Doctors are quitting - Not enough money. Too much BS. Too much fighting.

[TexasFight]

Honestly, I'm just glad to see an article putting doctors in a good light. I've read too many articles that sing the tune of "Do doctors get paid too much?".

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[neuromd03]

I know a Stanford-trained OB who basically set up shop as a non-invasive cosmetic specialist. She basically has a fee for service practice that caters to rich patients who make six figures or more. She also practices some gynecology but mostly in a primary care manner. She does no surgeries so the cost of her liability insurance is low.

There are other doctors who have set up health spas, too, and are in the Botox business.

 

[Parts Unknown]

Interesting article I saw today:

http://www.investors.com/NewsAndAnalysis/Article.aspx?id=506199

Ugh, Investors Business Daily has been a wretched resource in this debate. They have been a recurrent vehicle for Betsy McCaughey's insane rants.

Check the NEJM: 62.9% of surveyed physicians support a combination of private and public options, and 9.6% support a solo public option (read single payer).

While I would never say the current system doesn't have deep problems, I have been seeing exposes on this very topic of doctors fleeing medicine since at least the late 1980's. It's unfortunate that the real wolf hides amongst so much crying.

 

[deleted74029]

Chances are some RN, NP or PA will have a more expensive house and car.

Eh doubt it unless you're a resident or fresh out of residency.

 

[steelerfans888]

You are free to spend your money on whatever you want. Nobody is going to feel sorry for you during the tough days.

what tough days? This isnt finance or engineering where I can be laid off any second. Medicine is the most stable profession. As long as I am physically and mentally capable i am guaranteed high income.

 

[laxer]

My father is a family doctor and has been in private practice in both the US and Canada. He does make more money here, but his overhead is also MUCH higher. To soften the blows of the meager insurance reimbursements, he offers out of pocket services such as immigration physicals and drug addiction treatment. In Canada, he had one secretary that scheduled all appointments and did all of the billing. In NY he needs to have three secretaries working at a time to deal with all of the insurance bs. I doubt any truly effective health care reform will occur for at least another 10 years. If the situation doesn't improve by the time I have finished my training, I would seriously consider moving back to Canada.

 

[mrmilad]

To Obama and the Health Insurance Industry :

"I have spread my dreams under your feet;
Tread softly because you tread on my dreams" - Butler

 

[womp]

That poll from IBD is pretty BS. It's a mail-in poll probably with a bias toward older doctors who are about to retire anyway.

NEJM poll below:

Panel B: Support expansion of Medicare to include adults between the ages of 55 and 64 year:

 

[steelerfans888]

Who says you will be one of the doctors that makes $250k a year. Over half of doctors in our country earn in the $150k area. What if you have really high malpractice insurance, etc, etc. What if you get divorced? What if your house burns down and you maxed out all of your income with your boat, house in Florida (when you live in Seattle), etc, etc. You have much to learn about life.

first of all 150K is not a bad salary. Stuff like that can happen to anyone but with medicine you will always have a job and be able to pay off any debts you end up with.

 

[womp]

first of all 150K is not a bad salary. Stuff like that can happen to anyone but with medicine you will always have a job and be able to pay off any debts you end up with.

It's not a bad salary, except you don't get it until you are in your 30's. The average college-educated male ages 45-49 makes $100,000.

A pharmacist works 38-42 hours a week and nets $100k to $120k at CVS. No residency, no call, no MCAT. Most of the primary care doctors I know work close to 60 hours a week and make barely more than $120k.

 

[iCY]

Haha okay, I think the real reason we think that the OB woman who quit is an idiot, is not because she was complaining about making enough money. It's that she quit and became a jewelry designer. WTF?! This makes me question her judgment to begin with (and the medical school admissions committee that accepted her).

what an idiotic comment. do you really have nothing better to say than to show how stupid she is by poking fun of the adcom? seriously thats the best argument you could come up with? pathetic

how about.....she had enough money saved up so she quit medicine and did something else for fun ? people knit when they retire..she designs jewlery, uses her creativity.

so many stupid pre-meds on this fourm. and yes theres plenty of MONEY IN MEDICINE but think of a bell curve guys....it doesnt apply to the majority and not everyone can be in the majority. have you people never lived a day outside of your textbook? the world doesnt work out like it does in your optimistic dreams.

most of you are probably going to go to med school, realize how inefficient of a student you really are, get 70s on tests and end up with only PASS for most of your classes, not get into the tier 1 residencies/specialties, end up just like this woman did and say damn i wasted so many years of my life.


if i ever get to the point where my career frustrates me more than I enjoy it, i will also quit and find something i can enjoy. the doc in the article took up jewlery desigining.....ill paint?

