

  51. Ellie Rose*

    It’s so messed up that we simultaneously have medical offices being unable to pay their staff a living wage due to how much they receive AND people being unable to afford medical care because it costs too much.

    Someone is making bucketloads of money off of people’s suffering, and it’s not your average overworked medical staff.

  52. Snowball*

    I thought of the original medical provider post last week when my therapist told me she is going to stop accepting insurance. There’s 7% inflation this year, what she’s getting from me hasn’t changed in 3 years – her options are either to take on more clients or essentially take a pay cut. I’m fortunate that I can afford the new fee (and I might be able to ask insurance for an out of network reimbursement) but it sucks how our system is set up for many providers.

  53. FACS*

    I have a solo independent medical practice. This is late so I know that no one will see it. Just got home from work. I just sent my last inpatient home. Abdominal hysterectomy. Pre op, post op check twice a day, post op for 90 days. My reimbursement $990.
    When I went to medical school tuition was $6000 a year. Now the same school is $46, 800. We still need to eat and live somewhere. I worked 90 hours a week for 4 years, starting at the princely sum of $24k as a resident.
    If I have a bad day at work someone can be hurt. My medical malpractice is $21, 000 a year despite me never being sued in 29 years.
    Every year my take home pay decreases. I have a child in college and one in professional school, no financial aid. Anyone who thinks that physician in front line specialties are making big dollars is delusional. The pediatricians, psychiatrists, family or internal medicine docs out there are just doing the Lord’s work.
    My spouse (also a doc) and I continue working for insurance and to pay cash for the children’s school. We could retire otherwise.
    I also work to care for my staff. They are well paid, each gets a half day off a week, fully paid health insurance (including me at $2450 a month), salaried, retirement. In exchange they are highly competent and know their areas in entirety. And if anyone thinks that I could not have made more in finance, dream on.
    Practicing physicians here are required to take ER call. I was up doing a tubal pregnancy surgery last night and she is uninsured. My fee $0.
    We will just retire early, as so many physicians do. We take our expertise with us. The system is brutal. My parents have Medicare and I am one of a handful of physicians that participates. I lose money often. The model is not sustainable over time. After 4 years in medical school and 4 years of additional training, yes, I think I should be paid for it. Ask yourself, if I mess up at work can a I be sued for $2,000,00? Do you show up for work for free in the wee hours? My sons have chosen other work as they have seen the cost.
    I love my work and occasionally do meaningful good. I teach surgical technique and PA students. But when the time comes I’m out.

    1. Missing the good old days*

      I feel for you; it sounds overwhelming — and I appreciate your commitment to your work and your patients. I worry for my niece who is now in her residency in internal medicine and hope she finds reward and personal satisfaction in her chosen work.

    2. mockingbird2081*

      I work with an OBGYN group as their administrator. Just like you said, average they get paid for a hysterectomy can be $600 to $1000 depending on what they do. They work 80 hour weeks to make sure all babies are delivered safely and moms are taken care of. The work brutal hours and see a lot of patients they make money but they also come into careers with $250,000 or more in school loan debt. And patients get upset about cost constantly. They want a refill on their meds but don’t think they should have to come in for a visit…even just once a year. They accuse the doctor of being in it for the money. NO, they aren’t asking you to come in because they see dollar signs, but they do want to know about your general health, how the meds are working for you etc so they can make sure writing that RX one more time will be good for you and not detrimental, just because a medication refill visit can be a quick visit doesn’t mean that the skill level to decide if that medication is appropriate is a low level skill. You pay for the experience and the knowledge rarely for the time…though that can be a factor when you bring 12 issues to one visit and take an hour.

    3. delta*

      I genuinely don’t understand how this system is feasible. How can you work hours and not be paid? Why are you not paid directly by the hospital or department of health?

  54. Missing the good old days*

    I agree with the opening comment. I started working in 1981, 40 (!) years ago; there was no such thing as a co-pay. Healthcare was never cheap — but it was much more affordable. True, eyeglasses weren’t covered — but they were affordable too.
    What’s different? The influx of insurance companies touting the magic, cost saving benefit of HMOs, managed care, copays and isn’t everything wonderful! And they built themselves an empire, with themselves as kings at the top — all very, very highly compensated — millions of dollars in annual compensation. Healthcare costs and premiums have skyrocketed to pay for this massive insurance infrastructure (people, real estate and process) that didn’t exist 40 years ago — and now exists today to deny services, deny payments — so the premiums stay in their pockets. It’s become impossible for small practioners to maintain their business; insurance regulations and keeping up with all the variations of coverage are incredibly complex. If you’re on Medicare or GOOD private insurance, you might be ok. For the rest of us — patients and medical practitioners alike — it’s a nightmare.

