NYT article about EmCare

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To play devils advocate. Once you have market share. Shouldn't you get paid the most you can? If insurance companies can gang up and drive reimbursement lower for medical providers for them to be "in network". If both parties cannot come to agreement. The consumers will end up paying more.

And that's why health care in the USA is so expensive.

My buddy in Texas bills $400/unit out of network for anesthesia services.

So it's not just the big AMCs doing it.

So would you rather negotiate $70/unit in network like my brother in Los Angeles or $400/unit out of network in Texas? Remember the CEO of these health companies make millions each year.
 
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anbuitachi said:
I dont know if 'shady' is the right word. EmCare is a business and they are doing what all businesses do, increase profits. Their goal is to maximize profits, not to maximize patient care..
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And that's what's wrong with healthcare in this country.

In the past when health premiums were low and deductible were low. Patient out of pocket costs were low, being "over billed" didn't have any impact on patient since "everything was paid for"

But as self employed doc up to earlier this year. I was paying $1700/month for family of 4 plus a $7200 in network deductible and a $14000 out of network max cost.

So if my basics emergency appy were billed at 20k. I'm basically paying almost everything out of pocket if it's billed out of network. Insurance would pay $6000 and I'm responsible for the $14k.

95% of Americans simply cannot afford to pay those type of bills.

Even as a doc making 200-500k. Paying 20k plus a year on just health premiums and another 10-15k on out of pocket. That's potentially more than 10% of you salary. It's not sustainable.
 
aneftp said:
And that's what's wrong with healthcare in this country.

In the past when health premiums were low and deductible were low. Patient out of pocket costs were low, being "over billed" didn't have any impact on patient since "everything was paid for"

But as self employed doc up to earlier this year. I was paying $1700/month for family of 4 plus a $7200 in network deductible and a $14000 out of network max cost.

So if my basics emergency appy were billed at 20k. I'm basically paying almost everything out of pocket if it's billed out of network. Insurance would pay $6000 and I'm responsible for the $14k.

95% of Americans simply cannot afford to pay those type of bills.

Even as a doc making 200-500k. Paying 20k plus a year on just health premiums and another 10-15k on out of pocket. That's potentially more than 10% of you salary. It's not sustainable.
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That's just because you suck as an anesthesiologist, and are not able to find yourself a decent job. 😛
 
okayplayer said:
The Company Behind Many Surprise Emergency Room Bills

Wonder how much shady billing is going on with the various AMCs.
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Why is this shady?

This was a small-town hospital, wanting to offer 24/7 ER services. They had trouble staffing it themselves and turn to EmCare. EmCare does the job - no apparent argument there - but someone has to pay for it. They are not in business to give away their services. The hospital is being disingenuous at best with their attitude.

News flash - not every physician/physician group is going to be in EVERY network that their hospitals are members of, nor should they be, nor should they have to be. Some insurance companies - shocking - attempt to push reimbursement below Medicare/Medicaid rates. I don't know about your practice, but Medicare rates of under $75/hr doesn't pay an anesthetist's salary, much less an anesthesiologist or an ACT duo, much less cover the overhead on top of that. You can only suck up the loss from low government payments so much, and passing off the underpayment to other payors is what happens.

This is a widespread problem with all hospital-based specialties. Hospitals pressure groups to be in the same networks that they are, but that's just not always possible. At a certain point, the offer becomes unaffordable, and you walk. It's got nothing to do with being shady. It's got everything to do with simple economics. Income<<Expenses=ain't gonna happen.
 
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jwk said:
Why is this shady?

This was a small-town hospital, wanting to offer 24/7 ER services. They had trouble staffing it themselves and turn to EmCare. EmCare does the job - no apparent argument there - but someone has to pay for it. They are not in business to give away their services. The hospital is being disingenuous at best with their attitude.

News flash - not every physician/physician group is going to be in EVERY network that their hospitals are members of, nor should they be, nor should they have to be. Some insurance companies - shocking - attempt to push reimbursement below Medicare/Medicaid rates. I don't know about your practice, but Medicare rates of under $75/hr doesn't pay an anesthetist's salary, much less an anesthesiologist or an ACT duo, much less cover the overhead on top of that. You can only suck up the loss from low government payments so much, and passing off the underpayment to other payors is what happens.

