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Would doctors prefer being salaried (like they are in many countries) rather than doing all the billing themselves?

It depends on the doctor. Something has dramatically changed over the past 30 years. It used to be that the vast majority of physicians owned their own practices. But now there are more employed than self-employed physicians.[1][1][1][1]In 2018, 47.4% of practicing physicians were employed, while 45.9% owned their practices.But among employed physicians, many are “employed” by physician-owned practices. What this looks like in practice is that new physicians who join the group are employees for a year or two, then given the chance to buy a partial share of the practice. Once that happens, they become partners and get a share of the annual profits.In 2018, 10% of physicians were employed in practices that are entirely owned by other physicians, also called private practice. In total, and including the practice owners and the physician employees and independent contractors who work for them, more than half of physicians—54% in 2018—worked in practices that are entirely owned by physicians, according to the PRP. That number is down from 2012, when the share stood at 60.1%. But the numbers indicate the downward trend has been slowing because half of the shift occurred in just the first two years of that six-year period.Meanwhile, the number of physicians who worked directly for a hospital or in a practice at least partly owned by a hospital rose between 2012 and 2018. For example, 26.7% of physicians in 2018 reported working in a practice that had at least some hospital ownership, up from 23.4% of doctors who reported that in 2012.The proportions of employed vs self-employed is very age and specialty-dependent.Older physicians are more likely to have practice ownership—54.3% among physicians 55 and older; 25.5% among those under 40.Nearly 65% of surgical subspecialists own their practices, as do 53.8% of ob-gyns, about 52% of internal medicine subspecialists and almost 51% of radiologists.Emergency physicians have the lowest percentage of physician owners—26.2%.Nearly 43% of physicians belong to a single-specialty group, a number that has been stable since 2014.Just under 15% of physicians are in solo practice, down from 18.4% in 2012.Nearly 57% of physicians work in a practice with 10 or fewer physicians, down from 61.4% in 2012.Nearly 15% of physicians are in practices with 50 or more physicians, up from 12.2% in 2012.One of the main driver of this trend has has been the consolidation in the healthcare marketplace, with big hospital systems and private equity buying physician practices.[2][2][2][2]The strategy focuses on acquiring 60-80% ownership of a practice, paying between $1-2 million per physician, and then reaping all or most additional revenues.For my own part, I’ve bucked the trend. I’ve never been salaried. The norm is for physicians my age to graduate from residency and find an employed position. Usually, there is a base salary for a year or two coupled with productivity bonuses. But this filled me with anxiety. How would I know that I wasn’t being underpaid? I was familiar with data showing that black physicians were paid less than their white counterpart.[3][3][3][3]These income differences remained after adjustment for physician specialty, hours worked, practice characteristics, insurance mix, and geography. Although income differences between white and black male physicians are substantial, these differences are smaller in magnitude than well documented differences between male and female physicians overall.I didn’t want to take the risk of being given some low ball offer that I would struggle to evaluate objectively. I also didn’t like the idea that part of my billings would go to my employer. Finally, the best job offer I found had an income guarantee of $240,000 for the first year. But I wasn’t to be an employee of the hospital. I was to be an independent contractor. I figured that if they were comfortable offering me that much—it was about as much as I had dared to hope for—then the expectation was that I would indeed make at least as much.I’ve been an independent contractor for 2 years now, and I am now better to assess the pluses of minuses of employment vs self-employment.As an employee, you have more security. You’re going to get a good malpractice insurance. You’re going to get a good health insurance policy. You’re going to get a certain number of guaranteed weeks of vacation. And you’re going to get a guaranteed minimum income. Another way to say that is that your income floor is going to be higher. This much I could have said from day one.But there are others things I have come to appreciate. Part of what I as a self-employed physician have to do is:Apply to be in-network with all the major insurers of my area.Make sure I only see patients whose insurance will pay me. Several times, I have taken care of a patient for a week or two at the hospital, only for their insurance to tell me that they would pay me nothing because I was out of network. This would happen even though the