Some people are tired and others are permanently drained. No matter the profession, if you have no energy, your abilities suffer. Medicine is a demanding field, no doubt, and we should expect our providers to be resolute and intelligent. Why should patients care about their doctor’s well-being? Doctors also happen to be human beings—they too can feel the vice-grip of burnout. A burned-out physician hurts your care and threatens any chance of having a great medical relationship. Patients need to recognize when their doctor isn’t fully present or just going through motions. In today’s episode, you’ll learn how to spot the signs of provider burnout.

There are so many sources about workplace exhaustion—everyone has an opinion about the subject, and rightly so. Of all this issue’s possible angles to comment on, the consequences to patients are the focus. Drained physicians are dangerous not only to themselves but also to patients carrying the consequences of that exhaustion. Patients need to know why providers get burned out and how that weariness is a personal and systemic problem. Doctors are people too—they make errors like the rest of mankind. That doesn’t mean patients have to stop holding physicians a higher standard. Rather, the patients able to identify burnout can either switch to another provider or make an effort to repair the sacred patient-doctor relationship for the better. These options present themselves only after having a clear idea of what occupational exhaustion is.

Burnout is both a nature and nurture phenomenon. Some people have an innate disposition for work to suck away their well-being. Others may be vigilant but their organization could bring unnecessary pressure to perform. The problem at hand isn’t hard to find. According to Medscape’s most recent annual burnout report, ~47% of physicians are burned out. The study’s main criteria defining burnout revolved around depersonalization and lack of fulfillment from work. ~60% of surveyed physicians noted that excessive bureaucratic demands of their respective workplaces were a cause of their exhaustion. Regarding internal characteristics, ~33% of doctors reported burnout having a direct connection with personality. Per the study’s parameters, common symptoms included more irritability, less patience, trouble with concentration, and full lack of empathy. A doctor unable to care for themselves won’t be able to care for you long-term. For simple medical problems, burnout may not be an issue, but when medical conditions get complex, the provider’s lack of energy becomes palpable. Burned-out physicians don’t last in one place for long. Excessive turnover stunts the continuity of any patient-doctor relationship. Even if the treatment is spot-on, the experience at the clinic could be awful.

Physician burnout itself was classified as a thing back in the 90’s. Providers generally agree that stress precedes burnout. Of course, a million things at the office can raise your blood pressure. Stress is a part of being a medical professional since, well, life is at stake with every decision. Researchers from the Stat Pearls medical education database list a host of burnout catalysts. Piling on more hours, spending more time entering medical data instead of seeing patients, a laser-like focus on productivity, and lack of support from peers to draw meaning from work are the factors standing out the most. The worst possible journey that can happen is stress creating burnout, with the compensation for that burnout leading to fatigue, depression, and even suicide. Patients can’t always see how eroded a physician becomes with time. However, patients do know when they’re treated badly. More diagnostic errors. Lack of engagement. Less safety checks. Even the most high-functioning burnt-out provider can’t avoid those mistakes forever. The greater challenge for both patients and doctors is the fact that burnout’s easy to misdiagnose. Someone could just be chronically tired. Any number of outside factors affect social versus clinical depression. Addiction or general anxiety could also be a predisposition that can’t be fixed without major intervention. Sometimes a doctor enjoys their job but has the personality of a stone statue. It’s easier to play whack-a-mole than identify your doctor’s burnout ahead of time.

Many have tried to explain workplace exhaustion, but one physician in particular built a helpful framework. Dike Drummond, a family medicine doctor who runs an empowerment organization called ‘The Happy MD,’ believes in three kinds of energy—physical, spiritual, and emotional. Burnout happens when there’s a deficit in those categories. Exhausted doctors can still forge on if they’re drained, just like how a government can operate in the red, but with a steep cost. Seeing patients for long hours without taking enough time to eat and sleep well is just the standard of medical training. Doctors also have to bear the weight of their patients’ many issues. Taking in hundreds of patients’ needs a day numbs physicians’ emotional capacity. At the spiritual level, physicians need to feel validated for choosing their profession, along the lines of “this is why I chose to practice medicine.” Not having enough of these moments breeds professional hopelessness. Physicians then begin to tell themselves “I’m not sure I can keep this up,” or “why should I bother doing more for my patients if my work doesn’t mean much to them?” Dr. Drummond argues that providers can recharge their batteries through building personal relationships outside of the clinic and taking pride in the best patient outcomes. I’ll link his work’s detailed follow-up on my page at rushinagalla.subtack.com.

This burnout concept is reflective to doctors themselves, but where do patients fit in? Patients can set up meaningful interactions by wanting to be involved in their care and by demonstrating appreciation to the doctor. I’m not staying you should write a thank-you note to every provider, but taking a short moment to thank your physician for their help in a small but focused way might just prevent their career from eroding their soul. Healing burnout at the individual level is wonderful, but persistent organizational dysfunction (e.g. a toxic or high-pressure workplace) blocks any progress. Systemic incentives die hard. Government organizations like the Agency for Healthcare Research and Quality argue for implementing flexible schedules and delegating work to mid-level staff to combat the pressures of medicine (e.g. time slots, data entry, general chaos). These are classic “sounds good, doesn’t work” policies. Most physicians and their employers make their income through volume more so than outcomes. Obviously, everyone steers clear of a bad clinic—healthcare still obeys some market laws. Imagine two primary care clinics with doctors accepting insurance plans with similar payouts. Clinic A has better staff and training (i.e. more doctors with expertise on specific conditions using less mid-level staff), but clinic B sees 50% more patients. Clinic B stays in business while A goes under. It’s that simple. If a medical office’s staff each need to see 100 patients a day and earn an average of ~$500-$1000 per insurance claim after contract deductions (assuming this is a traditional outpatient consultative practice), rational providers will see that many patients at whatever personal cost, including well-being. Our country’s insurance plans and the nature of American medical training need some reform (to say the least). I’ll spend more time on possible solutions in a future episode, but asking patients to fix those nationwide issues is too unreasonable outside of voting for someone with enough political will to handle the challenge.

It’s not all doom and gloom. Patients can still play a role in erasing burnout through collaborating with (rather than submitting to) their doctor, asking thoughtful questions, and demonstrating appreciation to the doctor for handling the demanding realities of medicine. Give your doctor assurance of their chosen profession being a positive and noble choice. Medicine is meant to be a craft, not an impersonal transaction performed in some beige-painted, windowless exam room. Thanks to telemedicine and new technologies, more providers are having somewhat of a blast to the past in practicing medicine outside of the clinic. House calls are (kind of) getting back into fashion. In the next pod, you’ll find out if home health is all the rage or just a gimmick. Subscribe and stay tuned to Friendly Neighborhood Patient to know what matters most to healthcare consumers. I’ll catch you at the next episode.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

In the old days, we called them doctors. Now everyone sees a “provider.”

Many other professionals from the scribe to the physician assistant complement the doctor. These positions are supposed to make the clinic experience better for all patients. You might have a choice to see a nurse practitioner now or wait longer for your physician. In some places, you may not ever see a doctor again unless your medical condition is complicated or severe. Given how quickly norms change, patients need to ask two questions. Should nurses and physician assistants play a bigger role in medicine? And more importantly, do they deserve the patient’s trust? The answers reveal much about why you should care deeply about who’s responsible for your health.

Titles carry heavy weight in medicine.