This is a widespread problem with all hospital-based specialties. Hospitals pressure groups to be in the same networks that they are, but that's just not always possible. At a certain point, the offer becomes unaffordable, and you walk. It's got nothing to do with being shady. It's got everything to do with simple economics. Income<<Expenses=ain't gonna happen.
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Of course it's shady.

If the hospital is in an insurance network, so should be its ER. We are not talking about elective stuff here. Patients shouldn't have to worry that they go to an "in-network" hospital and get hit with shady overpriced "out-of-network" bills. It's absolutely ridiculous to expect an inpatient to ask every single provider about his/her network status in a non-elective situation. The law should oblige inpatient providers to either contract with the same networks as the hospital or not be able to take care of an inpatient (unless they have a pre-existing outpatient relationship).

The alternative fix would be to oblige insurers to charge every patient based only on the network status of the facility, regardless of the status of the various providers, and pay all bills generated during the hospitalization (so if a patient gets charged out-of network rates, s/he would still pay only in-network amounts). That way things would change into better very fast, because insurers would do something about the practice, something little people can't.

This is one of the reasons why we have medical bankruptcies in this country, because of all this unethical crap going on. This is why it's so important to have organizations like the Consumer Financial Protection Bureau (which Trump and his cronies want to castrate), for every sector of the economy.
 
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FFP said:
Of course it's shady.

If the hospital is in an insurance network, so should be its ER. We are not talking about elective stuff here. Patients shouldn't have to worry that they go to an "in-network" hospital and get hit with shady overpriced "out-of-network" bills. It's absolutely ridiculous to expect an inpatient to ask every single provider about his/her network status in a non-elective situation. The law should oblige inpatient providers to either contract with the same networks as the hospital or not be able to take care of an inpatient (unless they have a pre-existing outpatient relationship).

The alternative fix would be to oblige insurers to charge every patient based only on the network status of the facility, regardless of the status of the various providers, and pay all bills generated during the hospitalization (so if a patient gets charged out-of network rates, s/he would still pay only in-network amounts). That way things would change into better very fast, because insurers would do something about the practice, something little people can't.

This is one of the reasons why we have medical bankruptcies in this country, because of all this unethical crap going on. This is why it's so important to have organizations like the Consumer Financial Protection Bureau (which Trump and his cronies want to castrate), for every sector of the economy.
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Can't you see what you are arguing for puts hospital based doctors at the mercy of insurance companies? Being forced to accept whatever crappy terms are offered because they are forced to be in network. That's complete BS. The only leverage we have for a decent contract is the ability to bill out of network. The insurance companies sitting across the table are as shady as they come and are willing to use every advantage they can. Why should doctors be sandbagged at the negotiating table?
 
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FFP said:
Of course it's shady.

If the hospital is in an insurance network, so should be its ER. We are not talking about elective stuff here. Patients shouldn't have to worry that they go to an "in-network" hospital and get hit with shady overpriced "out-of-network" bills. It's absolutely ridiculous to expect an inpatient to ask every single provider about his/her network status in a non-elective situation. The law should oblige inpatient providers to either contract with the same networks as the hospital or not be able to take care of an inpatient (unless they have a pre-existing outpatient relationship).

The alternative fix would be to oblige insurers to charge every patient based only on the network status of the facility, regardless of the status of the various providers, and pay all bills generated during the hospitalization (so if a patient gets charged out-of network rates, s/he would still pay only in-network amounts). That way things would change into better very fast, because insurers would do something about the practice, something little people can't.