 

[Kramerica]

That poll from IBD is pretty BS. It's a mail-in poll probably with a bias toward older doctors who are about to retire anyway.

NEJM has been pretty pro-goverment biased for a quite a while. When I was reading Herzinger's Who Killed Healthcare in America (granted the book is libertarian) she cited several examples. I'm at work and don't have the book on me but can take a look later. It is difficult to find non-partisan polls in this debate either they are hugely conservative or liberal.

 

[Parts Unknown]

NEJM has been pretty pro-goverment biased for a quite a while. When I was reading Herzinger's Who Killed Healthcare in America (granted the book is libertarian) she cited several examples. I'm at work and don't have the book on me but can take a look later.

I just now stumbled across a pretty hilarious blog entry on this IBD vs. NEJM debate. It pretty much rips your "poll" a new one:

It turns out that the poll was a mail-in questionaire, not the usual phone-based poll. This is important because of selection bias; doctors who are predisposed to feeling threatened by proposed health care legislation will be more likely to respond. Also, mail-in responses tend to be skewed towards older repsondents, who also are more likely to be skeptical, or at least more willing to retire.

The poll itself was terribly written; one of the questions read, "Do you believe the government can cover 47 million more people and it will cost less and the quality of care will be better?" which is really three questions, and heavily biased towards skepticism (indeed, 71% answered No). It's worth noting that the pollling outfit has a horrendous track record; polling demigod Nate Silver comments:

As we learned during the [Presidential] campaign -- when, among other things, they had John McCain winning the youth vote 74-22 -- the IBD/TIPP polling operation has literally no idea what they're doing. I mean, literally none. For example, I don't trust IBD/TIPP to have competently selected anything resembling a random panel, which is harder to do than you'd think.
​

Nate also notes that the poll hasn't released any details of methodology, and bizarrely also says "responses are still coming in." Responses are still coming in? Why would they release any results until all responses have come in? The percentages are utterly meaningless otherwise! Nate advises people to ignore the poll entirely; it's going to be taken up by right-wing idealogues of course, but that was its intended audience from the beginning.

 

[NoMoreAMCAS]

Who says you will be one of the doctors that makes $250k a year. Over half of doctors in our country earn in the $150k area. What if you have really high malpractice insurance, etc, etc. What if you get divorced? What if your house burns down and you maxed out all of your income with your boat, house in Florida (when you live in Seattle), etc, etc. You have much to learn about life.

****, he didn't say he was ******ed with money. How about, move to somewhere with lower malpractice costs, insure your home, don't buy multiple houses unless you can actually afford them. They're all common sense. Buying a bunch of **** you CAN afford will not ruin you.

 

[Kramerica]

That poll from IBD is pretty BS. It's a mail-in poll probably with a bias toward older doctors who are about to retire anyway.

From NEJM supplementary materials section:

Survey Administration
We adopted the Total Design Method to optimize physician survey response.3 This
approach is designed to minimize the respondent's burden by using a brief survey with
personalized content (personalized letter, signed cover letter, postage stamps) and
follow-up contacts. The mailed survey was sent in three waves.

 

[Parts Unknown]

From NEJM supplementary materials section:

Well, if the NEJM has that bias and still turned up 72% support for a public option, you guys are really ****ed.

 

[Food]

Agreed, what would be the point in having money if you aren't going to spend it?

It's not about spending money. I have no problem with spending money. It's just how I spend it and what I spend it on that is an issue. For example:

Why get a BMW or Mercedes? Seriously? Why? Every other "rich" person has one. It's not like it sets you apart. Plus a "luxury" car is a terrible investment. You lose so much money on cars. If you like cars, buy a rare car. Every time I seen a BMW, Mercedes, Infinity, etc I roll my eyes. They are too common. I'd much rather invest in a car that is actually worth seeing. I like to set myself apart. I don't want to join the ranks of a group of people who buy cars because they are status symbols. To me, humility accompanied by financial prowess is a powerful combination. I have more respect for Warren Buffet than every other rich person in the world combined.