Doctors of course have been around since ancient times. Nursing as we know it began with Florence Nightingale in the 1800s. Physician assistants, or “PAs,” were a product of the US military in the 1960s. These roles evolved with time. Doctors specialize and then sub-specialize with their interests. Nurses target various patient groups and can practice medicine as well after proper training. PAs can plug themselves into nearly any medical discipline. For today, I’m just going to focus on why nurses and PAs are building a larger foothold in overall patient care. Some economists believe that PAs and nurse practitioners (NPs) should replace all primary and standard care in America so doctors can instead handle the most complex problems. That’s a dramatic change some argue is happening as we speak. Before weighing in on that major trend, patients must know the exact roles of their non-doctor providers. Understanding each of these professionals’ responsibilities is the first step to questioning if they’re doing their job right.

You’ve probably met a registered nurse (RN) at least once. An RN takes many forms, whether it be a midwife, anesthetist, or a practitioner. Most nurses find themselves in broad medical categories like primary care and women’s health. NPs can do more tasks than a general RN can. PAs usually specialize by medical discipline as physicians do. Both NPs and PAs have overlapping skills, but their training differs. Nursing school after undergrad focuses more on treating the patient in a given care setting and PA school is centered on treating the disease (similar to traditional med school training). PAs usually have a few years of clinical experience (normally as a medical assistant) post-undergrad before enrolling in a two- to three-year PA school. NPs need a master’s degree to become an RN first, then finish a graduate degree and licensing exam. In certain states, NPs can practice independently without doctor oversight. PAs on the other hand legally need physician supervision. To put the education in context, a PA or NP likely spends a maximum or four to five years, including job experience, after undergrad before practicing medicine. A physician spends about eight to 12 years after undergrad (depending on the specialty) before they can see a patient. That’s a lot of school.

If someone asks you who to trust with your care, it’s an easy choice. However, we do not live that kind of a vacuum.

Reality has other ideas. As I’ve said in past episodes, there are only so many doctors to go around while healthcare usage climbs.

The differences in providers’ training are one thing, but the demand for NPs and PAs in particular keeps rising.

Markets are saying their piece—according to the Bureau of Labor Statistics, the number of PAs is projected to grow ~30% between 2020 and 2030. For all nurses (RNs, NPs, etc.) the forecast is 45%. Doctors’ estimated job growth is sitting at just 3%. I’ll link the more detailed BLS data on my page at rushinagalla.substack.com. The largest driver behind these expectations by far is nationwide aging. Chronic diseases like diabetes and heart issues play a role too, but nonetheless, PAs and NPs are necessary to keep up with secular trends bringing about more patients in need.

Let’s be practical for a bit. When heading to the clinic to deal with a medical issue, you may or may not have a choice in who you see. If you draw a Venn diagram of the tasks that doctors, NPs, and PAs can do, there are several commonalities in the middle. All three of those professionals can do physical exams, make diagnostic assessments, order tests, prescribe meds, and perform routine procedures (e.g. biopsies, injections). Yes, even surgeons have PAs who know how to hold a scalpel. ~19% of PAs pick a surgical sub-specialty. From the patients’ viewpoint, these basic clinical skills are everything medicine appears to be. NPs and PAs likely do a few other administrative tasks the physicians don’t need to worry about, but you shouldn’t get blamed for believing that doctors and other providers are interchangeable for certain responsibilities. In the heat of the moment, two providers (with different degrees) writing the same prescription or doing the same routine procedure appear to deliver equivalent service. It’s no coincidence that NPs and PAs command a much lower median salary ($121K and 124K, respectively) than what a physician can claim ($200K+ depending on specialty and practice setting). What you can’t visualize are the wide gaps in education and experience unless you have a complex medical issue.

So what should you do if there’s a choice to wait longer for the doctor or see the NP or PA now?

Your condition drives the answer to this question. At the same time, patients should prioritize getting seen rather than waiting for an experienced professional—if your condition is unusual or too complicated for a PA, you’ll get referred to a doctor quickly. PAs in particular have been fighting for looser oversight restrictions since the advent of their position. In May 2021, the main PA society changed its name to the American Academy of Physician Associates (rather than ‘assistants’). Doctors weren’t exactly pleased with that development. Groups like the policy-focused American Medical Association pushed back, arguing that changing titles will confuse patients. Anti-PA sentiment points out that midlevel providers handling too many patients cause more errors. Pro-PA sentiment suggests instead that doctors can use extender staff to free up time away from routine care and onto the difficult patients. Most state legislatures and regulatory bodies haven’t enshrined the new “associate” term. Doctors may be disgruntled, but they’re still employing new midlevel staff to handle demand. Market forces are still at play. PAs can exist in any care setting, but ~53% of them are employed at doctors’ offices (vs. 47% for nurses).

I do not believe patients have to settle for a winner-take-all reality. Patients shouldn’t let their doctors be unreachable.

But patients shouldn’t also toss NPs and PAs to the curb. Both of those midlevel providers share some abilities with the physician, and in most settings, can spend more time with you. Patients are trading medical experience for accessibility. Some people are uncomfortable with that truth, especially because medicine is a field where oversimplification—'patient A has a given disease, takes treatment X and recovers well’—is dangerous. Give PAs and NPs the opportunity to become the modern, first-line PCP to deal with your problems in a timely manner before the doctor steps in. However, use what you learned in this episode to know the limits and bias of each provider you’ll meet in your healthcare journey. Physicians with multi-decade careers or brief stints after graduation have adventures of their own. Sometimes their struggles manifest in ugly ways, hurting both themselves and their patients. The next pod will cover the essence of doctor burnout and the role patients like yourself have in helping physicians feel better about their job. Subscribe and stay tuned to Friendly Neighborhood Patient for medical field breakdowns. I’ll catch you at the next episode.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Have you ever heard something nice about Medicare in the last few years?

It’s the behemoth among our country’s fragmented medical systems. We also pay for it with taxes. So why is it always close to running out of money? Today you’ll learn what insolvency means, how our national coverage actually works, and what we should do about their unintended consequences.

Patients have a right to know what they’re paying for. Medicare, our national insurance for seniors, is no exception. Knowing that an entitlement will be weaker by the time you age into it is the first step in preparing for other coverage ahead of time. As of this year, the Medicare Board of Trustees still estimates our national insurance for seniors will become insolvent in 2028. That’s an improvement from last year’s report claiming 2026 as the doomsday. I’ll spend a bit of time later on the economics behind that, but what does insolvency mean? What happens when Medicare runs out of money? It’s best to start with how the program’s funded. It turns out taking care of the country’s seniors isn’t cheap. The full cost of Medicare is 12% of our federal budget. However, Medicare did make a surplus in 2021 behind $888B of revenues. ~80% of that is funded by a combo of general income taxes and payroll taxes. The Medicare and Social Security taxes draining your paycheck now make up your safety net at 65. Anyone younger than 65 might wonder if there’s any point to giving Uncle Sam that money if there’s no pot of gold at the rainbow’s end. Breaking down Medicare’s four sections (part A, B, C, and D) tells another story.

Part A, AKA the hospital insurance trust fund, is what you inherit upon turning 65. That pays for the kind of inpatient, overnight care I discussed in a recent episode. Part B is health insurance for all the usual medical work you can think of, but you have to sign up and pay a monthly premium to get those benefits. Part C is a bit of a zebra among the horses because that section of Medicare makes deals with insurance companies to sell private coverage. Last but not least, part D is for drugs. Because of these choices you have to make, do not take your foot off the gas pedal at 65 for healthcare or anything else. Each section has different funding streams, but income taxes are the overall support beams. When the government says that Medicare’s becoming insolvent, part A (i.e. the hospital care) is the specific area that’s running dry. Parts B and D are within a different trust fund supported by taxes and premiums from its members—both those programs are projected to stay in place for several decades. That doesn’t mean they’re invincible, but government accounting can be flexible. Math works differently for federal entitlements.