This is one of the reasons why we have medical bankruptcies in this country, because of all this unethical crap going on. This is why it's so important to have organizations like the Consumer Financial Protection Bureau (which Trump and his cronies want to castrate), for every sector of the economy.
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I got charged 1000$ when i went to see an ENT whos covered by my insurance, but apparently the hospital facility isn't so the 1000$ charge is for the hospital. I found that to be ******ed. Luckily i was able to get them to waive it since i was a med student at the hospital at the time
 
nimbus said:
Can't you see what you are arguing for puts hospital based doctors at the mercy of insurance companies? Being forced to accept whatever crappy terms are offered because they are forced to be in network. That's complete BS. The only leverage we have for a decent contract is the ability to bill out of network. The insurance companies sitting across the table are as shady as they come and are willing to use every advantage they can. Why should doctors be sandbagged at the negotiating table?
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Good point. That's why my alternative fix is probably better. Anyway, it's completely unfair to patients to get out-of-network pricing at an in-network hospital, for non-elective healthcare.
 
FFP said:
Good point. That's why my alternative fix is probably better. Anyway, it's completely unfair to patients to get out-of-network pricing at an in-network hospital, for non-elective healthcare.
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Yeah absolutely agreed, I only know where to go based on what "facilities" are covered by my insurance - how the heck am I supposed to know ER Group Y in Hospital X is out of network? This isn't the first I've heard of this.
 
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anbuitachi said:
So much easier if we can get universal healthcare and salary all doctors. 500k for 40hr work week for anesthesiologist, 1.5x hrly rate for overtime
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I'll have what he's having.

It's a nice fantasy, but universal healthcare will not lead to such salaries and reduced work hours for physicians here in the states.

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algosdoc said:
Keeping it in perspective- the median income for a full time worker in the US is $29,000. When anesthesiologists make 11-15 times this amount per year, it is difficult for the population to draw any other conclusions than anesthesiologists are indeed "getting rich".
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We easily have 11-15x the training, have lost 11-15 employed years acquiring said training, and couldn't be replaced by 1/(11-15)th of the population. People are entitled idiots in this country.

If some sort of universal pay for physicians drops to 150-200k you're going to see a future of midlevels only in medicine. The pool of people who will go through what we have for 200k will be drastically smaller. And that's if educational loans are paid by the govt.
 
Robotic Wis-Hipple said:
We easily have 11-15x the training, have lost 11-15 employed years acquiring said training, and couldn't be replaced by 1/(11-15)th of the population. People are entitled idiots in this country.

If some sort of universal pay for physicians drops to 150-200k you're going to see a future of midlevels only in medicine. The pool of people who will go through what we have for 200k will be drastically smaller. And that's if educational loans are paid by the govt.
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only way is for government to make medical education nearly free. or have a robust loan forgivement plan. otherwise, med school alone is costing ~250k these days.

but i think salaried doc 500k and universal healthcare can decrease cost a lot. currently physician salary is <10% of total healthcare spending. universal healthcare should cut out some of the waste. and salaried docs will no longer be pushing for more testing, more unneccessary surgeries, etc. And you wont need as many administrators/billers.

also transition everyone to same EMR would help too. universal healthcare, same emr, will help w research studies, and in long run reduce costs
 
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There's a good discussion about this article in the EM forum (
NYT article on EmCare).
Between hospitals, insurance companies, Anesthesia Management Companies, corporate EM entities, and other similar corporate medical groups, doctors and especially patients are getting absolutely screwed.

We are fools to think it'll get better anytime soon. American healthcare is the trainwreck we can't look away from. The corporate lobbyists are legislating through lining the pockets of legislators. Our patients (and us by extension) don't stand a freaking chance.

We absolutely have to get corporate interests out of patient care. There's money to be had by the big, greedy ****ers, so I don't see it happening.
 
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anbuitachi said:
only way is for government to make medical education nearly free. or have a robust loan forgivement plan. otherwise, med school alone is costing ~250k these days.

but i think salaried doc 500k and universal healthcare can decrease cost a lot. currently physician salary is <10% of total healthcare spending. universal healthcare should cut out some of the waste. and salaried docs will no longer be pushing for more testing, more unneccessary surgeries, etc. And you wont need as many administrators/billers.

also transition everyone to same EMR would help too. universal healthcare, same emr, will help w research studies, and in long run reduce costs
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Look at the DoD, VA, or Indian Health System. That is not the case. All three are bloated systems filled with redundancy, waste, and tons of administrators and middle men who add nothing to patient care, yet pull in good salaries with extensive benefits and pensions.