 

[DrYoda]

Why get a BMW or Mercedes? Seriously? Why? Every other "rich" person has one. It's not like it sets you apart. Plus a "luxury" car is a terrible investment. You lose so much money on cars. If you like cars, buy a rare car. Every time I seen a BMW, Mercedes, Infinity, etc I roll my eyes. They are too common. I'd much rather invest in a car that is actually worth seeing. I like to set myself apart. I don't want to join the ranks of a group of people who buy cars because they are status symbols. To me, humility accompanied by financial prowess is a powerful combination. I have more respect for Warren Buffet than every other rich person in the world combined.

You make a good point, to gain real respek your car needs to be six-figures plus!

j/k.





I agree on terrible investment, I only buy used cars for that reason and probably allways will.

 

[deleted74029]

How is driving an SUV, a good sized house (think $400k in Madison, WI) and a family of two any different than your average couple that both have college degrees and make a combined income of $65k-$100? To go above that, you are making risks. Last time I checked, this couple, if the doctor is single that has $250k of debt, will live a better life as far as money goes for at least a decade....

True, but most doctors are probably married, and another fact that seems to be unbeknownst to most posters on here; life doesn't suddenly stop at 35....or even 45.

 

[Red Leader]

This is pretty exciting news. I can't wait to become a doctor then quit.

Just kidding! I will fight the man with my scalpel!!

 

[NoMoreAMCAS]

It's not about spending money. I have no problem with spending money. It's just how I spend it and what I spend it on that is an issue. For example:

Why get a BMW or Mercedes? Seriously? Why? Every other "rich" person has one. It's not like it sets you apart. Plus a "luxury" car is a terrible investment. You lose so much money on cars. If you like cars, buy a rare car. Every time I seen a BMW, Mercedes, Infinity, etc I roll my eyes. They are too common. I'd much rather invest in a car that is actually worth seeing. I like to set myself apart. I don't want to join the ranks of a group of people who buy cars because they are status symbols. To me, humility accompanied by financial prowess is a powerful combination. I have more respect for Warren Buffet than every other rich person in the world combined.

Sweet, so don't get a BMW or Mercedes. Personally, I would just go buy whichever car I liked the most. If i don't like the way it looks and drives, i'm not going to want to drive it.

So lets say you're lucky enough to make good money, 400k a year, what would you spend it on? You want to live in a regular middle class neighborhood and drive a camry, what are you going to do with your money?

 

[womp]

So lets say you're lucky enough to make good money, 400k a year, what would you spend it on? You want to live in a regular middle class neighborhood and drive a camry, what are you going to do with your money?

Buy a sailboat and go scuba diving in Australia during the winters here.

Plenty of better ways to spend money than buying a Mercedes that breaks down three times a year.

 

[Food]

Sweet, so don't get a BMW or Mercedes. Personally, I would just go buy whichever car I liked the most. If i don't like the way it looks and drives, i'm not going to want to drive it.

So lets say you're lucky enough to make good money, 400k a year, what would you spend it on? You want to live in a regular middle class neighborhood and drive a camry, what are you going to do with your money?

Buy Starcraft 2. On a serious note though, there are creative ways to use money. It just requires creative interests. I believe I have creative interests. In the end, I just want to live within my means.

 

[NoMoreAMCAS]

Buy a sailboat and go scuba diving in Australia during the winters here.

Plenty of better ways to spend money than buying a Mercedes that breaks down three times a year.

So you still want to spend the money, that's cool. That's all i was getting at, you have to blow it on something.

You can get a mercedes or bmw for 30-40k, do you guys honestly think thats too much? I personally just buy cars that are slightly used because you get a HUGE discount. But even new, you could pick up one of those cars for a pretty low cost.

And just to be on topic: yeah i'd quit if being a doctor sucked.

 

[NoMoreAMCAS]

Buy Starcraft 2. On a serious note though, there are creative ways to use money. It just requires creative interests. I believe I have creative interests. In the end, I just want to live within my means.

Lol, isn't that a computer game? Do you really have to wait another 10 years to get it?

 

[NoMoreAMCAS]

Buy Starcraft 2. On a serious note though, there are creative ways to use money. It just requires creative interests. I believe I have creative interests. In the end, I just want to live within my means.

