Insured price $2,758, cash price $521

It's the same logic as refusing delivery of a shipped good when it comes to contract law (IANAL). It's expected that when a good arrives, the buyer pays. If the buyer refuses to pay then the good is not 'delivered.' In the transition to services the 'delivery' is the invoice you get and that is the moment you are compelled as the buyer to pay that invoice. If you start paying it then you have accepted the invoice as valid because you paid for part of that invoice. Given this the context of being sued would be that the seller observed that the invoice was valid by the buyer paying something towards that invoice, and therefore they should be compelled to pay the rest of the invoice.

On the other hand if an invoice is never realized because it's in dispute, then you have a stronger leg to stand on. A different way to look at is in sit-down dining. You receive service, you are delivered a bill, you are then expected at the moment the bill is delivered to review it and pay it, and if you pay it the bill is settled. If you have a dispute because nobody ordered a diet coke, then the bill is rejected and hopefully sorted out before a final bill is presented and people pay for it. The same sort of logic ends up applying here. If you paid for half the meal and left that has different outcomes compared to not paying the bill and causing a stink.

We see a lot of people trying to justify medical salaries due to the cost of education and malpractice insurance, but an integrated program could work around that.

We should treat it like the infantry. If you want to drive a tank and blow up people, you don't apply to a college and get a Doctorate in Blowing People Up. You don't buy insurance to cover if you blow up the wrong people. You join the army.

I'd like to see health care reform inspired by military structure. A high-schooler eager to get into medicine joins the Health Corps, and gets their education covered in exchange for n years of working in state-run facilities. There's strongly restricted legal recourse if the Health Corps hospital cuts off the wrong foot-- here's $500 and a really nice wooden peg.

As a self-contained system, I could also imagine it working around some of the structure that's restricting the industry. I'm picturing programmes to advance in both through direct study and training, and where appropriate "field promotions" (think of the 20-year term nurse who knows more than most of the doctors from experience, but will never be able to escape their position without expensive and onerous formal training/certification)

Emergency medicine most definitely can be a profit center. That's why you see all of these new freestanding emergency rooms that look like an urgent care center but are open 24 hours and bill 2x as much.

I have a family member who is a doctor, and he and his friends regularly get together to figure out how to bill the most money.

I'd be fine with it if it wasn't healthcare. He doesn't even like being a doctor. Something is broken.

Disclaimer: I'm still a medical student, take my biases into account when you read this.

It seems like mid level providers are being granted more and more autonomy each year. In fact, they have full practice authority in 20 states (no need to work under a physician). Knowing that, are the AMA et al truly strangling the supply side of healthcare? From the politico article you linked, it seems that the number of specialists we have is unnecessary, so that can't be it.

I'd like to think that most doctors aren't trying to out-compete mid-level providers, and that most doctors are trying to do right by their patients. Maybe that's naïve.

I also agree that the wages for physicians are too high, and that reform from the ground up (education costs, healthcare costs, and reimbursements) is desperately needed. However, to state that providers are the core problem is tremendously naive. The average salary of physicians, even at $250,000/yr, with 1 million physicians in the US is $250 billion/yr. In comparison, the revenue from the health insurance industry was around $1 trillion in 2017. The hospital industry made $970 billion in 2016. The pharmaceutical industry made $450 billion in 2016, I can only imagine that number went up. I can see how the insurance industry and hospital revenue would be tied in physician reimbursements somewhat, and obviously pharmaceutical payments, but the pharmaceutical industry shouldn't be impacted by physician salaries.

As a side note, very few doctors I've had the pleasure of knowing have any idea what their services cost patients. Proceduralists generally have a better idea.

For those of you interested, I'll try to explain what is needed in a residency program. Your program needs to provide you with the training necessary to be proficient at all aspects of that specialty by the end of your training. That means you need the patient volume, mentorship, and variety to meet that standard. It just so happens that it's very difficult to meet that standard unless you're at a larger institution. Community programs do exist, but today the vast majority of programs except for family medicine are at academic centers.

What that also means is that you can't train too many doctors in one place at one time. Especially in the case of surgical specialties - You need as many procedures as you can get in your residency, extra residents take those procedures away from you.

That isn't to say that more family medicine and primary-care track residencies aren't needed, they absolutely are. At the same time, without more Medicare funding for these residencies (per the politico article it takes around $150,000/yr to train a resident physician) hospitals aren't willing to take on the extra cost. A bill is hopefully making its way through the House to increase the funding for more residencies (15,000 new spots over 5 years).

Ultimately, I think the trend is going to be that more and more doctors will specialize, and mid level providers will be mostly nurse practitioner or physician assistants. Hopefully the data will continue to be positive in terms of outcomes, and prove that we just don't need the amount of training we thought we did for those providers.

P.S. While I'm not going into primary care, I loved my family medicine rotation in school. I felt like I had genuine impact on my patients, met some of the most down to earth doctors, and it was an active day with lots of variety.