I just noticed someone asked in a comment on my blood transfusion post, "How much does the hospital charge for a blood transfusion? How much does it pay? (Is the blood donated? What's the processing fee?)"
The question makes me laugh. How much does the hospital charge? I have no idea. The processing fee of a blood transfusion? Beats me. We order things, they get done, we are completely insulated from whatever the billing process is. And I'm glad. Not just because the last thing I want is more paperwork-- we write tons of notes as it is, we spend a great fraction of our day sitting in front of computers and typing instead of actually doing patient-care-related things-- but the last thing the system should encourage is making decisions centered around things unrelated to patient health.
Yes, I think the system is broken-- I know hospitals charge what seem like insane amounts of money, and if you don't have insurance, any little medical issue can absolutely bankrupt you-- and I think that's bad, and troubling, and frightening. But I don't think the answer would be asking our patients if they'd rather have the $3,000 TEE or the $0 "lie in bed and wait for another heart attack." We do things because they're necessary-- the fact that they cost money is unfortunate but I don't think we want doctors deciding on the balance between cost and health, and I don't think patients are equipped to sensibly make those choices-- is the procedure worth it even if you need to default on the hospital bill and declare personal bankruptcy? Well, if it means the difference between life and death, I think it probably is, and I don't know who wants to argue that it isn't.
What I do know is that the billing doesn't always make sense. Insurance companies have deals with the hospital where they pay a fraction of the "retail" rate that self-pay customers are billed. Patient might get a bill for $500 when an insurance company would have been able to settle that claim for $50. That's clearly unfair to patients who, for whatever reason, aren't covered. And that doesn't just affect the uninsured-- it affects people who are seeing doctors outside of their plan-- which isn't always the patient's fault-- the hospital sends over a specialist for a consult, you have no idea if they take your plan and you're in no position to do anything about it even if they don't. There are tests that aren't covered, there are claims that get rejected. It's a mess.
But the fortunate thing for residents is that we deal with none of it. And, frankly, I can go on and on about how in an ideal world I don't want to be a hospital-based physician, I want to see patients in private practice, I want to see them when they're well and not when they're dying-- but there are huge advantages to being based at a hospital and spending part of your week dealing with inpatients-- the hospital deals with all of that back-end stuff, you don't need to deal with the billing and the insurance, you don't need to deal with finding and maintaining office space, and having a staff and the infrastructure you need to effectively run an office. You get to spend your time seeing patients instead of being an accountant. So there's certainly benefits there.
But, gosh, the last thing I want to do is think about how my patients are paying for their medical care. I just want to worry about getting them healthy enough to leave.