Agreed. I like to a do a lot of stuff, i can find endless uses for money. Just to make sure there's no confusion, I wasn't advocating living beyond your means. But if you've worked hard and you're now making good money, blow it on whatever makes you happy.

 

[Red Leader]

Lol, isn't that a computer game? Do you really have to wait another 10 years to get it?

Actually we have been waiting over 10 years for Starcraft 2 man...

As for medicine vs. everything else you should always choose medicine or manager with daddy issues at a cardboard box company. Anything else kinda sucks. In case you ever get lost on an island.

 

[Food]

So you still want to spend the money, that's cool. That's all i was getting at, you have to blow it on something. What else you gonna do with it?

You can get a mercedes or bmw for 30-40k, do you guys honestly think thats too much? I personally just buy cars that are slightly used because you get a HUGE discount. But even new, you could pick up one of those cars for a pretty low cost.

And just to be on topic: yeah i'd quit if being a doctor sucked.

I don't know man, it's just about perception to me. I don't want to be perceived to be fitting a certain "type" or "group" in society. I feel like living in a well known rich neighborhood, buying an M6 or C class would put me in with a crowd I really have very little in common with (and rather less respect for - again this is wrong, but I suppose the people I grew up around are somewhat responsible for this). I just wanted to be a doc who was like a normal person, drove a normal car and didn't socialize exclusively with other doctors.

Call me an idealist, but I see my refusal to buy a luxury car as an attempt to prevent my inevitable transformation from an ideal-driven person to a material possession-driven person. I figure the more I try now, the less I will end up hating myself on my deathbed.

 

[Food]

Actually we have been waiting over 10 years for Starcraft 2 man...

As for medicine vs. everything else you should always choose medicine or manager with daddy issues at a cardboard box company. Anything else kinda sucks. In case you ever get lost on an island.

Yeah. More like 12-13 years now. Whatever, Blizzard is dead to me.

 

[Red Leader]

Yeah. More like 12-13 years now. Whatever, Blizzard is dead to me.

SC 2 looks pretty sick though. I doubt my computer will be able to run it. At least the Korean progamers are still sticking with BW for now so its not going to die off anytime soon.

btw I remember you had a marine as your profile pic before.

 

[NoMoreAMCAS]

I don't know man, it's just about perception to me. I don't want to be perceived to be fitting a certain "type" or "group" in society. I feel like living in a well known rich neighborhood, buying an M6 or C class would put me in with a crowd I really have very little in common with (and rather less respect for - again this is wrong, but I suppose the people I grew up around are somewhat responsible for this). I just wanted to be a doc who was like a normal person, drove a normal car and didn't socialize exclusively with other doctors.

Call me an idealist, but I see my refusal to buy a luxury car as an attempt to prevent my inevitable transformation from an ideal-driven person to a material possession-driven person. I figure the more I try now, the less I will end up hating myself on my deathbed.

Well if you ever need to rid yourself of all that extra money, just PM me. I love to travel, party, do pretty much anything adventurous. I'll give your money a nice home.

 

[NoMoreAMCAS]

Actually we have been waiting over 10 years for Starcraft 2 man...

As for medicine vs. everything else you should always choose medicine or manager with daddy issues at a cardboard box company. Anything else kinda sucks. In case you ever get lost on an island.

Dude, that blows. If i had to wait that long for my favorite game's sequel, I probably would have just given up by now.

 

[iCY]

I will call your "you're an idiot" and raise you "you're a giant *****ic imbecile who is so IQ deficient that it is actually somewhat laughable"

She went into Jewelry because she thought it might be fun to do and she's retiring? You have feces for brains, my friend. No, it's because she gave up on medicine. She loves Jewelry more than medicine. That's a little disappointing. And she seemed all bitter about it. So yeah, I think she went wrong somewhere in her path to medicine. I have fun doing lots of other things. But If I have a chance at a career in any of em, I'd pick medicine. Even if that means I have to live in a rat-infested hell hole.

Also, I'd rather be a "stupid pre-med" than be a patronizing and presumptuous pre-med whose idea of a coherent argument means accusing other people of being "optimistic" and "pathetic". Seriously. Just shut up. I could talk circles around you for hours. Save yourself some headaches.

so typical. full of talk, mostly bullsh*t talk.

