How to Avoid Getting Screwed -Healthcare Costs, Mole Removal

[MagnificentUnicorn]

Paywall, thanks.

The problem isn’t that doctors are paid too much, it’s that some are paid too much and some are paid too little. There’s a disparity in the value of RBUs. RBUs generated by a general/thoracic surgeon are worth less than those in other specialties like Ortho/Neuro/Ophthalmology. Same with things like radiation oncology, their RBUs are worth more than other medical/radiology specialties. It’s because of lobbyists. It’s a really wacky system. Assuming more risk as a provider often means making less money and working more hours.


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[XXX-er]

This is partially true, but the whole system is bloated and costs for EVERYTHING are grossly inflated. It’s just a result of the system being built with profits as goal with quality/equity being a distant second and third (probably further down the line than that even)

The unspoken truth (because doctors/health professionals are held in such high regard) is that salaries are also inflated. Yes, med school debt. Yes, grueling training. But is the gulf between what US docs make and the rest of the rich countries’ docs not a sign that this cost center is also a factor? My dad is a retired physician so I don’t fault anyone for getting paid (I have benefited from it!) but it’s part of the whole system that we need to somehow get in check. The only solution is single payer. Anything short of that will perpetuate the bloat.

we got single payer up here and the avreage MD still makes really good coin, I think if you don't pay the MD's lots they can just go wherever they can get paid better like down there because an MD in Canada is really just an independant business people

25 yrs ago there was a whole schwack of MDs who came to Canada from South Africa to practise which was great cuz you got an instant fully trained MD altho they still have to write the boards

I think the Doctors in Cuba don't get paid much $ but I don't think they can't leave either, when my buddy was in Cuba staying at a casa particulare the operator who was also an MD told bro he makes more $ from running the BnB than being a doctor

so maybe communism is the answer eh

[Conundrum]

Something that isn’t discussed much is the removal of lifetime maximums with ACA. Prior to ACA, once an insurer paid out $1m for a person, they were done paying for that person forever. Then there were very few treatments or pharmaceuticals that cost more than $1m to administer and claims for an episode were rarely north of $1m. No point to charge more than that because most people lack the ability to pay without insurance backing.

Now that insurers can’t ever stop paying, $1m claims/treatments are common and many drugs waiting for FDA approval are over $1m a year.

I have no evidence that this is either manufacturers are attempting cutting edge interventions or a pure money grab. I do have opinions though. Seems like R&D was moving along fine here before ACA and in other countries currently. Allow more reimbursement and weird, stuff got more exponentially more expensive.

[MagnificentUnicorn]

^^^We waste entirely too much money on hopeless causes in medicine. I say this as a 35+ year veteran as a health professional. The money spent on dying patients is shameful considering how little is spent on younger, healthier patients


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[Trackhead]

How much debt to Canadian physicians carry after Med school?

Bennymac? Any other first hand accounts?

[oldnew_guy]

Paywall, thanks.

The problem isn’t that doctors are paid too much, it’s that some are paid too much and some are paid too little. There’s a disparity in the value of RBUs. RBUs generated by a general/thoracic surgeon are worth less than those in other specialties like Ortho/Neuro/Ophthalmology. Same with things like radiation oncology, their RBUs are worth more than other medical/radiology specialties. It’s because of lobbyists. It’s a really wacky system. Assuming more risk as a provider often means making less money and working more hours.


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Doctor salaries make up something like 8-9% of US healthcare spending. I think you have your finger on it. Anecdotally, not many med students I have known are interested in primary care from a general interest, financial and work environment perspective.

[bennymac]

Guess: 150 - 300k cad by the time school and residency are completed?

Also need to factor in the undergrad degree costs on top of that.

And the 10-13 years of potential earning and then investing that are lost (so a lot of years missing out on compound interest).

Also zero pension or benefits so retirement has to be completely self funded.

No trying to play a sad fiddle tune here.

The highest paid doctors in Canada bill 1.5 to 2 million per year. That’s the rare top 1% but it skews the “average” that XXXr mentioned.
And that top 1% all work in a couple specific fields that are historically overpaid.

Most docs are like 1/5th of that - my guess. Chop 30% off that for anyone paying overhead to run their clinic space and pay for their staff.

[XXX-er]

Guess: 150 - 300k cad by the time school and residency are completed?

Also need to factor in the undergrad degree costs on top of that.

And the 10-13 years of potential earning and then investing that are lost (so a lot of years missing out on compound interest).

Also zero pension or benefits so retirement has to be completely self funded.

No trying to play a sad fiddle tune here.

The highest paid doctors in Canada bill 1.5 to 2 million per year. That’s the rare top 1% but it skews the “average” that XXXr mentioned.
And that top 1% all work in a couple specific fields that are historically overpaid.

