I’ve gotten a bunch of e-mail on the subject. I’m exhausted from the fair. So I’ll just post some. Starting with this one from a longtime reader:

Jonah,
I’ve written you before, but I thought this time I’d include my title, in the hopes that it might give more credibility to my statement.
First a surgeon receives a fraction of what a hospital is paid. (They don’t, after all, pay for the surgery crew and all the other costs associated with running and OR; the hospital does. That’s why there’s both a professional reimbursement for the doc and a facility reimbursement for the hospital.) The amounts the college of surgeons cited are correct.
Now, on to the hospital. If Medicare was paying, we’d get about $12,000. That’s on the high end of what Medicare pays (it’s regionally adjusted for wage differences, and California, of course, is higher than most other regions.) The biggest issue I have with the e-mail you reproduced was the statement that if you don’t have insurance you pay 50K.
I won’t go into the reason the difference between ‘list’ and actual reimbursement is so high, but I can tell you that very few, if any, hospitals ever receive list for a surgery from an uninsured patient. First of all, if the patient is poor (and many diabetic patients are), he or she is likely to be on Medicaid. We help all such patients become eligible if they are not yet enrolled and I imagine most hospitals do the same. (An interesting aside – many of the ‘uninsured’ are Medicaid-eligible individuals who simply haven’t enrolled.) Medicaid, at least in California, pays less than Medicare.
Most hospitals (at least the vast majority here in California) have discount policies for patients who don’t have insurance but who don’t qualify for Medicaid. Ours is typical; we have a sliding scale that’s based on Medicare, increasing with the patients resources. You can receive a discount at our hospital if your family’s income is five times the federal poverty level. If you qualify the most you pay is 150% of Medicare.
Sure, you can always find an anecdote about some hospital charging full list and putting a lien on someone’s house, but in my experience it’s just very, very rare.
Also off topic, I’ve scared to death about a single payer. There’s an enormous ‘hidden tax’ in the system, as Medicare and Medicaid generally pay below cost and the difference is made up from commercial insurance patients. The tax, of course, manifests itself in higher insurance premiums. Going to single payer, as would quickly happen under the House bill, does absolutely nothing about the system’s underlying cost structure, and with no personal incentives provided, the cost curve simply isn’t going to ‘bend’ – at least not downward. Then we would see rationing.
[Name Withheld]
Hospital Chief Financial Officer.

And:

Hi Jonah,
I feel like I need to respond to a couple of points on Obama v. Surgeons Con’td. Let me start by saying I work as a health psychologist in a department of hospital medicine for Kaiser Permanente in Georgia. This means that I see patients in the hospital (only) for a variety of reasons, substance abuse, poor diagnosis/prognosis, psychiatric disorders and non-compliance to medical advice.
The vast majority of patient we see with leg amputations are diabetics (type 2 – adult onset) that have a long history of noncompliance with medical advice and medications. They are often poor surgical candidates because of other health behaviors (smoking, drinking, overweight) and often take poor care of themselves post-surgery (missing follow-up appointments, not filling prescriptions).
Here in the Deep South, we make the cynical joke that almost all our patients have diabetes, cardiac disease, and kidney disease (the kind that progresses to dialysis). For these patients we provide individual and family consultation and education in the hospital, including right before discharge. If there are financial difficulties, we start the process for meds from drug companies, medicaid/disability filing, encouraging the patient and family to seek sources of help from their church. We have an intensive case management system, including a case manager for the first 2-4 weeks after hospital discharge to make sure the patient fills their prescriptions and goes to their follow-up appointments, and then transition them to our complex case management program.
All this is lovely, however, since I specialize in behavior, here is what I know….the best predictor of future behavior is past behavior. I also frequently refer to Thomas Sowell’s quote from Race and Culture, “a man cannot be reasoned out of a position he did not reason himself into.”
So, all that to say, surgeons are right to feel insulted when portrayed as money-grubbing MDs, when many factors are out of their control. Preventive healthcare and education doesn’t magically fix things. Some people have other priorities.
Ok, now I”m being paged….
Have a good day.
[Name withheld]