"so yeah, i think she went wrong somewhere" what a great argument

how about, she doesnt need anymore money so she quit her ****ty job and doesn't care if naive immature people like you don't understand and judge her for it

 

[Charles English]

always choose medicine or manager with daddy issues at a cardboard box company. Anything else kinda sucks. In case you ever get lost on an island.

yeah, i'm totally brushing up on my boar hunting skills ... you know, just in case

 

[DrYoda]

Actually we have been waiting over 10 years for Starcraft 2 man...

I remember I bought Starcraft in junior high. Now I'm in med school and still no Starcraft II.

 

[mcattitude]

Tort reform, now!!

Different finger directed at malpractice lawyers...

 

[loren646]

Wait until obamacare is in place. Doctors of the past will be no more. You'll be booked all day. You'll make cents on the dollar for each person coming in the door. you'll see 10 patients an hour for 12 hour day and make paltry money.

Don't believe me? I've seen it in Mass. Look there.

 

[Food]

Wait until obamacare is in place. Doctors of the past will be no more. You'll be booked all day. You'll make cents on the dollar for each person coming in the door. you'll see 10 patients an hour for 12 hour day and make paltry money.

Don't believe me? I've seen it in Mass. Look there.

It's like you people have a recording placed in your voice box. Same words, every day, all year.

 

[mrmilad]

Wait until obamacare is in place. Doctors of the past will be no more. You'll be booked all day. You'll make cents on the dollar for each person coming in the door. you'll see 10 patients an hour for 12 hour day and make paltry money.

Don't believe me? I've seen it in Mass. Look there.

Listen hard times mean sacrifice, everyone out there is hurting right now and people have to make sacrifices. Yes we all want to have successful careers and make money, but becoming a physician is more than that. You have to want to help people, and there is always going to be a need for someone who cares and will work for the patient.

 

[DrYoda]

Listen hard times mean sacrifice, everyone out there is hurting right now and people have to make sacrifices. Yes we all want to have successful careers and make money, but becoming a physician is more than that. You have to want to help people, and there is always going to be a need for someone who cares and will work for the patient.

Lol. How does the temporary recession compare with what will most likely be a permanent sacrifice on the part of physicians?

 

[DrYoda]

Wait until obamacare is in place. Doctors of the past will be no more. You'll be booked all day. You'll make cents on the dollar for each person coming in the door. you'll see 10 patients an hour for 12 hour day and make paltry money.

Don't believe me? I've seen it in Mass. Look there.

Or we can look to other countries. The only reason that physicians here put in crazy hours is that they can still generate enough per hour to make up lost wages (from the reimbursment cuts) by working longer hours. If reimbursment drops too much the 60+ hour work week no longer becomes worth it.

If some kind of pay physicians get payed peanuts bill gets passed I'm guessing were going to eventually see alot more 40 hrs/week, 1 hour lunch break type practices.

 

[pharmacy85]

I wish I had your personality I unfortunately am a materialistic person. But I mean if we do end up becoming doctors there's nothing wrong with indulging yourself i mean we work extremely hard. Everyone has there own way of bragging. For me it would be a new mercedes. For you its showing off how altruistic and righteous you are

this made me lol

 

[Food]

Lol. How does the temporary recession compare with what will most likely be a permanent sacrifice on the part of physicians?

I honestly think this recession / economic downturn / decline of American economic prowess will be longer than any sacrifice on the part of physicians.

 

[Food]

I wish I had your personality I unfortunately am a materialistic person. But I mean if we do end up becoming doctors there's nothing wrong with indulging yourself i mean we work extremely hard. Everyone has there own way of bragging. For me it would be a new mercedes. For you its showing off how altruistic and righteous you are

Yeah, I can't tell if you're kidding or being serious. Oh well. We're all materialistic. I just want to be unique in my materials. I hate conforming to particular societal standards (where those standards are superficial).

 

[neuromd03]

Or we can look to other countries. The only reason that physicians here put in crazy hours is that they can still generate enough per hour to make up lost wages (from the reimbursment cuts) by working longer hours. If reimbursment drops too much the 60+ hour work week no longer becomes worth it.

If some kind of pay physicians get payed peanuts bill gets passed I'm guessing were going to eventually see alot more 40 hrs/week, 1 hour lunch break type practices.