Loan forgiveness sounds good in theory, but it's just shifting hundreds of millions of dollars per year onto the backs of the taxpayers, as they end up paying back our loans, rather than us. Do you think that is something that the lay public is willing to do when we'd still be 'rich' under that system?

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Student loan forgiveness wasnt really intended for high-earning doctors and lawyers. It was written for teachers, social workers and higher ed grads who can expect an income somewhere between 35-60Kish, making it much harder to pay off graduate and possibly undergraduate debt. But docs and JDs jumped on the bandwagon in droves, of course.

The program for now is totally unsustainable, but the easy answer is to place some sort of a cap on forgiveness tied to income (they tried to do that by stipulating working for a nonprofit, but particularly for physicians almost all hospitals and academic centers fall into this definition and still pull in a high wage). The high earners are the low-hanging fruit there, fair or not. Maybe we'll get lucky and the gov will still pay some proportion, but who knows.
 
algosdoc said:
I don't think the public is composed of idiots and in most cases, doctors do not have 11 times the education as the median worker. Doctors incomes in America are certainly part of the very high health care cost in the country. Compared to other countries: Top 10 Countries with the Highest Salaries for Doctors
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Did you actually read that article?

3. United States
The USA comes in at number three, much to the surprise of many who think these doctors make the most. A specialist can expect to make $230,000 a year while a general practitioner makes roughly $161,000.

Those numbers aren't even close to true. First, we don't really have many GPs anymore. Second, FPs are making more than 161k on average - everyone from Medscape to MGMA to the AAFP agree on that.

Also, specialists only making 230k? That's just plain ridiculous.
 
VA Hopeful Dr said:
Also, specialists only making 230k? That's just plain ridiculous.
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There are plenty of nephrologists, infectious disease docs, endocrinologists, rheumatologists, neurologists, hospitalists, pediatric specialists, etc..making less than 230k. Most of the CRNAs I work with make more than my non-procedural IM specialist friends.
 
algosdoc said:
I don't think the public is composed of idiots and in most cases, doctors do not have 11 times the education as the median worker. Doctors incomes in America are certainly part of the very high health care cost in the country. Compared to other countries: Top 10 Countries with the Highest Salaries for Doctors
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What koolaid did you drink? Physician income is small compared to payouts for hospitals, drugs, DME, and compared to what insurance companies are making.
anbuitachi said:
only way is for government to make medical education nearly free. or have a robust loan forgivement plan. otherwise, med school alone is costing ~250k these days.

but i think salaried doc 500k and universal healthcare can decrease cost a lot. currently physician salary is <10% of total healthcare spending. universal healthcare should cut out some of the waste. and salaried docs will no longer be pushing for more testing, more unneccessary surgeries, etc. And you wont need as many administrators/billers.

also transition everyone to same EMR would help too. universal healthcare, same emr, will help w research studies, and in long run reduce costs
Click to expand...
Don't forget tort reform, malpractice insurance costs, product and drug liability costs, costs of CYA practices, etc.
 
GravelRider said:
There are plenty of nephrologists, infectious disease docs, endocrinologists, rheumatologists, neurologists, hospitalists, pediatric specialists, etc..making less than 230k. Most of the CRNAs I work with make more than my non-procedural IM specialist friends.
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Really? Cause I've got an MGMA here on my desk saying different.

