Patients' Medical Costs

Insurance premiums for Medicare and Medigap policies are described in 9 pages on SeekingAlpha. There is also information on SeniorCare and Medicare Rights Center about differences in Medigap plans. Medigap covers a lot of copays not covered by Medicare Part A and B. You can't use Medigap if you have Medicare Part C (Medicare Advantage). If you don't get a Medigap policy when you start on Medicare, in most states you may not get it later.

• Only four states (CT, MA, ME, NY) require Medigap plans to offer continuous or annual eligibility for people with pre-existing conditions.
• In all other states and D.C., people who switch from a Part C Medicare Advantage plan to traditional Medicare may be denied a Medigap policy due to a pre-existing condition, with few exceptions, such as if they move to a new area or are in a Medicare Advantage trial period. This denial may lock you into Medicare Advantage, with its limited networks, limited appeal rights, and sometimes worse care for the sickest patients (12% higher death rates and more preventable emergency room visits for non-elderly in California 2009-2013).
  

Several groups have proposed changes in Medicare premiums. Cancer Today discusses high drug copays.

Community Health Centers get federal grants and often have lower costs than average.

The Wall Street Journal has a good free guide to looking for health care costs, no matter if you pay with Medicare, other insurance, or cash. Finding costs before you get treatment is hard. Dr. David Belk explains about the confusing cost of office visits, including higher pay from HMOs than from fee-for-service. The Atlantic describes 2019 laws and practices of debt collection for unpaid hospital bills.

Each patient's cost depends on his or her insurance.

• Insurance companies negotiate costs, and patients pay this up to their deductible or copay.
• For understanding and negotiating Medicare coverage and some aspects of medigap policies, help is free.
• A 2020 HCCI survey lists (a) average cost paid by private insurance, (b) average cost that would have been paid by Medicare, (c) numbers of patients and providers. These are in 2 spreadsheets: (1) summary for each state and metro area, (2) detail for each type of office visit or injection for each state and major metro area. Summary citing previous studies and methods.
• A 2019 RAND survey lists 1,600 hospitals and the average prices negotiated by insurers for inpatient and outpatient care, as multiples of Medicare prices (averaging 2-10 times as high for outpatient care, 2-4 times as high for inpatients): xlsx list of 1,600 hospitals, pdf summary, AHA comment.
• For people without insurance, the Medicare level for each service, and the private insurers' averages, are starting points for negotiation.
• In order to know total costs, patients can ask the doctor's office whether an anesthesiologist, assistant surgeon or hospital fee will be needed.
• Anesthesiologist fees are in the Specialists tab above.

Doctors' fees under Medicare are in the Specialists tab above. They show what Medicare pays, and the list price for each procedure from each provider. Medicare costs include the total paid by Medicare, supplemental insurance and patients.

Hospital fees for the most common 100 diagnoses are in hospital spreadsheets from Medicare, and are mapped nicely at ClearHealthCosts. 

For example the data files show that surgeon costs for knee replacement are typically around $1,500, assistant surgeon $300, anesthesiologist $200, and hospital costs (for "major joint replacement or reattachment of lower extremity") averaged $14,000 if there were no major comorbidities and complications (MCC), or $23,000 if there were.

For a few procedures (primarily imaging, tests, counseling, dental extractions or implants, cosmetic procedures), ZendyHealth gives (free) a range of local prices within a radius you choose. They offer you a doctor based on how much you want to pay ($49 referral fee). You cannot use insurance with the doctor, but Zendy helps you submit a claim to your insurance company, so your cost counts against the deductible. For these and other procedures they offer a free consultation. You have to pay their legal bills if there's a problem ("indemnify"), and accept arbitration. You have no choice of provider, and see the name assigned to you only after you have paid the referral fee. For example different MRI centers have different strength magnets, and you are likely to get the cheapest, weakest magnets, which give less precise images. If you have time to search the Specialists tab above, you can find the lowest price providers and negotiate directly.

Costs for treatments in North Carolina are available from Blue Cross/Blue Shield of North Carolina, based on their patients and their contracts with providers: bcbsnc.com/content/providersearch/treatments. These have actual costs for a treatment episode, including hospital and doctors. Very easy to access. The free system compares all providers within any radius of a zip code, up to the whole state. You can sort by cost, name or distance. However there are only 1,200 procedures, no info on how often each doctor does the procedure, voluminous output with typically 3 providers per screen, not downloadable, only North Carolina, no procedure codes, so it is hard to be sure what each item covers,  no lab costs or drug costs. Their data come from one year, but they don't say which year.

Doctors' Incomes

Doctors' incomes derive from the payments above and the volume each doctor does. Average incomes (after expenses)  by specialty range from $200,000 per year for Public Health and Pediatrics to $500,000 for Plastic Surgery and Orthopedics, with wide variation. Concierge (2% of doctors) and cash-only (5%) doctors earn slightly more than average, comparable to other self-employed doctors. 13% are direct primary care doctors, generally subscription-based but lower fees than concierge. Three quarters do not charge for no-shows, whatever their policies may say. 70% see patients for 45 hours per week or less, but they spend 10 hours or more on paperwork and administration.  A fifth to a quarter of most specialties would not choose medicine again if they had the chance. Wealth averages $1-2 million, depending on specialty and age. A quarter of doctors have over $1 million by the time they are 35, and two thirds do by the time they are 50.

​Most doctors at hospitals work for large groups (TeamHealth, Schumacher) which contract to provide hospitalists, radiologists, emergency doctors, etc. Some companies provide doctors to hundreds of hospitals (Envision + Amsurg). Hospital doctors earn $200,000 - $400,000 per year. About half feel fairly compensated. Only a quarter "regularly" discuss the cost of treatment with patients. Over three quarters would choose medicine again and the same specialty.

Insurance payments are complex, and are further discussed throughout this site. A glossary defines insurance terms.