Let’s think about a classic equation: revenue minus costs equals profit. A regular business can’t lose money forever unless they have unlimited cushion from a venture capitalist or institutional investor. Medicare’s hospital insurance (i.e. part A), among other parts of the government, can ignore this. Part A operates on a ‘paygo’ basis, meaning that every new expense has to be offset by revenue at some point. This is similar to what the government tried to do with major bills like the $1.9T American Rescue Plan. The taxes Medicare brings are credited to the US Treasury as government securities (like bonds) that sit on the trust fund’s books and generate interest. When inpatients get their benefits, the treasury makes the real payment and then Medicare writes off a corresponding amount of their government securities.

All is well when payments stay below taxes and interest income. That doesn’t happen very often. From 2008 thru 2021, there have been only three years where Medicare part A had a surplus. Medicare then redeems bonds to plug those multi-billion-dollar holes. But what if there are no accessible government investments? The treasury has to keep borrowing to make up those gaps for Medicare alongside the rest of our country’s needs. It turns out that Medicare can’t escape a different but also timeless bit of math: equity equals assets minus liabilities. Because of this, insolvency happens when an entitlement can’t pay benefits with tax revenue, interest-bearing assets, and redeeming bonds (i.e. the ratio of asset reserves to annual program costs goes negative).

For now, let’s step away from the finance. Insolvency is no revelation: the government publishes their historical Medicare insolvency projections. Why is hospital insurance going through a near-constant state of money trouble? Overall demand for healthcare is rising faster than workers can pay for it with taxes. More of our population is elderly and needs extended care. The economy plays a role too—weakening GDP expectations invites more unemployment leading to less payroll taxes. The government already borrows heavily and can’t add more reserves to Medicare part A forever. In order to keep back insolvency for a while longer, Congress may adjust taxes and budgeting, Medicare could reduce physician fees, or a public health transformation needs to happen. But since Congress has trouble agreeing what today is, and given the fact that our country is getting older, major change is slow. That being said, Medicare won’t disappear; that’s not what insolvency is. If the worst comes to pass in 2028, inpatient benefits would fall 10% through 2046 and then 20% through 2096. There is no Social Security Act provision declaring what happens next; at this time, the treasury can’t use general revenues (i.e. giving the money directly rather than paying interest on bonds) to cure the shortfall without legislation. Patient benefits and physician payments would be delayed. The rest of Medicare that enrollees sign up for remains the same. Medicare’s hospital insurance and SMI fund combined will still grow from 3.9% of GDP now to 6.2% by 2046. There are ~64M seniors on Medicare today, and those using parts B and D pay $204 a month on average for those benefits. The government also has more latitude for allocating taxes to backstop the fund, but the Congressional Research Service estimates that personal and corporate income tax dollars would need to climb ~20% to maintain the current share of part A/B/D contributions. The Social Security Administration’s 2022 report details these outlooks a bit more—that source among others will be on my page at rushinagalla.substack.com.

There’s no shortage of politicians and economists throwing possible solutions at the wall of Medicare’s problems, hoping one will stick. It’s easy to look outward for proposals, whether they be from our elected officials, hospitals, physicians, or pharmacies. Fiscal policy can help bridge the funding gap but the unintended consequences of changing our tax code or budget might a cure worse than disease. Keeping physician and hospital payments below inflation just incentivizes our country’s providers to shun Medicare patients, who may get sicker due to deferred care. The young have to budget even more now to compensate for reduced benefits in the decades to come. You get the idea—the externalities go on and on. Not to mention that medical conditions can be out of our control. Let’s still accept those facts, but work to improve ahead of an obstacle rather than be a victim of it. We human beings have incredible adaptation skills. There’s no reason to let ourselves grow old and be resigned to withering away. Unpopular doctors tell you to eat well, sleep more, and move more. They’re correct, but that framing doesn’t work. People respond to incentives. Think of it like this: spending a little time every day to eat better, sleep better, and think better will cut your future Medicare premium and liabilities by $X. Now patients can create a positive butterfly effect helping both themselves and their fellow Americans in old age with a less-strained medical system. Enough big-picture stuff. At the ground level, doctors are trying to reach more patients and streamline medicine by using more physician assistants and nurse practitioners. Is this good for your local healthcare? You’ll find out in next week’s pod. Stay tuned and subscribe to Friendly Neighborhood Patient for all the healthcare commentary you need. I’ll catch you at the next episode.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Sailing your own ship is harder than it looks. The world of medical insurance can feel like an unending ocean of choice and complexity, especially when you get a new job, age into Medicare, or turn 26 and thus can’t stay on your parent’s coverage. Every ship captain needs a helmsman, so I want to pass along learnings from my own search about how a broker can be a major help and hindrance for picking the best possible health plan. After today’s pod you’ll know why (and why not) to use a broker.

The point of an insurance broker is to help find a plan fitting best with your situation. Health plan brokers, who are licensed in each state they practice at, give you quotes, walk you through all the complicated terms, and explain the final choices in detail, among many other responsibilities. These professionals help both employers and individual patients buy coverage. Most brokers specialize to some degree. For example, your local broker might only help patients with Medicare options (Medicare is complicated enough that such arrangements are necessary). You might hear someone use broker and agent interchangeably. That’s a major point of confusion for many patients. Health insurance agents have agreements to promote and sell only one company’s plans. A company like United Healthcare of course has a zillion different health plans, but you’ll still have less options presented to you if working through agents. Brokers can tag in with however many plans they wish. According to the Zippia career search website and data from the Bureau of Labor Statistics, there are ~140k agents, and ~160k brokers in the US. Both are more likely to work for a private than a public firm. In any case, you don’t pay these people directly—both kinds of healthcare shoppers get commissions from the insurance plans themselves. We’ll spend more time unpacking how a broker’s incentives affect you a bit later, but first it’s critical to know what brokers will ask during the shopping process.

Your broker will probably check if this is your first time getting health insurance and if you’re covered or not at the moment. There should be at least a general discussion of your health needs—how often do you need to visit doctors and specialists? How attached are you to your current providers? Are you taking prescription drugs? Are those medications branded? These medical-focused questions will be similar to what you’d ask yourself when reviewing health plans as I’ve covered in past episodes. There will also be plenty of time spent on outlining a budget and how many dependents need to be managed as well. If you’re not getting insurance from an employer, then your broker can help shop for a plan on what’s called an exchange. This is a state-run platform or federal site (like healthcare.gov) to buy coverage from. Some brokers can recommend off-exchange plans as well in a similar fashion to an off-market real estate deal. No matter where you buy plans, a broker should also help translate Summaries of Benefits and Coverage (SBC) documents, direct you to specific insurance support people, and confirm your drug benefits (if applicable). All the info I mentioned so far is not by any means an exhaustive broker-patient checklist but it should be a reasonable foundation. Whether you meet a broker for the first time or are going it alone to buy health insurance, use those prompts and guidelines to make the process efficient and smooth. Regardless of whether a rookie or master shopper is on your side, there are a few guidelines to have a great relationship with that person. A better agent or broker gives you more than just a quote. Because there are so many choices for plans, your broker should make side-by-side comparisons simple. Health insurance shoppers’ jobs are not finished after you buy coverage. Agents need to help you with renewal and customer service as needed. If you’re getting a plan from a company like Aetna, make sure to get contact info for the matching service rep who can answer your billing and coverage questions.

If that all sounds complicated, that’s because it is—there’s a reason brokers have jobs. Buying insurance is convoluted enough that major exchanges have people called navigators. These staff are kind of like agents but are paid by state and federal grants instead of insurance companies. Navigators aren’t required to be licensed in all states and can’t promote one health plan over another. Think of these people like the information desk staff at the mall or hospital. I’ll link a useful table explaining the differences between navigators and brokers on my post at rushinagalla.substack.com. Now that you know what makes an effective health plan broker, how do you find one? Agents don’t show up at the front porch. The best place to start is asking your personal connections, but your state’s insurance commission or online platforms like eHealth Insurance are helpful as well. Website solutions may be health insurance company pages, broker platforms, and purchasing alliances (which are employer-insurer liaisons offering packaged insurance for one consolidated fee).