same insurance company had authorized their stay at my hospital.Send bills to the various insurance companies of my patients. Keep track of which patient owes how much, which portion of the bill will be paid by their insurance, and which portion is owed by the patient.Fight with insurance companies that refuse to pay me. Some of them have incorporated declining payments to physicians into their business model. They request all notes pertinent to a hospitalization before they will issue a payment, as is their right. They know that some physicians will fail to submit at least some of the required documentation. Once the records are submitted, the insurance will deny payment anyway. They know that at least some physicians will give up on disputing the payment denials. This is very mentally exhausting. In practice, I contract with a billing company that does all of the above.The great thing about being employed is that you don’t have to worry about any of the above. The hospital will give you a guaranteed salary plus bonuses based on your billings. The hospital will then go collect the money from the various insurance plans. Easy peasy.Another thing employed physicians don’t have to worry about is the “payor mix.” This describes the proportion of various insurance plans you send bills to in a particular location:Medicare: single-payer system for people 65 and older. The pay is not exceptional, but it is fair for an inpatient physician like me. Medicare is by orders of magnitude the easiest insurer to deal with.Commercial insurance: Aetna, BCBS, Pacific Source, Kaiser, Moda, etc. You have to be in network first, and they may decline to add you to their network. But once they do accept you, they pay you really well. My commercial plans were I work will pay me at 1.75X the Medicare rate.Managed Medicare: This is a process where the federal government, for some reason I will never understand, contracts with a commercial insurer to administer a Medicare beneficiary’s policy. They pay at the same rate as Medicare, but you will have all kinds of headaches. They give you the most capricious payment denials. I have no idea how they get so many people to sign up, but it’s a real pain to deal with as a provider. Unfortunately for me, about a third of the plans were I work are some kind of managed Medicare.Medicaid: state-administered federal program for the indigent. Pays about 2/3 of the Medicare rate. Also more of a pain to deal with than straight Medicare. Less money, more headaches. Quite often, there is also more work. Many of the patients who come with Medicaid also have more social issues that impacts their health. Those have to be addressed too. But the people need help. And getting paid something is better than getting paid nothing. I’m never going to get warm and fuzzy feelings about Medicaid, but I’m glad it exists.Managed Medicaid: the absolute worst. You get all the headaches of managed Medicare plus the low compensation of Medicaid.Now, if you’re employed, you don’t care about any of these. Your employer converts your billings into relative value units (RVUs) and pays you a bonus based on how many patients you saw and at what level you billed.So, given those headaches, why do I prefer to be self-employed? The short answer is money. The longer answer is below.I don’t consider that it’s all that hard to get myself a good health and malpractice insurance policy. I don’t need an employer to do that for me.The difference in earnings is truly stupendous. I make so much more than what an employer—unless I was willing to work in Minot, ND or some place—would offer, that I would feel uncomfortable even asking for such a salary.I’m not confident that my race wouldn’t impact what my base salary would be as an employed physician.I like the benefits associated with being a business owner and electing to be taxed an an S-Corp.I like the fact that I can take however many weeks of vacation I want. In return, I only get paid when I work.You could say that mine is a more American way of doing things: fewer protections, more risk, more rewards. This will surprise people who know only politics. But what I choose for myself is different from what I think would benefit most people.Footnotes[1] Employed physicians now exceed those who own their practices[1] Employed physicians now exceed those who own their practices[1] Employed physicians now exceed those who own their practices[1] Employed physicians now exceed those who own their practices[2] Private Equity Purchasing More Physician Practices[2] Private Equity Purchasing More Physician Practices[2] Private Equity Purchasing More Physician Practices[2] Private Equity Purchasing More Physician Practices[3] Differences in incomes of physicians in the United States by race and sex: observational study[3] Differences in incomes of physicians in the United States by race and sex: observational study[3] Differences in incomes of physicians in the United States by race and sex: observational study[3] Differences in incomes of physicians in the United States by race and sex: observational study

What makes the US healthcare system so expensive?

