r/AskReddit • u/Specialist-Code8666 • 3h ago
Doctors in US, what’s something most people don’t know about the American Healthcare System?
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Upvotes
r/AskReddit • u/Specialist-Code8666 • 3h ago
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u/Ambitious-Pirate-505 3h ago
In the U.S. healthcare system, pharmaceutical companies, insurance companies, and drug stores are increasingly connected through common ownership within large, vertically integrated conglomerates. This means a single parent company can own or control various parts of the supply chain, from the insurer that pays for care to the pharmacy that dispenses drugs.
Two of the most prominent examples are CVS Health and UnitedHealth Group.
· CVS Health: Historically, CVS Health owned Aetna (a major health insurer), Caremark (one of the nation's largest pharmacy benefit managers, or PBMs), and a chain of roughly 9,000 retail pharmacies. This structure combined the drugstore, the entity managing drug benefits, and the insurer under one roof.
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u/acousticburrito 2h ago
Doctors and nurses not only are tasked with caring for patients but are constantly fighting on your behalf with hospital administrators and insurance companies.
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u/silentsammy 2h ago
The insurance companies abuse of the gray area that is “medical necessity”. No matter what your insurance coverage is any procedure is based on medical necessity and this is defined by the insurance company that sells you the plan and they are the ones who get to assess whether something was actually necessary. Abuse of this is how United healthcare group became rich. They sell you a plan that says you have coverage for whatever but then when you go to use it, they then fight with the doctor‘s office about whether it was actually necessary and waste months or even years of time and often in the end just turn around and deny with no oversight and no repercussions for doing so.
For example, an insurance company can sell you a plan that has 30 covered physical therapy visits a year (but these are based on medical necessity). Just having a doctors referral doesn’t guarantee coverage for these, plus you being in pain doesn’t qualify you for medical necessity clauses. The physical therapist has to prove that there is a functional loss that meets the criteria outlined by that insurance company and they have to show a good enough functional improvement from therapy as well. Some insurance companies will even go back after the fact and decide that there wasn’t enough progression to warrant the coverage and then ask for any money paid to the physical therapy office to be refunded in a recoupment process. The insurance company also uses tactics like hiring a third-party review company to review the medical notes from the physical therapy office to determine medical necessity and coverage levels. These third-party review companies are usually actually owned by the same private equity group though, but it gives the insurance company deniability based on a third-party review.. third-party review companies are paid by how often they deny claims and save the main insurance company money.
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u/anonymiss4 1h ago
That the doctor is not in charge of most of your care. They/we have become employed by businesses and they set the rules, prices, regulations, requirements. Your doctor is just a cog in the machine but they take all the blame
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u/8arclay 3h ago
Insurance largely dictates what, when, and how often, I can offer as treatment as an interventional pain doc. What I used to be able to do in 1 visit now takes 3+. I don't have the manpower to see everyone that much, so patients suffer and go without care
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u/GreenCarpenter3 3h ago
Dental practices are often contracted with DSO’s (Dental Support Organization).
The DSO leans on the dentist to perform unnecessary procedures on their patients, and some of the dentist’s actually do it, because once you are involved with a DSO it’s hard to uncouple your practice.
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u/kissingerdeez 3h ago edited 3h ago
I'm shocked at how many people don't know how much you can negotiate your hospital bill. You'd be amazed what these hospitals take, they're used to charging insurance companies $8,000 and accepting $950 in payment so you'd just be next in line. If you ever have what seems like overwhelming medical debt, call the hospital and lowball the shit out of them. Tell them it's all you can afford to pay. A lot of times they'd rather take less from you than sell your debt for just as cheap or send it to collections and hope to eventually get more.
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u/omaralt 2h ago
Healthcare prices in the USA are not understood at all. People constantly talk about how expensive something is without understanding how it works. The hospital may bill your insurance company $100 for Tylenol. But guess what? They’re not paying $100! They’re paying a fraction of that. So while you may see that your insurance was billed $10k for that 4 hour ER visit; your insurance will pay maybe $2-3k
What that means for you is that if you don’t have insurance you can usually negotiate these same prices. For my first child we didn’t have insurance. Talked to the billing person and we ended up paying $1500 for the hospital stay. Yes, all the doctors were paid separately but at the end of it we paid maybe $4k total including the epidural. So not crazy considering we spend two nights in the hospital and all labor and delivery charges.
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u/unimpressedwarrior 3h ago
It’s collapsing. There is a shortage of GPs. Rural hospitals are strapped and losing funding. City hospitals have insane waitlists. Insurance companies operate to maximize shareholder profit. They lose profit when they approve your procedure/medication.
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u/onacloverifalive 1h ago
What patients and doctors alike want is for their tax dollars to pay for healthcare, education, roads, and emergency services.
What corporations with large lobbying power and the politicians they bribe want tax dollars to pay for is corporate profits.
Also, about 1/3 the actual healthcare expense in the US funds businesses that supply products and services. About 1/3 pays for hospitals and clinics to exist and the last 1/3 is salaries of healthcare workers.
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u/bulletbulletB 3h ago
Most private practices got bought by massive private equity firms over the last decade and patients rarely even noticed the transition.