  55. Rachel*

    I wonder what type of medical practice this is. My dad is a dentist, and long ago decided his practice would not contract with any insurance companies. He had a whole form letter to send to current and potential patients who were unhappy about this regarding the reasons why (dental insurance rates have not gone up in 50 years, meaning they cover less and less, meaning the care insurance dentists can provide is usually not great). He sold his practice to another dentist a few years ago as he was preparing for retirement and last year they sold it to a large corporate entity.

  56. Marie*

    This is a huge problem in mental health care, too, as many people above mentioned. I’ve seen a real shift in the last ten years in how new grads talk about their future practices. It used to be absolute dogma that *of course* you accept insurance, that’s the only way to ethically and equitably practice. Now the dogma is switching to *of course* you do private pay — it’s the only way to be sure you’ll actually be able to provide the treatment a patient needs, or even be able to be a paid therapist at all.

    There’s two things here a lot of people out of the industry don’t know.

    In a lot of places, insurance panels are simply closed to new mental health providers. They deny every new application to become part of their network, stating that they have enough providers. I’ve seen people get around this by resubmitting the same application 7-12 times, then suddenly being approved, but that’s no guarantee. This despite clinicians and agencies in my state having 3-6 month long of simply closed waiting lists. Unless you go to work for a large entity, typically owned by the health insurance company itself, sometimes the *only* way you can be a therapist is through private pay. I cynically assume the reasoning here is that health insurance companies simply do not want people to be able to access their benefits (and thus diminish their profits). If everybody has to go to private pay and never hits their deductible, there’s no downside for health insurance companies, only everybody else.

    Mental health providers in private practice are constrained from ever sharing their reimbursement rates with each other. Health insurance contracts include an NDA over their proprietary fee structure, and private practitioners are considered business entities, so are further constrained by monopoly and price fixing laws. If a health insurance company routinely pays out less to BIPOC vs. white clinicians, female vs. male clinicians, clinicians serving one kind of population over another, clinicians of comparable credentials, etc., or if an insurance company has raised reimbursements for everybody but you for the last five years, you legally cannot find that information out. If you do find it out, you legally cannot act on it. Mental health providers are always able to individually negotiate their rates, of course, but they have to do it with absolutely no knowledge of what others in their field are making.

    There are a lot of articles and think pieces right now about the lack of mental health providers. There is no lack. We are here. There is only a lack of mental health providers that health insurance companies are willing to pay.

  57. Ergo DNA*

    This letter hits the mail on the head perfectly! As a healthcare provider with a small practice that does not, and never has, accepted any insurance, I cannot fathom how small practices survive! Our healthcare system is a dumpster fire, and the general population has no idea how bad it is. My husband, who is a CPA that has always worked in large multinationals frequently tells me he would not believe what a wreck healthcare is if he were not married to me and wasn’t experiencing the dysfunction through me. We are in for a reckoning in this country!

  58. delta*

    So what I’m hearing is that literally every single aspect of the American healthcare system is massively flawed.

  59. Mannequin*

    Small clinics are losing money and business because the US healthcare system is trash. That is a given. And I’m sure it absolutely sucks to be a Dr or healthcare provider put in the positions that have been described all through this thread.

    But you can’t solve this problem by underpaying the people that work for you, or denying them good benefits, either. It’s unethical and immoral to subsidize your business on the backs of the lowest level employees that keep it afloat, and no amount of sadness for failing small businesses excuses the practice. If you have already cut the salaries/unnecessary perks of your highest paid staff, and still can’t pay a living wage to the lowest, or provide absolutely spectacular benefits to make up for it, people ARE going to keep leaving for jobs that will. It’s just a fact. And if you can’t afford to pay your workers, maybe you can’t afford to stay in business, or stay in business using the same model. Perhaps working to help change our f’d up system would get you further than expecting low wage workers to suffer.

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