The healthcare in the US is not expensive because is a system designed for profit. If that were the case, hospitals would be following six-sigma quality guidelines and follow evidence based medicine.No.It is because it is a system where EVERYONE profits from waste.1) The doctor profits when he orders unnecessary tests and procedures. BUT if he works for a system where the insurer and the hospital are the same entity (For example, Kaiser Permanente) he may be penalized/rewarded for ordering/denying tests, procedures and referrals even if they are medically necessary.The hospital profits when doctor does (1) and(2) When the good doctor fucks up. See that healthy man that whose sepsis was misdiagnosed and resulted in limb amputations? He becomes a cash cow for the hospital for the rest of his life. If the crappy doctor on the other hand, works for a system such as Kaiser's, he/she will save millions of dollars to the HMO by refusing to order necessary tests and treatments. That is why poor doctors are kept on the job for years, even though according to the National Practitioner Data Bank Public Use File;The vast majority of doctors – 82 percent – have never had a medical malpractice payment since the NPDB was created in 1990.Just 5.9 percent of doctors have been responsible for 57.8 percent of all malpractice payments since 1991, according to data from September 1990 through 2005. Each of these doctors made at least two payments. (Source Public Citizen)But what about frivolous lawsuits? you may say. Tort reform and arbitration have made pretty much impossible to sue a doctor -but to go through that issue is the source of another long post. The reality is that only 3% of valid medical malpractice cases go to trial, and the plaintiff loses 75% of the time. The chances of the hospital having to do a huge payout to a patient are extremely slim. The cost of preventable medical errors is staggering - some estimates put it as high as $780 billion a year (source The economics of health care quality and medical errors. ). Guess who gets the majority of that money - you have it right: The Hospital and doctors. Medical boards all over the country are nothing but cartels safeguarding crappy doctors. Did you prescribe methadone as a pain reliever after a tonsillectomy and the patient dies of an overdose a few days later?. A "public" letter of reprimand will suffice (see Page on ). No probation, no suspension. If the case is pretty bad, the good doc will lawyer up and settle for a single act of negligence and leave it at that.BUT! you may say, can't the victim testify or witness the proceeding?THESE HEARINGS, THEIR FINDINGS, THE NAME OF THE DISTRICT ATTORNEY ASSIGNED TO YOUR CASE (IF YOU MAKE IT THAT FAR) ARE ENTIRELY CONFIDENTIAL. Imagine a secret trial in which the prosecutor and the defendant can discuss as good pals what kind of disciplinary actions they would like, and the victim is not even allowed to show how badly harmed they were?. Yup, that is the way the disciplinary hearings from the Medical boards work in the US. In fact, they still are debating whether you, as a patient, should be notified if you good doc is on probation (Your doctor’s on probation: Should you be told?) You get more transparency in your pick of Vietnamese restaurant than of the doctor that makes life and death decisions for you.BUT!! you may say. How about the Insurers? Medicaid? Medicare?. Wouldn't it be in their best interest to improve safety practices and do evidence-based medicine?. Ideally, this would be the case, BUT!!!3) VENDORS do not have any sort of transparency in prices. From medications, to the cost of the band-aid, or a simple test, and you may get staggering differences in price (see A blood test can cost from $10 to $10,000 in Calif. hospitals, according to a study). Insurers negotiate prices with HMO's so this kind of magical math happens all the time.The cynic in me believes that the vendors and the insurers are in cahoots: inflate the price 1000%, and the 20-30% percent patient co-payment alone would shift the majority of the REAL cost to the patient -and even make a tidy profit. The poor fellow with the Bronze plan? please pay up the whole price, credit cards accepted, pronto.Not only that, but if the situation becomes too bad, Insurers can always raise prices. Or in the case of Medicare, instead of going against the powerful AMA and the health insurance and pharmaceutical industry, we start saving money by denying benefits to those who may need it. Prosthetic devices? See Rescind the Medicare proposal restricting access to prosthetic limbs and returning amputees to 1970’s standards of care. Same goes for wheelchairs Stop Medicare from Making Inappropriate Cuts to Complex Wheelchair Accessories. When Medicare goes into full mayhem mode, and refuses to pay for complications generated by easily preventable hospital conditions (see Medicare's no-pay events: Coping with the complications), then the hospitals start releasing the sick patients to SNF (skilled nursing facilities) and saying that the condition was acquired there.But how about the patients?, you may say4) But the patients have also a big responsibility in this whole mess. You have a kick ass program at work? You think nothing of ordering unnecessary tests "just to make sure", and "treating yourself" via chiropractors, accupuncturists