Also, are they making enough less to offset the 500k+ ortho, neurosurgery, 300-400+ general surgery, OB/GYN, radiology, anesthesiology, EM, ENT, urology, cardiology, GI, pulmonology, pain management, ophthalmology, psychiatry, heme/onc and dermatology,
 
algosdoc said:
I agree the numbers cited in the incomes for US physicians were far too low and it appears the 2014 report that was reprinted over and over up to 2016 in different sources was based on 2010 data. The 2017 Medscape Physician Compensation survey pegged specialists pay at $316,000 and primary care at $217,000. The overall physician's income average has increased from $206,000 to $294,000 over the past 7 years, or a 43% increase. The top 4 specialties in the survey averaged over $400,000 per year. Using 2015 MGMA data, the medians are much higher than the Medscape report: specialists $412,000 and primary care $241,000. Therefore physician specialists in the US make 14.2 times as much as the medial worker in the US. Based on the incomes of all workers in the US, primary care physicians earn the 98.4th percentile and specialists earn 99.5 percentile.
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What's your argument that they(we) shouldn't make 98th+ percentile?

If you can't take the median person off of the street to replace me, median salary means nothing to me. If it takes you 99 people to find someone who could do my job, then I should be paid as such. I honestly don't see an argument for docs making 60-70th percentile.

This is a political and PR issue. I know real estate agents making >200k annually. You know what the public calls those people? Successful. Why is that ok but we are greedy?
 
algosdoc said:
You can be replaced by a NP making 1/3 as much unless you are a surgeon- that is eventually coming too.
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Perhaps, and we should all be careful what we wish for in that case. But in our field it's more like 1/2 to 60% of my salary. For 36hrs punching a clock and overtime/holiday pay with no liability. Let me pay my loans off and I may sign that contract .
 
algosdoc said:
I don't think the public is composed of idiots and in most cases, doctors do not have 11 times the education as the median worker. Doctors incomes in America are certainly part of the very high health care cost in the country. Compared to other countries: Top 10 Countries with the Highest Salaries for Doctors
Click to expand...

Then you're an idiot. And those salaries quoted in your Mickey Mouse article are a joke.
 
algosdoc said:
I agree the numbers cited in the incomes for US physicians were far too low and it appears the 2014 report that was reprinted over and over up to 2016 in different sources was based on 2010 data. The 2017 Medscape Physician Compensation survey pegged specialists pay at $316,000 and primary care at $217,000. The overall physician's income average has increased from $206,000 to $294,000 over the past 7 years, or a 43% increase. The top 4 specialties in the survey averaged over $400,000 per year. Using 2015 MGMA data, the medians are much higher than the Medscape report: specialists $412,000 and primary care $241,000. Therefore physician specialists in the US make 14.2 times as much as the medial worker in the US. Based on the incomes of all workers in the US, primary care physicians earn the 98.4th percentile and specialists earn 99.5 percentile.
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As well they should. Perhaps you'll donate some of your income to the "less fortunate."
 
Where are you getting 1-3 years after med school in the UK for specially training? Their residencies (and those of pretty much every other Western nation) are longer than ours. So, while they may save a year or two on the front end, with undergraduate and medical school often being lumped together, they add more time on the back end due to longer training time. Of course, they also work less and make more than US residents, so they have that going for them.

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algosdoc said:
The problems with excessive physician compensation in the US compared to other countries and in ratio of income to the median worker income is that at this time, the excessive salaries are indeed justified because of unnecessarily protracted education systems (the US typically requires 8 years to MD then another 4-6 for residency/fellowship or 12-14 years after high school; in England, it is 4-6 years for the MD and 1-3 years thereafter for a total of 5-9 years after high school. In France it is 8-11 years after high school. In Germany it is 7 years after high school.).
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I agree with @psychblender above. In the UK, and other Commonwealth nations like Australia and New Zealand, the typical path is either undergraduate medicine (which is becoming less common) or postgraduate medicine (which is becoming more common). If undergraduate, then it's high school graduation, 5-6 years med school. If postgraduate, then it's high school graduation, 3-4 years bachelor's degree, 4 years med school. Afterwards, whether undergraduate or postgraduate, it's 2 years in the foundation programme (PGY1-2), usually at least one more year to strengthen your CV (e.g., doing an entire year in the ICU) so you can apply for a specialty (PGY3+). Hopefully get in your specialty the following year which is called becoming a registrar (PGY4+). Most (though not all) specialties are then another 5 years minimum to complete (PGY9+). But it's not uncommon to see people in PGY10+ and still a registrar in their specialty. However, if you're fast, then maybe you can finish earlier (e.g., for anaesthetics the absolute minimum time you could finish would be after PGY7). And the traditional degree has been the MBBS, not the MD, though that's changing somewhat too.
 
