You are correct. Bills should clearly itemize the charges.

You are absolutely correct in your observation that there is some funny business in billing. The “fee schedule” is based on the relative value scale that Medicare uses. It is inherently The fee schedules for all procedures and levels of office visits are based on the Medicare relative value scale that is skewed towards higher reimbursement for procedure (like three little stitches) than evaluating and managing a patients condition. Those fee schedules are re-evaluated every five years in a process that, by law, is subcontracted to the AMA whose Reimbursement Update Commission meets behind close doors and is dominated by specialists, who do procedures. Need I say more?

As for “containing costs”… It’s our job to take care of peoples’ needs and, partly because of fear of liability, we have become intolerant of uncertainty and, therefor, quite prolific in the tests that we order to make sure we aren’t missing something. It’s hard to be concerned about constraining costs in that environment.

Now, you ask, how much should a doctor get paid? How much is too much is easier to identify than how much is enough. A number of the specialist expect to make mid-six figure incomes while primary care doctors make on the order of $170,000 to $200,000/year, less in some states like Oregon. I would say that $350,000/year should be enough but there are many specialists who believe they are worth, and earn, far more than that. As a group, physicians have lost perspective on how much money $350,000 is to the average person. I can safely state that virtually every doctor has someone (from the billing office) looking over his/her shoulder coaching them to maximally document and optimally code every chart so that “we don’t leave any money on the table.” For most of us, how much is enough is how much money is on the table. We are just human beings.

The reason the doctor quite reasonably dropped his charges have to do with cost shifting. We charge far more than what we expect to get paid, contractually, by insurance companies, Medicare, and Medicaid. If we charged less, we would get paid less. Sadly, self pay people see the bigger bill but only some doctors let people know, up front, they they would (should?) get a discount for paying cash promptly… just like the insurance companies.

The Vermont Workers Center meetings were advertised in the Baker City Herald and LaGrande Observer to encourage attendance from the communities and to generate questions, both hard and otherwise. Had you attended, your questions may have been answered. Would you like to add your name to our mailing list so you won’t miss our next appearance?

Your point about private clinic expenses is well taken. Perhaps the largest expense in any primary care clinic is the cost of collecting money from private insurance companies, roughly $80,000 per year per physician. Private insurance companies deny 30% of all first claims, and those of us who have run our own practice know that these claims are being denied not because we are trying to defraud the insurance company but because insurance companies stay in business by denying valid claims. With a single payer system, this administrative cost is converted to health care.

Medicare costs are increasing. So are health care costs around the world. Medicare attempts to protect access to health care for seniors by considering new delivery and payment mechanisms. Private insurance companies compensate by raising premiums, cutting benefits, increasing co-pays and deductibles, excluding patients who need care, dropping healthy patients who get sick, denying payment to providers, and generally providing less care to fewer patients.. Neither is attractive, but Medicare is the better bargain.

You are correct that not-for-profit private insurance companies are no less piratical than for-profits. Both generate a 40% loss of premium dollars to administration, roughly ten times that of Medicare and twenty times that of more efficient single payer systems. We need to eliminate all private insurance companies, for-profit or not, as the parasitical intermediaries between patients and physicians.

We absolutely agree that familiarity with the strange and twisted economics of American health care is essential to understanding any reform proposal. Any seemingly simple and easy “solution” should be received with skepticism. Fortunately, single payer systems have demonstrated their ability to provide better care to more people for less money ever since the concept was invented in America eighty years ago. Single payer systems provide care to our armed forces, our veterans, and 26 million other Americans who get care via multi-employer health plans.

Single payer financing is the American solution to America’s health care problems.

Samuel Metz MD

Thanks for your comment. For your one letter there are probably hundreds of people who feel the same way.

The over-riding motivation for our two tours this year was to make sure Oregonians recognize that the US health care system (really a sick-care non-system) is causing unnecessary severe suffering here and around the nation and is collapsing under its own weight. We think there are ways to reverse this tragedy. First we must decide as a society that it’s in our best interests to keep each one of us as healthy as possible, that health care is a human right and public good, and from those concepts enact laws that do include everyone and control costs. All this would seem beyond achievable except that twenty two other nations have done it. True, they all face financial and ethical struggles, but they have figured out how to provide health care for all their people at about half the US cost per-capita, while our extravagant spending provides adequate care for only about half of our population.

The medical bills you mention are way too high for a variety of reasons that are correctible. We currently finance our health care system by making sure we do lots of medical procedures at the highest reimbursement rate we can get by with. We depend on inflated reimbursements from CTs, MRIs, surgeries, and drugs to bring in enough revenue to keep our hospitals and clinics open, support the costs of those who cannot pay, and create generous to massive incomes for segments of our health care industry. The people who can’t pay for their care are you and me except that they have been excluded from healthcare because of cost and pre-existing conditions.

It would be as though we financed our fire department by underfunding the fire-prevention unit and allowing other conditions that cause houses to catch fire. Then we would respond to calls from owners of the burning houses, ask the owner if he/she had paid the fire protection premium that month, if not, allow the fire to continue until serious damage had occurred, then expend much manpower, equipment, and water to douse the flaming ruins, then charge the owner thousands of dollars.

The RVU system you mentioned is at the center of this dysfunctional health care “fire department”. The AMA owns the CPT coding system and makes $ millions on royalties from it. The secretive RUC Committee of the AMA is the determiner of RVU rates and is 85% specialist in membership. Procedures are rewarded “as the market will bear”. But of course this is not a free market; the providers control price and the demand. Primary Care is left behind and gets far less reimbursement for counseling patients in ways that would prevent illness and cost.

Then of course our health care (non)-system pays for many unnecessary middlemen. Private health insurance is an investment business only tangentially related to health care. The motivation in this industry is to minimize costs so profits will be high. Therefore the people who might get sick are systematically excluded from coverage. Removal of this parasitic industry from health care would remove about 15% of the current costs.

But it all gets back to what we want a health care system to do. If we want it to be an income stream for as many people as the system can fund, we will continue on our present course until the system collapses. If we view health care as a human right, a public good like fire and police protection and public education, water safety, road safety, we will all benefit as part of a much healthier society.

Michael Huntington MD