As I mentioned earlier, you don’t (in most cases) pay brokers directly. The economics of selling health plans is the largest con for hiring a shopper. Companies incentivizing brokers to offer certain plans sounds okay on its face, but there’s a transitive property here—brokers are paid by insurance plans, those commissions are reflected directly on insurance premiums, then employers (and by extension you) pay those higher premiums. Agents representing one insurance company tend to get other bonuses as well. Even brokers fielding dozens of plans may bill large clients separately for specialized advice. A rational broker will offer a plan with the highest bonus to them. This is a straightforward conflict of interest similar to pharmaceutical companies in the old days giving overt kickbacks to doctors prescribing certain medications. Employers and patients won’t know insurance pricing breakdowns unless they ask. So do ask for the fee schedule of whoever you end up hiring. Quotes for health plans themselves are not final to begin with, since most companies say their estimated premiums are ‘representative.’ You only discover a true cost once the official insurance application and underwriting finishes. There are more transparent and independent brokers now who get paid only by patients and employers, but these deals are made for larger clients.

Regardless of the misaligned incentives, brokers are useful if nothing else for walking you through health insurance’s foreign language. A number of Americans still don’t know what a deductible and out-of-pocket-max are. I started this podcast to help spread the word about these concepts among other topics, but a friendly broker can help bridge that insurance knowledge gap for you. Just don’t lean too hard on them—remember, they fight for the health plans’ money, not yours. There is nothing stopping you from going it alone. In hiring a broker, you’re effectively making your final health plan more expensive in exchange for personalized guidance. What matters is that you know this tradeoff exists. Let this knowledge put you ahead of other patients and employers. If you do choose a broker or agent, let them do their job. Take recommendations in stride, but know that neither kind of insurance shopper can represent you. You or your employer are the final arbiters of what plan to use. A broker simply turns your many choices into plain English. Stay focused on making sure that’s all your broker is doing. You have the freedom to accept or reject insurance, but you won’t fully control the money in the health plan’s coffers that makes coverage work for all their members. Unfortunately for our fellow Americans on and preparing for Medicare, funds are running dry. Next week’s topic will cover Medicare’s pending insolvency and outlook for what Americans can and should do about it. Subscribe and stay tuned to Friendly Neighborhood Patient for more medical field insight. I’ll catch you at the next episode.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

You’re awake most of the time when getting medical care. But the future is a funny thing. It’s not a given that you’ll be able to speak or even write your healthcare desires tomorrow or in 20 years. Advocating for yourself is difficult when you get incapacitated or can’t think and act clearly. If you’re in a coma or become unable to make decisions, someone else has to act on your behalf for many items like money, last wishes, and health. On the medical side of things, patients can avoid these confusing and traumatic situations by picking a healthcare proxy. Today’s episode isn’t legal advice at all, but I do want to offer some background on preparing for the worst situations where you need someone to know your healthcare preferences through and through.

If you can’t talk, write, or move, someone else has to carry out your healthcare wishes. This is where a healthcare agent or proxy comes in. Family members don’t always take the wheel for driving your care because every state has its own rules. A healthcare agent picked ahead of time in writing is entrusted to make your medical decisions if you’re down and out. Some help from a lawyer makes this setup possible. You’ve probably heard of a common document like a living will. Healthcare proxies are in that mix as well. A living will includes many nonmedical items, but also states healthcare wishes, including directions for what to do about life-prolonging or life-ending care. A healthcare proxy on the other hand involves a named person to make healthcare decisions in the event a patient can’t act for themselves. ‘Advanced directive’ is the term covering those instruments. A finished advanced directive usually has both the wishes laid out in a will and the persons named as health proxies. Patients can revoke them if changes need to be made for a proxy or specific medical desire. Bringing a written document to your doctors with healthcare wishes and designated agents leads the way for a clear medical direction. The earlier this is outlined, the better. If you get a will, healthcare proxy, or some combination, give that completed info to both your primary doctor and whoever’s managing your hospital care if necessary. The major situation to avoid is a patient becoming incapacitated and the physician asking the family what the patient would want, and then getting no answer.

So how many people use these legal tools for medical needs? To find out, the Health Affairs journal reviewed ~150 past studies of US adults with a completed living will, healthcare power of attorney, or both. Based on a sample of ~800K adults’ medical chart notes, the authors estimated that 37% of patients had completed advanced directives. The event behind this study and similar efforts was Medicare’s 2016 decision to reimburse physicians for advance care planning and counseling. If choosing a healthcare agent and having written-down last wishes matters so much, why aren’t that many people getting them set up? Not all advanced directives are thorough and some doctors may not be on board for them. It’s great that patients can make contingency plans in one place, but writing healthcare wishes on a napkin isn’t good enough. According to the American Bar Association, advanced directives usually require two adult witnesses. Each state has its own rules and in some cases these documents need to be notarized. Having a lawyer whip up a living will can be $500-$750+ depending on the state. That’s a significant expense for many families. Not everyone needs healthcare proxies or medical wishes—healthy patients don’t usually plan for their demise. To adjust for these realities and affective forecast errors, the study authors plotted how many adults within major disease groups completed advanced directives. Patients with issues like heart disease, cancer, and neurological problems tend to exceed the national share of adults with finished advanced directives. That figure and other sources in this pod will be on my post at rushinagalla.substack.com. Given these facts, it’s possible to think of living wills and healthcare agents like insurance. You may not use it, but if you need to, you’ll be happy that it’s there. Having a healthcare proxy knowing your clear medical desires also saves providers time in executing treatment, which saves money.

Let’s assume that you know exactly what should be done for medical care if you’re incapacitated. You’ll still need an agent that everyone can trust. The best times for thinking about getting a proxy would be as a patient ages, when a major life event happens, or if a serious illness gets diagnosed. Healthcare proxies are expected to speak for the patient’s wishes, have access to said patient’s complete medical record, and collaborate with various providers. Most hospitals and clinics follow HIPAA guidelines for privacy—upon choosing a proxy, you’ll have to add his or her contact info to your health record. Family, friends, and peers of a similar faith are candidates to start with. Regardless of who you choose, make sure that person is decisive. No other character traits for a proxy matter nearly as much as quick-thinking and knowing your wishes by heart.

If you remember nothing else from today’s episode, know that a proxy is linked to a person, and a will is linked to wishes. Every patient has different needs and situations. It’s a personal choice to build contingency healthcare plans, but more patients should be informed of all the pros and cons to make better decisions. Having someone by your side when life doesn’t go smoothly is a plus, even if that person isn’t legally representing you. Another useful kind of agent to have at your side is a health insurance broker. American health plans, among many other parts of our medical system, are complicated. I’ve spent a bit of time walking you through health plan concepts in past episodes. That basic knowledge is still crucial. In the next episode, you’ll know how an insurance broker matching up with your aims goes a long way to finding the best coverage possible. Stay tuned and subscribe to Friendly Neighborhood Patient for all the goods on ground-level healthcare topics. I’ll catch you at the next episode.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Sometimes patients need to see the doctor more than once a year or even for more than a few days in a row. When a hospital trip comes around, you’ll need to pack more than just your clothes and a toothbrush. After this episode you’ll know the differences between inpatient and outpatient care as well as how to prepare for any long or short healthcare journey.