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A possible trade-off of the government significantly subsidising if not entirely paying for the medical education of its future physicians is that future physicians could be beholden (at least to some degree) to the government. The one who holds the purse strings holds those dependent. That could cash out in many different ways (e.g., perhaps the government will have even more say than it does now in where to allocate physicians in terms of hospital placements around the state or nation based on geographic or population needs, perhaps the government may have more say in what specialties to allocate medical graduates). Historically, Americans have tended to resist this kind of dependency on the government, but who knows what the future holds.
 
algosdoc said:
My information came from the NHS from the UK. Many UK medical schools are 5 years but there are 16 that are now 4 years. If you think about it, the course for medical training is far too long given what is used functionally in a medical job. Yes, yes, it is nice to be well rounded, but the price has become enormous for the luxury of being well rounded with a BS in Chemistry or a BA in Art or Humanities. Fellowship training is super-specialized training that should largely be incorporated into residency, and medical school should be a continuum with residency, not a separate program. As residencies have progressively lengthened and more and more fellowship training added onto the end of residency, the number of years of training is excessive, resulting in overtrained physicians who could largely be trained in lesser programs. I am not suggesting physician salaries should precipitously fall and training programs should collapse, but that indeed the overall length be shortened, the cost controlled, and the government should contribute far more to the cost of that training. Given the amount of training of the US physician and the dichotomy between the length of that training and the rather dismal statistics on patient outcomes in the US compared to international measures, perhaps it is time to recognize that lengthy training programs are unrelated to health care outcomes.
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Aren't the UK med schools that are now 4 years long postgrad? If so, then you still need to do a bachelor's degree like in the US, then get into med school. Given this, plus what I wrote above, the length of training really isn't all the different between the UK and the US, all things considered.

Also, the NHS is currently in a downward spiral. Just Google all the junior physician strikes that have been occurring. The strikes occurred primarily because the UK government slashed the compensation for junior physicians -- i.e., the government slashed their total compensation, while raising their base salaries, so it doesn't seem bad publicly, but obviously UK junior doctors are up in arms about it, while at the same time not giving more than token respite in their workload and work hours. Also, Google to see all the junior physicians leaving the NHS and moving overseas to places like Australia and NZ to seek a better future. In fact, the NHS even started campaigns trying to bring back junior physicians who have left, and essentially saying things like "it's not so bad in the NHS," since so many of their junior doctors have left. There's (ironically) even debate about privatising the NHS in order to try to save it.

In other words, it's not all a bed of roses in the healthcare systems of nations like the UK either.
 
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bashwell said:
Aren't the UK med schools that are now 4 years long postgrad? If so, then you still need to do a bachelor's degree like in the US, then get into med school. Given this, plus what I wrote above, the length of training really isn't all the different between the UK and the US, all things considered.

Also, the NHS is currently in a downward spiral. Just Google all the junior physician strikes that have been occurring. The strikes occurred primarily because the UK government slashed the compensation for junior physicians -- i.e., the government slashed their total compensation, while raising their base salaries, so it doesn't seem bad publicly, but obviously UK junior doctors are up in arms about it, while at the same time not giving more than token respite in their workload and work hours. Also, Google to see all the junior physicians leaving the NHS and moving overseas to places like Australia and NZ to seek a better future. In fact, the NHS even started campaigns trying to bring back junior physicians who have left, and essentially saying things like "it's not so bad in the NHS," since so many of their junior doctors have left. There's (ironically) even debate about privatising the NHS in order to try to save it.

In other words, it's not all a bed of roses in the healthcare systems of nations like the UK either.
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yea i dont get it. its so stupid. junior doctors are cheap labor. how much are they really saving by cutting their salary a little? it's so stupid. doctors are teh ones making healthcare possible in the first place. it's never smart to target them when they are the ones who make the system work
 
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