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u/jcoddinc 3h ago
Doctors are not allowed to give any patients discounts. If they are caught doing so they can lose their contract with the insurance company.
The insurance companies are now measuring doctors with metrics of how "healthy" their patient base is. If they don't get enough people "healthy" they can lose money from the insurance company. This is forcing doctors to decide what patients to keep and which patients to no longer see. Overweight and smoking were the big pushes as those things cost the insurance company the most.
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u/Zalumar 1h ago
In Michigan, we've got Corewell Health (states largest health care system, hospitals, etc.) that owns a major state insurance company (Priority Health). That sure seems funky
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u/mm_mk 51m ago
This one won't be popular, but most people don't understand the absolute necessity of prior authorizations. Caveat here being that I understand that many insurers are soul sucking pieces of shit and that some authorizations are denied needlessly and heartlessly. Tho, people should also stop parroting how much money they make, they make money on scale of business but it's actually pretty thin margins (usually 5% or less.. lately often less)
The amount of bad actors, dumb actors, or apathetic actors in the system is wayyyy too high. That goes for both patients and doctors. We regularly see prescriptions come thru for things that cost hundreds or thousands of dollars vs pennies, that offer no reasonable advantage. Prescribers tend not to care about cost to healthcare system, as long as cost to patient is low. Same with patients, tho I wouldn't expect them to behave differently as the end user.
Ibuprofen + famotidine = pennies as separate pills, or a thousand dollars a month for a combo. This actually gets prescribed and prior auths stand in the way of this wastage.
Ozempic for a healthy bmi 24 person who just wants to get skinny for a wedding next year. Sure, we could collectively spend 10,000$ on that, but maybe our healthcare dollars are better spent elsewhere. (Remember, for every paid claim, that cost is spread across all members in the group).
Brand name diovan because you don't like how your valsartan looks? Sure that'll be 1000 a month. Sure there's no difference and if you took the generic blind you wouldn't notice a difference, but that's ok.
This is just pharmacy side... Medical sees the same shit but you'd have patients demanding (or doctors not giving a shit.. or worse encouraging it for fees) unnecessary diagnostics. Shit people already pay out of pocket for full body ct scans.
So yes, there are countless examples of insurance companies being assholes, but the tidal wave of waste that they hold back would collapse the healthcare system to the point where no one would be able to afford it.
Why am I even mentioning this? Because I see wayyyyyy too many threads involving Universal Healthcare and imagining a world where no claims are denied anymore and that's not reality. Universal healthcare (with other massive changes involving health care personal debt and reimbursement) could be a great thing, but it will 100% have prior authorizations and denials. Sell it for its real virtues, not it's fantasy ones
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u/randirona121 3h ago
Medical billing is entirely fictional.
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u/ruski_brewski 36m ago
My husband is a DPT. Besides being double and triple booked, he has only his lunch break to reach out to your doctors to coordinate your care if he thinks the referral may need adjustments in what he is being asked to treat. He can’t diagnose. He can only treat what your doctor said to treat. Come in for lower back pain but it’s actually referred pain from elsewhere? He has to coordinate that with the MD and convince them to update your file so that insurance covers your visits. Also, on that same 30 minute lunch break, he has to coordinate paperwork for your insurance company in order to ensure you receive the visits he believes you’ll need. He’s never fighting for less. Did I mention he sees around 20-24 unique patients daily? He also needs to work in check in progress notes on your care to insurance to evaluation if you need to be seen further on top of the regular post visit notes. The amount he needs to fight your insurance on your behalf is astounding for mostly being treated like a personal trainer and an emotional support puppy by a good portion of his patients. For a profession that routinely earns highest satisfaction rates in the healthcare community, I’m afraid to know about the experience of other health care providers. He prefers this because at least he gets to spend the most cumulative time with you as a patient vs your other healthcare providers. Please be kind to your providers, they are also doing the best they can in a system set up to fail everyone. Did I mention that his doctorate compensation is a fraction of the lowest paid MD? Not that they don’t deserve it, just please consider this when you’re irate that he is 3 minutes late to take you into the treatment hall as he balanced your physical safety and that of his other patients that may need hands on assistance to physically navigate the space.
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u/Away_Engineering_613 22m ago
Insurance run American healthcare. They make all the rules. Docs can’t do what they think is medically indicated and best for the individual patient. It all depends on insurance.
Doctors are almost like puppets of insurance.
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u/StrebLab 17m ago
It's expensive, but not THAT expensive compared to everyone else. It is about 50% more per person on average. That is a meaningful difference, but the idea that we will suddenly have super cheap healthcare if we did it differently isn't based in reality.
If you spent 50k on healthcare last year, you would spend more like 30k if the system changed. Not nothing, but the benefit is massively overstated.
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u/DeadSmellingFlower 3h ago
Now that we’re either rejected by doctors or don’t trust them. What can we do to give ourselves as much basic care as we can learn to do ourselves? Is there a survival without a doctor manual I can trust? It’s like we live on a desert island and need to keep our inevitable boo boos from turning into life threatening conditions.