When thinking of how to get medical care, you’re probably imagining a visit to the doctor’s office or a telemedicine app. In any case you’re in and out the same day. That’s outpatient (or ambulatory) care. You can visit a hospital for regular office care—think of how a square is a rectangle (i.e. getting outpatient care anywhere) and how a rectangle isn’t always a square (i.e. inpatient care nearly always occurs at the hospital). Regardless, spending more than one night in that kind of facility means you’re an inpatient. Most patients don’t wake up wishing to go to the hospital. Inpatient medicine happens when you’re admitted for an emergency, planned care ahead of time, or for a particular service like childbirth. In any case, you get a bed and room with around-the-clock monitoring. Once the doctors and staff feel that you don’t need more care, the discharge process begins. When you leave the hospital, the discharge notes should have instructions along the lines of getting medications, following up with your usual doctors, or miscellaneous guidance. A bit later we’ll dive into how you can be 100% ready before, during, and after inpatient care. Knowing the actual scope of inpatient versus outpatient medicine gives necessary perspective.

More people are going to the doctor’s office for less than a day than others staying overnight or longer. Although knowing the split between outpatient and inpatient care remains imprecise, McKinsey and Company analysts provided some insight. That company reviewed ~$490B in 2016 commercial insurance claims then analyzed that dataset in 2020. The results showed 62% of those dollars being ambulatory, 11% as inpatient, and 27% as mixed-setting care. However, the insurance claim volume behind the money tells a different story. 97.4% of the claims were ambulatory and just 1% were inpatient-related! That disparity in costs between healthcare settings affects the whole country’s purse.

Hospital expenses take up ~31% of America’s annual healthcare spending—that’s $1.2T out of $4.1T. Based on 2020 data collected by the American Hospital Association, there are ~33M admissions per year, which is around 10% of the US population. What’s the point of these stats? Patients should be vigilant when they need inpatient care because a little guidance improves the odds of a successful hospital trip.

A typical, same-day trip to the clinic usually involves costs for procedures, lab tests, in-office medication, and the doctor’s time. At the hospital you have worry about those items and more, including medical equipment, administrative costs, nurses’ time, specialists’ time, more intensive medications, tests, and boarding. It should be no surprise that health insurance companies want you to avoid this. Health plans have a couple incentives among many: 1) to cover preventative care screenings (barring a deductible) lowering the odds of an expensive inpatient trip later and 2) requiring more permissions/authorizations to cover inpatients. When picking health insurance, keep hospital coverage in mind, especially if you don’t need more than a couple routine visits and labs per year. If you’re not visiting the hospital for an emergency, your doctor is probably doing the formal work to admit you. Although Covid had other ideas in 2020 and 2021, most patients get an elective or direct admission. Elective care involves you going at a specified time for a known condition. A direct admission is your doctor arranging your stay directly per their recommendations. Sometimes you might need to go in advance for lab tests or general monitoring for an issue like a heart or lung condition. Because hospitals tend to have specialized equipment and facilities, certain procedures are only possible in an operating room. Feel comfortable asking your regular doctor what kind of admission to expect when inpatient care is needed.

Having a better inpatient experience involves a few helpful tips beyond the usual prep I’ve mentioned for outpatient care in past episodes. Before any hospital stay, a simple packing list is a great start. Besides the minimum of phone/wallet/keys, do bring emergency contact info, all insurance cards, and your primary doctor’s office and fax number. For the medical side in particular, get a written list of medications, allergies, past surgeries, and known family history of conditions in order. Your doctor may forward this EHR info ahead of time. If nothing else, make sure your meds are updated. Inpatient physicians need to make quick decisions for you. Missing drug information alone can be the difference between a shorter and longer hospital stay. In the hospital you’ll see more than just doctors and basic staff. Nurses spend a ton of time administering medications, contacting other staff, checking vitals, and prepping you for procedures. Most hospital physicians do rounds throughout the facility to check on the inpatients. Other doctor-extension staff like physician-assistants and nurse practitioners are present as well. Social workers and hospital administrators round things out. While you’re getting settled in a room, ask your nurse what the doctor’s visitation hours are and who your case manager is. Case managers track your overall stay. After all this preparation, let the hospital staff do their job, but do ask them questions along the way as needed.

After the care itself, you have another step to finish before the hospital journey is over. Staff must officially discharge you. Inpatient discharge handouts include why you were at the hospital (or whatever your health issue was), the next steps for care (i.e. getting medications, following up with someone), and why you need to do those steps. Contact your case manager ASAP if you don’t get a discharge note with those aforementioned points. Also double-check that your primary doctor is getting any forwarded notes and lab results. You could access your EHR to move everything directly instead. Be thorough so you don’t need to return. Just because you leave the hospital for a given condition doesn’t mean you get an automatic one-year pass to go back for help with the same issue. Unnecessary re-admission is a risk all patients should work to prevent with the help of their providers. The clinical resource website called UpToDate offers a few a more checklists both doctors and patients can follow to avoid re-admissions. Besides a complete discharge handout, you should have clear, written points on how to get home, what family members to seek for assistance, knowing if your home is the best place to rest, a plan to get medications, and outpatient follow-up. Before going home, let the staff have you explain the major discharge instructions back to them. This final step raises the chance to prevent unnecessary inpatient care.

There’s no doubt that inpatient medicine is complicated. In reality, you won’t always have time or a clear mind to make decisions on any kind of healthcare. It’s hard to make smart choices when in a coma or cardiac arrest. Patients can avoid these problematic situations with a healthcare proxy’s assistance. Next week’s theme covers the pros and cons of having someone manage your healthcare when your ability to choose disappears. Subscribe and stay tuned to Friendly Neighborhood Patient for more healthcare system insight. I’ll catch you at the next episode.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Two doctors in the same field have equal years of experience with similar expertise about your condition. Assume you can choose either without needing to wait longer for the other. Does it matter if one of them cares a bit more about you as a person? The answer might surprise you. After this episode you’ll know how much emotional intelligence your physicians have on top of their medical intelligence.

It’s easier to judge a doctor’s abilities over a long period of time. If an orthopedic surgeon has done a few thousand knee replacements or if a dermatologist has been seeing melanoma patients for over 30 years, you can be reasonably confident that such professionals are solid at their job. This skill isn’t obvious during a random moment in the clinic. In the exam room, however, you can see a few things. The doctor looks into your eyes without typing away on a laptop. The doctor gives bad news about a diagnosis without a soft landing. The doctor listens to your story without interrupting. You might get shamed for being unhealthy. The doctor may encourage you to be active in medical care. There are thousands more interactions showing if your doctor cares about treating a disease as well as treating you, the patient. Immediate behavior gives away much of the doctor’s emotional intelligence that a years-long body of work on paper can’t explain. What is emotional intelligence (or EI)? It depends who you ask, but in the realm of medicine, EI matters for providers acting based on controlling their emotions, having empathy for a patient when needed, and being aware of their responsibilities. Coaching in sports is a simple but comparable example. Coaches have to adjust their approach based on their players and game plan. How coaches use players and execute a strategy is skill-based. However, interactions with the players have to vary. Some players need to be yelled at to make progress while others are better left alone.

In the exam room, certain patients want to participate in their care. Other patients want to just be in and out of the clinic to follow the doctor’s instructions without a second thought. Some patients like paternalistic doctors and others want an equalized discussion. Physicians noticing these subtle preferences personalize care for their patients to a new and practical level.

Bedside manner is not a new concept in medicine. Johns Hopkins’ first medical chief, Dr. William Osler, cared about physicians managing their behavior as well as treating both disease and patients. Dr. Osler’s The Principles and Practice of Medicine, which brings up some of these subjects, was published in 1892! Dr. Osler didn’t forget about science. The evidence-based medicine we have today is due to his belief that medicine needed a rational and consistent scientific basis. These (at the time revolutionary) ideas led to his famous quip that “practice of medicine is an art based on science.” Doctors are supposed to be patient-focused and not just locked into treating a condition. No surprise there. That being said, there’s a massive difference between a clinic saying it’s patient-centered, and being patient-focused in reality. There are few moments among many revealing much about the doctor’s character and attention for you.