Most docs are like 1/5th of that - my guess. Chop 30% off that for anyone paying overhead to run their clinic space and pay for their staff.

I don't remember suggesting an average but I would kind of guess 250 K ? Half of all md grads now days are women so they are sharing practises/ getting pregnant/ having kids/ working less and i assume driving down averages ?

my now retired ski bud told me what tuition was back in the day and it did not sound like very much, 1800$ for a year

[XXX-er]

https://www.cbc.ca/radio/whitecoat

hey you guys down thar might dig dr Brian Goldman ... medicine from the other side of the gurney

there is also Dr Iris Gorfinkel who actualy looks hotter than the name would suggest, I had always pictured Iris as some husky aging medical researcher

[skaredshtles]

I’m pretty stoked, I got an email from the VA last week and through the PACT act they are extending 100% health coverage for all Gulf War veterans. This will allow me to transition to part time and full retirement years earlier.


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FKN'A!

Only thing keeping me from really early retirement is the prospect of health insurance premiums for a decade.

[skaredshtles]

The drastic increase was viewed by staff and senior managers (AVP’s/VP’s, but not executives) as a pay cut.

And that's exactly what it was.

[Kevo]

Something that isn’t discussed much is the removal of lifetime maximums with ACA. Prior to ACA, once an insurer paid out $1m for a person, they were done paying for that person forever. Then there were very few treatments or pharmaceuticals that cost more than $1m to administer and claims for an episode were rarely north of $1m. No point to charge more than that because most people lack the ability to pay without insurance backing.

Now that insurers can’t ever stop paying, $1m claims/treatments are common and many drugs waiting for FDA approval are over $1m a year.

I have no evidence that this is either manufacturers are attempting cutting edge interventions or a pure money grab. I do have opinions though. Seems like R&D was moving along fine here before ACA and in other countries currently. Allow more reimbursement and weird, stuff got more exponentially more expensive.

IMHO, the removal of lifetime caps and pre-existing condition exclusions was one of the best parts of the ACA. I do agree with you that there are perverse incentives built into the ACA that increase the cost of drugs and care and insurance.

The ACA did help me personally- Pre-ACA I was kicked off my parents' insurance as soon as I was no longer a student. My first job post college graduation was as a wildland firefighter, and at the time non-permanent employees (most wildland firefighters) didn't have health insurance benefits.

I tried to be responsible by buying my own health insurance, but I was denied by every insurer in the state because I had orthopedic surgery two years prior that meant that I "didn't meet their risk profile." It wasn't a "hey we aren't going to cover anything related to this condition and you'll have to pay higher premiums", it was straight up "you had a claim for tens of thousands of dollars in the past, we will not insure you."

Without insurance, I couldn't find a primary care doc to see me and I made a little too much income for medicaid. Every primary care doctors that I tried to see at the time would flat out refuse to see patients without insurance, even if I offered to pay up front in advance. This meant that my only option was to go the ER for literally any health concern, which would have bankrupted me at the time. Despite trying for years to buy insurance on my own, I had no health insurance from the age of 22 until I was 25 and finally had a job deemed worthy of having insurance. It was a very frustrating- there was literally no way for me to access healthcare at the time.

I think another other major factor driving up costs is the 80/20 rule of the ACA. The rule (also called the Medical Loss Ratio or MLR) stipulates that insurers must spend 80% of the premiums they collect on healthcare costs. This has caused collusion between health insurers and providers- they both have a perverse incentive to increase healthcare costs every year. The insurers want to be able to keep 20% of an ever increasing number. The providers want to be able to increase costs year over year.

With most health insurance companies being publicly traded entities and an increasing number of providers being owned by private equity firms, it is no surprise that healthcare costs continue to skyrocket.

[Conundrum]

IMHO, the removal of lifetime caps and pre-existing condition exclusions was one of the best parts of the ACA. I do agree with you that there are perverse incentives built into the ACA that increase the cost of drugs and care and insurance.

The ACA did help me personally- Pre-ACA I was kicked off my parents' insurance as soon as I was no longer a student. My first job post college graduation was as a wildland firefighter, and at the time non-permanent employees (most wildland firefighters) didn't have health insurance benefits.

I tried to be responsible by buying my own health insurance, but I was denied by every insurer in the state because I had orthopedic surgery two years prior that meant that I "didn't meet their risk profile." It wasn't a "hey we aren't going to cover anything related to this condition and you'll have to pay higher premiums", it was straight up "you had a claim for tens of thousands of dollars in the past, we will not insure you."