and homeopaths, which are nothing but quackery (See Page on and https://www.Page on You overburden hospitals when you to to the ER when nothing is wrong with you, you refuse to vaccinate your children because of something you read on the internet, you bitch when Obamacare rolls in and you say "hands off my health plan", you are the first to demand that undocumented immigrants be forbidden to buy insurance in the exchanges, even though they contribute over $13 billion of dollars to our SS and Medicare systems on a yearly basis, and get less than $1 billion back (See Page on -and virtually ensure that they only get care in the ER's when their conditions are often lethal and incredibly expensive to treat. In fact, you, the patient, are a very integral part of the problem when you vote and without first getting a basic understanding of the inherent complexity of this matter.As a final note, here is a little reason of by I am so passionate about the subject.This was my husband - a triathlete, a marathon runner - handsome fella uhm?On January 2013, he sprained his ankle and developed a joint infection. His doctor, hurried and careless, told him it was just the flu and did not order any blood work nor cultures, even though he had a textbook presentation of septic arthritis of the ankle joint. Despite constant follow up calls to the hospital, they kept reassuring us that this was expected. The doctor that examined him initially, suspected that he has sepsis, but never told him to go to the ER. By the time we reached the ER he was in full septic and toxic shock from a common strain of Streptococcus pyogenes. A bacteria easily treatable with penicillin.Cost of treating him on time: $30.This is how my husband looks like nowNow, the breakdown of the cost of this errorHospitalization19 days in ICU: between $15,000-$$30,000 day (due to complex presentation, intubation, wound care and dialysis)= $285,000- $570,000141 days of regular hospitalization: on low end, $1975 x $ 141= $278,485Surgical costs (aprox 15 surgeries of 4-6 hours duration each) = Unknown, but average surgery for debridement costs $15,000. I am being conservative at putting the costs of surgery at around $225,00012 weeks of acute rehabilitation: $1,040,000 (and I got this much rehab because I bitched like a rabid dog)Total hospitalization: A conservative cost of $2,113,000Litigation: Our attorney (between experts, court reporters, etc) $150,000Kaiser (let's be conservative and assume they had the same costs as us) = $150,000But Kaiser alone had to pay for their attorney. Assuming the guy worked about 200 hours in the case (which is quite conservative, as the trial alone was about 80 hours), at $400/h, we are talking about $80,000 in fees.Arbitrator: 100 hours at $550/h= $55,000Total legal costs: $495,000Victim gets zero. Arbitration rules -but for insurers!!Anthem, and now Medicare, pay approximately $100,000/year in medical costs for husband. Prosthesis ain't cheap. At 20% copay, we had to pay close to $20,000/year in copays alone, that without including caregiver costs.Husband, an engineer, used to make close to $150,000/year. Luckily we had good LTD insurance, but still, I had to stop working in engineering as the time constraints and cost of care-giving made it impossible to continue working FT. That means that SS will stop receiving close to $620,000 in Medicare and SS taxes from us during our expected work expectancy.So to add it up:Costs of initial hospitalization: $2.1 millionLegal costs: $495,000Insurance costs through husband's lifetime (life expentancy of 75): $3 millionCosts to victims: $600,000 (based on same life expentancy)Loss of Medicare and SS earnings: $620,000Loss of wages: 2.3 million (wife), 1.1 million (husband - I am deducting his disability payments)Total cost to society: $10,215,000 (in 2015 dollars)So you can understand my frustration when PCP's tell me that it would be too cumbersome to test all suspicious cases?. With the cost of Husband's case alone, we would have been able to test and treat more that 300,000 patients.To this date, doctor still practices, despite having been found below the standard of care by the CA medical board. If we are lucky, she will get a public letter of reprimand and that will be it.You on the other hand, will pay dearly, when Medicare goes insolvent, or when your insurance rates increase. All because of the waste.

Why are answers on Quora collapsed?

Who knows?I don’t often do this, but this is my thirty second protest.I wrote a story last week about a brain-damaged infant who survived a horrible car accident (As a doctor or nurse, what case made you think "how are they still alive"? )— collapsed.Yesterday I wrote the innocent and heartwarming story of a brave six-year-old cowboy facing his first IV (As a doctor, what is the bravest thing you've ever seen a patient do? )— collapsed.Don’t know why. Who knows why?But my answer to As a doctor or nurse, what's the saddest scene you have ever witnessed? Was recently blatantly plagiarized by another Quoran— and reported as such by many, many readers who easily recognized the forgery— and yet. IT IS STILL THERE.I love Quora for the people. The administration however, leaves something to be desired.(Read quickly— I expect this will be collapsed itself soon…)

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