As a patient, ask yourself a few questions to help estimate a doctor’s emotional intelligence. Are providers being polite with you but with not their staff? If you are due for a hard diagnosis, does the doctor callously lay down the bad news or does the doctor ease into the next phase of your care with grace? If physicians make a mistake, what do they do next? Is the doctor only telling you things to do, or is there some room for collaboration? There’s another important question besides asking if the doctor has a competent treatment plan in mind. Are you being heard? You can only find these answers during and after your time at the clinic. An online search may spell out a doctor’s track record, but there’s no scouting report for situational awareness.

Emotions can be imprecise, but that didn’t stop a few Indian researchers from conducting a 2018 study in Chennai to measure emotional intelligence. A sample of medical students addressed prompts based on socio-demographic backgrounds, private versus government education, a special EI self-assessment test, and hypothetical situations a doctor may encounter at the clinic. The researchers built their own EI scale ranging from 0-160, with 160 implying that a doctor is the saint of empathy and master of emotional control. The medical students’ average grade was 107. Here’s the problem—it’s hard to screen prospective doctors for emotional intelligence because the participants being tested will report themselves as self-aware and in command of their behavior. Beyond that fact, medical exam scores weren’t compared with each student’s EI result to put the results in context.

Empathy can never make up for bad medicine. If you’re having surgery or a complicated procedure, the doctor’s skill with a scalpel and stitches matters way more than any kind of social awareness of your pain. It’s better to have a trained but mean surgeon rather than a kind but worse surgeon. Even for regular office visits, the doctor’s treatment and your response to that treatment will always be the main factor of a successful medical relationship.

This Indian study’s methods were flawed. However, the results showed (anecdotally) the most common positive and negative payoffs of solid emotional intelligence. I added a screenshot of the study’s useful framework on my Substack post which you’ll find at rushinagalla.substack.com. Emotional intelligence still matters to patients regardless of how ambiguous it may be.

Bedside manners are necessary for higher-level care, but seasoning is no replacement for a dish. Good seasoning improves a meal, but not having a main course, meaning your doctor’s lack of actual expertise, means you stay hungry or unwell.

Don’t wait for a provider to realize they need to treat you as well as your disease. Patients can prompt the doctor to care a little more about them. If the physician didn’t introduce themselves to you, ask their name and more about their overall role in the practice. Request the doctor to listen for a moment without typing on a laptop at the same time. Some patients need tough love and paternalistic advice, but it doesn’t hurt to ask for being a larger participant in your care. Make sure your expectations of care and the doctor’s expectations of treatment line up. Don’t hesitate to ask questions like you would for any typical visit, but do so to have your doctor explain a little bit about why they’re choosing a particular treatment or assessment for you. All of these prompts help your doctor adjust their care to your preferences.

Bedside manners in medicine are usually figurative, but sometimes a doctor indeed sits next to your bed. Physicians apply their knowledge and emotional intelligence anywhere, but their assistance changes if you need medical care for one day versus one week. Whether you are at the clinic for a few minutes or staying at the hospital for a few days, the next pod will tell you exactly what it means to be an inpatient and outpatient. Subscribe and stay tuned to Friendly Neighborhood Patient for all you need to know about partnerships in medicine. I’ll catch you at the next episode.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

America has severe doctor supply and demand issues, but the truth is we actually do have enough doctors. How is this possible? After today’s episode you’ll know how our medical system’s resources are misused and what our country must do to improve long-term medical capacity. The patients who understand this will be able to hold the necessary players accountable to make lasting change.

If the US healthcare system is a chessboard, and providers are the game pieces, America is playing those pieces with just one column and row instead of using the whole space! Several journals, economists, and medical professionals are on the record for saying that in the next 10- to 20-plus years, physician supply will be dangerously low. They’re 100% correct that supply won’t meet demand as we know it, but the reasons are flawed. Alarmists have been complaining about doctor shortages for decades. Physician retirement and burnout can’t fully explain the current forecasted gaps. The physician shortage everyone worries about remains instead a grand misallocation of our resources. Before moving forward, we have to understand the true influences of physician supply, demand, and then how those two elements change based on population-wide trends.

So how many doctors are out there? There are just over one million licensed physicians. According to a census run by the Federation of State Medical boards, the number of doctors grew ~20% from 2010-2020. Most of that growth (+168k physicians) is attributed to new graduates. In the same time frame, the US population rose ~7% to ~330M. It seems that doctors are better than keeping pace, but those headline numbers are misleading. Not all doctors practice the same amount of medicine. Younger millennial doctors seeking work-life balance, late-career doctors, and burned-out providers put in less hours at the clinic. The spread of 2010 to 2020 medical licensees shows the number of doctors aged 60+ grew 48% and those aged 49 and below gained 16%. Are there enough new graduates to replace others getting close to retirement? The number of medical graduates grew ~32% from 2011 to 2021. That percentage sounds nice relative to population growth (~7%), but the absolute 2021 number is small at ~28k grads. The US population is a slow growing mega-fountain while medical graduates/workers are a fast-growing sink faucet. Don’t expect both to balance each other without help. New residents, though climbing, remain a lagging signal since it takes years to produce a new doctor. More data gathered by the Kaiser Family Foundation also show the fact that ~47% of licensed doctors are primary care providers (~496k PCPs) with the remainder being specialists. This breakdown suggests that on average, one primary doctor serves 665 people, and one specialist serves 584 people. This is another numerical trick. The doctor-to-patient ratios appear extreme until you learn that most physicians can handle patient groups in the low-thousands. There’s a critical difference between real capacity and max capacity. If the US population doubled tomorrow, one average PCP would oversee ~1,300 patients and one specialist would take care of ~1,100 patients. These are reasonable expectations. So why do both patients and economists keep worrying about doctor capacity? Part of the answer is that shortage isn’t the same as supply.

Physicians don’t magically pop into clinics, see patients, and then poof away. Reality shows instead that Amazon.com is better at deliver at delivering packages anywhere in two days than we are with having doctors in the right place at the right time. Our doctor supply needs to be realigned instead of rebuilt. As Covid-19 was picking up steam in 2020, Harvard Business Review made some commentary about necessary supply-side changes to help America reach its max healthcare capacity. The authors stress that hyper-urbanized regions have too many doctors chasing relatively concentrated patients, and in turn rural areas have too few doctors for spread-out patients. Most physicians in private and public settings also work primarily during the traditional workweek—some professionals stuff their patients into a few weekdays. Having additional time over weekends or after usual hours gives opportunities for patients to get care when normal time-frames don’t make sense for some demographics. Physicians have to do paperwork as well as see patients, which introduces a brutal time crunch. Having more administrative staff might alleviate some hours for our doctors but the whole cost of the medical system climbs if enough facilities do that. Even if a physician has the availability to see thousands of patients, that doctor can still reject Medicare and Medicaid patients because the payments will be much lower than private insurance. The authors then claim that expanding AI solutions, targeting more patients by tuning availability, and expanding the non-physician workforce (e.g. nurses and physician assistants) can increase each doctor’s patient panel enough to keep up with demand. Of all these suggestions, redefining the available times for when primary care office doctors see patients and embracing technology like AI to clean up administrative hassles (i.e. patient charts, insurance claims) are the most appropriate supply-side adjustments we have to make. Of course, supply has to meet demand somewhere; the bigger story behind America’s doctor shortage is demand itself running way from our control.