What will likely happen is that more and more doctors will form partnerships to share overhead. They will share office space, supplies, and employees, such as receptionists, medical assistants, and billers. Because there are only so many exam rooms to go around, doctors will likely have to cut the number of days they practice. They may even change their office hours so that two doctors could share one exam room for the whole day. How is this done? One doctor would work from 7 AM to 2 PM and the other doctor would take over from 2 PM to 9 PM. They could alternate schedules to keep things fair and to increase the time slots available for patients who themselves have busy schedules and can only be seen before or after work. They may also lease out the office space on weekends when they are closed.

There are other ways to slash overhead, such as outsourcing transcription services to firms overseas and automating scheduling with web-based applications (simiilar to booking a reservation for a restaurant). It takes some creativity and some initiative on the part of the physician to apply sensible business practices to the private practice model.

Some physicians may even find working 30 hour weeks for half the regular pay more reasonable than working 60+ hours for a large income, especially when they have family and need more time than money.

 

[womp]

So you still want to spend the money, that's cool. That's all i was getting at, you have to blow it on something.

You can get a mercedes or bmw for 30-40k, do you guys honestly think thats too much? I personally just buy cars that are slightly used because you get a HUGE discount. But even new, you could pick up one of those cars for a pretty low cost.

It's not just the cost. A Mercedes just isn't that good of a car and smacks of faux prestige and showing off. A high school dropout with a $399/mo loan can drive a Mercedes. If I'm going to spend money, I'll spend it on gaining new and amazing experiences (that I would otherwise not easily get on a $60k salary), not sitting on the highway in a less-than-reliable black Mercedes, an experience that is essentially the same in a black Honda Accord, at half to a third of the cost (new or used). And doesn't buying a used Mercedes seem even more _____? I'll let you finish that sentence.

On the other hand, climbing Mt. Fuji is a considerably different experience than hiking the local hill. Having a cook around would also be pretty nice since the only thing I can cook is rice and ramen. Maybe a cooking class? And this one concerns me personally: how about being able to have enough disposable income so that your aging parents could have excellent home assistants, and not be forced into a dilapidated nursing home?

 

[halekulani]

I swear to God, if I ever become a doctor (which seems more hopeless each day), I will never have a BMW, Mercedes, etc. Or a large house. At most, I will have the type of house my parents raised me in. I didn't spend all of high school and college taking hard classes and enjoying learning just so that I could eventually buy a symbol of status that I ridiculed other people for having.

you judge people based on what car they drive and what kind of house they live at

gee, ever think about growing up a little?

 

[Food]

It's not just the cost. A Mercedes just isn't that good of a car and smacks of faux prestige and showing off. A high school dropout with a $399/mo loan can drive a Mercedes. If I'm going to spend money, I'll spend it on gaining new and amazing experiences (that I would otherwise not easily get on a $60k salary), not sitting on the highway in a less-than-reliable black Mercedes, an experience that is essentially the same in a black Honda Accord, at half to a third of the cost (new or used). And doesn't buying a used Mercedes seem even more _____? I'll let you finish that sentence.

On the other hand, climbing Mt. Fuji is a considerably different experience than hiking the local hill. Having a cook around would also be pretty nice since the only thing I can cook is rice and ramen. Maybe a cooking class? And this one concerns me personally: how about being able to have enough disposable income so that your aging parents could have excellent home assistants, and not be forced into a dilapidated nursing home?

Exactly - thank you. See? Whatever happened to being creative.

 

[womp]

The saddest thing would be to spend a decade training yourself to be a doctor and foregoing a decade of earnings, amassing a mortgage of debt, have your parents support you a little all that time, only to be still unable to support your own parents' care when you come out and when they need it most.

New York Times just had an article today on the high costs of caring for aging parents. It makes me anxious just thinking about it. When I get out of residency, my parents are going to be so old. It would not be worth it if I barely broke $100k then; it would be more a slap to the face.

 

[neuromd03]

This is how I see things turning out as well. Also outsource coding.

Coding is best done by the physician since only the physician knows the diagnosis. By coding I mean writing down the ICD-9 code when you submit the CMS-1500 claim form. I do this myself since it's not that hard. Plus, I do not want to risk having an amateur biller engage in billing fraud. Even if you hire a biller (usually for 6% of the total charges), it's a good idea to double check the biller's work to improve the odds of a clean claim submission.