Without insurance, I couldn't find a primary care doc to see me and I made a little too much income for medicaid. Every primary care doctors that I tried to see at the time would flat out refuse to see patients without insurance, even if I offered to pay up front in advance. This meant that my only option was to go the ER for literally any health concern, which would have bankrupted me at the time. Despite trying for years to buy insurance on my own, I had no health insurance from the age of 22 until I was 25 and finally had a job deemed worthy of having insurance. It was a very frustrating- there was literally no way for me to access healthcare at the time.

I think another other major factor driving up costs is the 80/20 rule of the ACA. The rule (also called the Medical Loss Ratio or MLR) stipulates that insurers must spend 80% of the premiums they collect on healthcare costs. This has caused collusion between health insurers and providers- they both have a perverse incentive to increase healthcare costs every year. The insurers want to be able to keep 20% of an ever increasing number. The providers want to be able to increase costs year over year.

With most health insurance companies being publicly traded entities and an increasing number of providers being owned by private equity firms, it is no surprise that healthcare costs continue to skyrocket.

I was only talking about lifetime max as a discussion point. We could have a broader discussion on the 80/20 rule but if it created collusion, those would be extremely isolated instances. What you will see is systems trying to become insurers and insurers buying providers but that isn't what collusion is. If you wanted to dig deeper, look into risk adjustment stipulations under the law and what is going on with contract negotiations between insurers and providers...it's not good. I do agree that removing pre-existing limitations was a good thing.

Back to my point of removing the $1m cap. Plenty of examples but here is some low hanging fruit.

Article from 2010 (just as enactment started): https://www.forbes.com/2010/02/19/ex...h=24375d6e5e10

The nine drugs on our list all cost more than $200,000 a year for the average patient who takes them. Most of them treat rare genetic diseases that afflict fewer than 10,000 patients.

Article from 2023: https://www.fiercepharma.com/special...est-drugs-2023

From bluebird’s thalassemia therapy Zynteglo at $2.8 million for a one-time dose to CSL and uniQure’s $3.5 million hemophilia B treatment Hemgenix, the three newest gene therapies. ... Orphan drugs such as Eiger BioPharmaceuticals’ Zokinvy—the first drug cleared in the U.S. for Hutchinson-Gilford progeria syndrome and processing-deficient progeroid laminopathies—costs about $1.7 million a year. Unlike the gene therapies, it isn’t meant to be a cure.

Basically, drugs are being developed that don't cure the disease, just relieved symptoms at millions a year or may take cycles of treatments at millions each cycle for very few people. Philosophically, everyone has to decide if reducing symptoms for a small minority of the population is worth the cost. Some drugs like Zolgensma can save the patient at $2.1m that had a 95% mortality rate by 18 months-another philosophical call for 500 newborns in the US a year. Could that R&D be placed elsewhere even if not as profitable? This wouldn't have happened with a $1m lifetime cap. Other countries are offering some of these treatments at a fraction of the cost because their governments won't allow them to be $1.7m a year or will reimburse the amount over four years based on outcome. The US is either a giant profit center or subsidizing care in other countries or both.

I also agree that PE funding and publicly trading medicine and financing the care is culpable.

[Kevo]

In no way was I taking your points about problems with the ACA as an attack on the ACA. I was agreeing with you that there are perverse incentives built into the ACA. I also talked about how certain portions of the ACA benefited me, while giving an example of another perverse incentive.

[Conundrum]

My apologies. I edited.

[old goat]

Are you talking ECMO? A buddy of mine had out of hospital arrest, ended up on ECMO for a few days and came out the other end with a functional brain. He was late 40s at the time. Still doing well.

But yeah, we go pretty damn far here in the states, just because we can I guess.

I would have no problem with ECMO for cardiac arrest if we had unlimited dollars and manpower to spend on health care.

[crashidy]

Regarding EMR, they don't transfer province to province. Would be nice. We actually just about have every hospital and urgent care on epic nownin Alberta. That's been helpful.
Family docs probably can make 200 to 250 a year prior to Cost and overhead.
Vancouver last year couldn't recruit any at 300g guaranteed because by the time rent, mortgage, overhead and repaying students loans they wouldn't make shit all .
Er physicians who are on fee for service can pull 300 to 450 average probably in Alberta.
Pathologist half a mil a year, Ortho and surgeons around the same. Radiologists are the big winner at around a mil a year.
20 years here in our healthcare system so I know I'm not out lunch on this

[bennymac]

Don’t forget opthamology - some are well over 2 million per year and a few top out around 4 million per year.

[Conundrum]

Don’t forget opthomology - some are well over 2 million per year and a few top out around 4 million per year.

Those are a problem in that the FDA approved them and a couple of years into use, they're "finding out" a second treatment might be necessary. I think Italy has it right-they do checks at intervals over 48 months and if the drug (gene therapy) works without additional intervention, the manufacturer gets paid.

[XXX-er]

the high buck specialists working out of a hospitol have no office or office staff = net mo money