US medical care’s true needs are what create the shortage in the first place. The Association of American Medical Colleges, or AAMC, publishes a 25-year forecast of physician supply. In their 2019-2034 review, the authors calculated demand based on demographic changes, incidence of diseases affecting those related demographics, and care delivery setting. We know the elderly are growing in number and need more assistance. Care for those ages 65+ takes up 34% of demand now and is estimated to reach 42% by 2034. On top of that, more people are contracting diabetes and heart issues. Those conditions are manageable, but not straightforward. The current trajectory of US medical needs suggests a shortage of ~38k-124k physicians and ~18k-48k primary care doctors by 2034. Those are massive gaps compared to ~28k expected new medical graduates in 2021, but the AAMC lowered both top ends of those ranges by 12-14% year over year from their last report. Why are these ranges so wide and why is the estimated doctor shortage not as bad as the AAMC thought? The report highlights four major countrywide scenarios improving real medical capacity and reducing shortage forecasts. Two of the outcomes are unrealistic and two are practical. These supply and demand futures as well as the other sources in this pod will be on my post at rushinagalla.substack.com.

The easy fifth scenario is everything just staying the same. If new medical graduate growth rates and population aging continue, then we get the shortfall numbers I mentioned earlier. The first interesting but otherwise impractical change is all covered patients becoming part of an HMO or ACO insurance plan. In this world, medicine, doctors, and money are vertically integrated like how a company may own its whole supply chain. Based on current US healthcare policy, insurance trade groups, and physician organizations, there would be unending political gridlock to reach this outcome. The next demand change scenario is magical thinking at its finest, but is a helpful reference point regardless. The AAMC modeled what may happen if we all decided work on losing weight, cutting glucose, quitting smoking, and reducing cholesterol. Population-wide health improvements are something we can strive for, but we’re human. That utopia is out of most patients’ reach. However, the next two possible futures seem a little more reasonable. Drugstores like CVS and Walgreens are sprouting their own clinics. The proliferation of these retail clinics introduces alternative primary care facilities treating minor but acute issues. It’s efficient for patients to get basic goods, prescriptions, and routine medical exams at the same place. If referrals to specialists are needed, then patients can still get those permissions and move on with their care rather than waiting too long for a traditional clinician’s advice. More registered nurses and physician assistants under strict oversight is another legit overarching trend for plugging the gaps of care doctors can’t easily reach. A combination of these scenarios may help to heal Americans faster and keep us from needing doctors to grow on trees.

Whatever the consensus definition is for the US’s physician shortage, cleaning up healthcare delivery, opportunity, and patient targeting is how supply and demand can rebalance closer to each other. Patients clearly seeing these needs will better handle whatever changes happen next to our medical system. Patients also should know how to judge a doctor’s confidence and empathy as well as skill in treating disease. Can your doctor both heal and connect with you? To answer that question, bedside manner in healthcare is the main theme of the next pod. Stay tuned and subscribe to Friendly Neighborhood Patient for all the medical field primers you need. I’ll catch you at the next episode.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

You might be wondering: how can a doctor charge several hundred dollars for a ten-minute office visit? Why can the hospital bill $100k for a three-day stay? Who makes up these numbers besides me? Today’s episode is going to answer those questions so patients can get closer to what price transparency in healthcare should become.

One hilarious irony of medicine is that you won’t always know how much you need to pay for a visit and providers themselves don’t know how much they’ll get paid for the same visit until long after the fact. The dollars on your medical bill are going to be all over the place because of what your insurance covers, doesn’t cover, and writes off. However, let’s focus on the largest and usually shocking number on the EOB or invoice—the actual dollar amount billed to you or your insurance before any discounts. To be consistent, that top-line figure is called the charge or chargemaster price. The charge is nearly 100% at the discretion of the provider or whoever owns the facility. A general primary care doctor running their clinic might wake up one day and decide that a new patient office visit is $500. Or maybe $50. In either case, that charge is going straight to the insurance company. Charges vary a lot based on arbitrary choices about what providers believe their expertise is worth. However, there are some other factors based on a little common sense that influence healthcare prices.

The first major drivers for charges are staff and equipment. Healthcare facilities are more than just doctors and front desk people. Nurses, administrators, and other professionals are necessary inputs for making sure the medical system breathes. Shortages of any given personnel will make the entire system more expensive. The extreme demand for nursing during these last couple years is one such clear example. Equipment quality and depreciation affects charges as well, especially for hospitals and larger medical groups. Getting an X-ray is going to cost you more than guessing if you have a compound fracture or not with a naked-eye glance. Two patients arrive with the same broken left forearm but patient A might have a blood clot or pressure problem that complicates treatment. If patient B has an otherwise unremarkable history, then charges for patient A would likely be higher due to the degree of care needed to deal with the same broken forearm.

Let’s return to our earlier example of a general doctor charging $500 or $50 for a standard new patient appointment (such a visit might be coded as 99203 for reference). Regardless of the charge, no two insurance companies will reimburse the same amount for the same visit code. Even if you control for the insurance company, the payout still changes based on the individual plan due to how deductibles and coinsurance are spread. Health insurers don’t automatically pay the doctor a negotiated fee if the asking charge is less. For example, if the doctor bills $500 for the appointment, the health plan may reimburse $200 and write off $300 (assuming the patient doesn’t have a copay or coinsurance). However, if the doctor chooses to bill $50, the insurance will pay $50 even if the negotiated compensation should be higher. Doctors have to overbill as part of this dance with the insurance companies. This incentive, more than any other factor, is why patients see astronomical medical charges. Dr. David Belk, who runs the True Cost of Healthcare website, shows this reality among other medical charge trends directly affecting patients. Dr. Belk’s site and the other sources in this post will be on my page at rushinagalla.substack.com. There should be little surprise that providers are charging amounts several times more than what the final payment is. The requirements to get paid vary between health plans. Some insurers pay by the service, by the time, or by the diagnosis. Since these policies vary, providers have to submit all information possible on their claims as well as overbill to claim the max possible reimbursement. And if the insurance company chooses not to pay the doctor, the pumped-up tab is 100% on you.

To follow up on this phenomenon, researchers at the Health Affairs policy journal reviewed costs for two portable and common procedures done at most facilities: colonoscopies and MRIs for lower limbs (which are coded 45380 and 73721, respectively). The study’s data taken from Mass General Hospital, the University of Michigan Health System, and Vidant Medical Center (Greenville, NC), track the variation in cash fees, private insurance payments, and public insurance payments. The chargemaster prices for each of the procedures were 27% to 24x greater than the lowest respective final reimbursements. These health systems, all of which have a similar bed count, have such gaps between charges due to both patient demographics and overbilling incentives.

These eye-popping numbers affect patients’ wallets. Even though you may not be on the hook for a full chargemaster price, any increase of that charge will make either your cash payment higher or your long-term health insurance premiums higher. Per conventional wisdom, hospital and office payments across types of plans suggest that privately-insured patients with higher charges are subsidizing the low-margin public and self-pay patients such that everyone is getting the same level of care. The Journal of the American Medical Association debunked this “cost-shifting” with their own review of evidence from the Medicare Payment Advisory Commission. The newest evidence implies that cost shifting does not 100% apply to making up reduced earnings from publicly-insured patients; rather, a rise in private health plan payments go toward dealing with the rising costs of production to take care of that corresponding population. One economic fact about healthcare applying to this situation is that medical offices have mostly fixed expenses. That is, staffing, equipment, and real estate costs have to be paid no matter how strong the business is. Hospitals and large groups notice they get paid more from private health plans and in turn direct that extra money to raise profits while adding higher costs linked to attracting more of those patients. Medicine is an otherwise low-growth business so major providers have to exploit these gaps when possible. Equalizing medical quality for patients isn’t part of the equation here. Reality shows that private vs public patients get different levels of care regardless of how payment trends change. Hence, cost shifting doesn’t happen unless a multi-millionaire is consistently getting the same quality of care as someone on a low-income plan like Medicaid.

Given all this commentary on how medical charges affect you, the last takeaway is that critical events are unfolding right now for helping you deal with the mysteries of billing. The Transparency in Coverage and No Surprises Act are recent laws among many requiring hospitals and insurance companies to disclose certain prices. Changes to come in 2023 make it so various health plans must offer price comparison platforms for 500+ common services and then for all major services in 2024. Although only 6% of US hospitals have been complying with publishing their cash prices as of July 2021, you can still be cognizant of the difference for what providers bill for service XYZ vs what insurance covers for service XYZ, and also be persistent in asking what the charges are.

More patients inquiring about pricing are better for our system’s accountability. By now it should be no surprise that Americans get sensitive to healthcare prices whether it be for drugs, services, or procedures. There is another certainty. No charges occur if there are no providers. Unfortunately, US doctors can’t keep up with the American people’s medical needs as things stand now. For the next pod, I’m going to break down the physician supply and demand time bomb that has a countdown much closer than we’d like it to be. Subscribe and stay tuned to Friendly Neighborhood Patient for modern healthcare consumer tips and tricks. I’ll catch you at the next episode.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit rushinagalla.substack.com

Health insurance is a privilege, but not everyone is so lucky. Even if you have a health plan, you may still get a better deal paying out-of-pocket for routine care. For those who don’t have insurance and need to navigate self-pay medicine, this episode is for them.

Since 2014, patients have been able to sign up for health plans via the Affordable Care Act (ACA), and the overall number of uninsured Americans fell. However, US adults without insurance remain persistent at between 10-11% the population. Analysis from the Kaiser Family Foundation also covers the reasons uninsured people claim to not be on a health plan. Around 74% of the sample note they’re uninsured because they can’t afford a policy to begin with. Beyond that, ~41% of uninsured adults disclosed the choice to decline seeing a healthcare professional because of their status. Even stranger, ~25% of respondents said they’re uninsured because they have no eligibility for insurance via employment, and ~21% noted that insurance wasn’t necessary or desired to begin with. The distribution of choices here is uneven because respondents were able to pick from multiple choices applying to them. I’ll have the related figures showing these stats on my Substack post at rushinagalla.substack.com. Regardless of how you feel about insurance paying or not paying for routine medical work, getting emergency coverage is critical given how quickly charges can stack up at the hospital. That’s why part of this episode’s purpose is to help with managing a cash-pay approach until you are ready to grab that chance to get a proper health plan.

So, what can you do if you’re uninsured and it wasn’t by choice? Being upfront about having no coverage is a good start. Whether you’re in contact with a regular clinic or hospital, mention that you are self-pay while transitioning to asking what cash discounts there are. Reasonable savings to ask for when paying cash are between 20% to 30%. To better focus that discussion, ask for a fee range associated with an office visit or whatever particular service you have in mind. But why would a doctor’s office give discounts for cash payment? Providers are willing to offer a cash discount if they save the marginal administrative costs from billing insurance. Check if a clinic does interest-free payments or gives benefits for paying in advance. You can also call around to multiple clinics to shop prices if you have no urgent medical need at the moment. However, depending on where you live, it can be sometimes overwhelming to pick a medical office or doctor especially with added stress from not having coverage. In that case, reach out to your state’s local insurance department to ask about charity care, community health clinics, and local Medicaid eligibility. Community health clinics are non-profit centers that do routine care—think physical exams, vaccines and preventative care, and women’s health—for a reduced cost or no cost. Walk-in clinics and some urgent care facilities may give discounts for self-pay patients if asked. In a worst-case scenario, the emergency room is an option that cannot turn any patients away, but of course it’s best to pursue the ER only if needed. Regardless of the final costs, using cash for healthcare gives you more choices for whatever provider or health system you wish to seek because you’re not limited by an insurance network.

Your health plan is probably not cheap for you or your employer. The insurance company eHealth assessed the ACA’s health plan trends from its first open enrollment in 2014 through 2020. Though most Americans get their insurance privately through work, the costs of buying insurance directly from a marketplace are a reasonable point of reference. The math is not pretty. According to eHealth’s analysis, 2020 average monthly premiums—meaning the amount you pay for the right to have insurance—were ~$456 per month for individuals and $1,152 per month for families, up 68% and 72%, respectively, since 2014. On top of that, average deductibles—the amount you have to pay out of pocket before coverage kicks in—were ~$4,364 per year with individuals and $8,439 per year with families. These levels suggest that your total annual cost of using marketplace health insurance would range from ~$9,836 to $22,263. The real all-in cost is higher still because these expenses would come before any copays or coinsurance. This is why you should consider, based on your current health needs so far, if such a price makes sense. For example, if you happen to be someone who eats well, sleeps enough, moves enough, takes very few medications, and sees a primary doctor maybe twice a year max for preventative care, you’d probably get a better deal paying for routine care with cash versus insurance. What’s the tradeoff? According to Solv Health’s pricing tools, the national average office visit cash price at a hospital is ~$300 with the full range being $180 to $675. With the top of that range you are paying just over $1,300 cash for two office visits. If those two appointments were billed instead through your insurance, your final invoice amount would likely be higher because of the deductibles in play and the markups providers add to their charges to create margins after insurance discounts, operating costs, etc. Note that your pharmacy benefits for prescription drugs are separate from medical services.

Make no mistake: I am not suggesting that you discard health plans on purpose. If, instead, you happen to be dealing with various chronic issues, quality-of-life conditions, or have an occupation involving risk of bodily harm, coverage makes perfect sense because there is a high volume of complex medical work to be done. The more critical takeaway to make is that insurance and self-pay don’t need to be mutually exclusive. Even if you have insurance to begin with, taking a self-pay approach for routine care may save you money. However, following a proper cash-pay approach regardless of being insured, under-insured, or uninsured, depends on how you answer three specific questions. What care do you need (routine preventative care, unusual specialist work)? Will you max-out a deductible or get close? How confident are you of not having a big-ticket service or procedure this year? If your answers to those questions suggest that you will probably spend less on medical care than whatever your all-in yearly health plan cost is, then it’s worth contacting local offices to learn the cash prices for routine services like physicals, blood draws, simple imaging techniques, and local outpatient procedures. With all this guidance in mind, patients can trade cash for vigilant but lower-cost preventative care while using health plans as a proper fallback.

The tolerance for emergency and general risk is where you draw the line for using cash versus insurance. Another major factor to know is that paying for medical care with cash usually doesn’t count towards your annual deductible. You can still call your insurance company, ask what the max allowable charge and ranges are for a given aforementioned service, then compare that amount with cash quotes from shopping around for care. It’s also worth noting that due to various price transparency laws passed between 2020 and 2022, hospitals legally have to disclose cash prices and good-faith estimates when asked—be persistent but polite in your search for prices. During your negotiation, using healthcarebluebook.com and solvhealth.com are helpful resources to get an idea of cash prices in certain regions. On the prescription side, goodrx.com is helpful as well for self-pay clarity. If any of you readers and listeners know about other helpful tips for self-pay patients, you’re welcome to comment on my Substack post or Friendly Neighborhood Patient’s YouTube channel.

Alternatives to health insurance besides paying cash do exist, but that will be a theme for another day. Instead, the next episode focuses on the insights for why doctors and hospitals charge what they charge and where the cash-pay numbers come from. Subscribe and stay tuned to Friendly Neighborhood Patient for more on medicine and money. I’ll catch you at the next episode.

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