Why Hospital Prices Are So Much Higher Than You Think

Most people blame doctors or insurance companies for the cost of healthcare.

But that’s not where most of the money actually goes.

In this episode, I break down the part of the healthcare system almost nobody talks about… hospitals.

Hospital care now makes up about a third of all healthcare spending in the United States. And over the past two decades, hospital prices have grown far faster than almost anything else in the economy.

So what’s really driving these costs?

We talk about price transparency, nonprofit hospital systems, government programs that quietly funnel billions into hospitals, and why the system keeps getting bigger and more expensive.

Once you see how the money actually moves through healthcare… you start to understand why costs keep rising.

In this episode, you’ll learn:

• Why hospital prices have risen dramatically compared to other medical care
• The surprising reason many hospitals still hide their prices
• How certain healthcare programs quietly shift billions into hospital systems

Learn more about Dr. Marion Mass:

• https://free2care.org/wp-content/uploads/2025/01/report.pdf
• https://www.bucksindependence.com/author/marion-mass/

Chapters:

00:02 – Where the Money Is in Healthcare

00:10 – Why Hospital Costs Are Growing So Fast

02:34 – The Problem With Price Transparency

04:07 – Why Hospitals Resist Showing Prices

06:43 – The Truth About Nonprofit Hospitals

09:34 – Inside Hospital Executive Pay

12:42 – Government Programs Funding Hospitals

14:55 – How Hospital Consolidation Happens

18:00 – Why Hospitals Buy Physician Practices

21:27 – The 340B Drug Program Explained

27:34 – How Payment Systems Favor Hospitals

33:31 – Who Actually Represents Physicians and Patients

38:41 – Why Hospital Care Costs So Much More

43:48 – How Hospital Systems Became So Powerful

Transcript

SPEAKER_00 0:00

When Willie Sutton was asked why he robbed banks, he said, that's where the money is. Well, in healthcare, the money is hospitals. That's where the money is. What happens is about one-third of the money we spend in healthcare in the United States is spent on hospital care. Now people don't know that. People think physicians are overpaid, they think the insurance companies are ripping them off, and that's because they see physicians when they go to hospital or their office and they pay their insurance all the time. But actually, we really need to do is look at hospital expenses. And when you look over time, so right now, like it's a third of all expenditures are from hospitals. So that's a huge amount, but it's growing fast. And from 1998 to 2021, the rate of inflation for hospital surrounds was 230%. That's about four times the rate of CPI for everything else. So it's unsustainable. Now here's the good news about this. The cosmetic procedures over that same time period. So this is plastic surgery, and where patients are paying cash, the CPI for that was half, was 38%, so about half overall CPI. So that means a couple of things. That means patients are really good at shopping for care. We give them the incentive, they're great shoppers. The other thing is that physicians do really well when we get rid of the middlemen. So what we need to do is get rid of the middlemen. And in this episode today, we're going to talk about why hospitals are overpaid and how we're going to fix that. And we're going to talk about physician-led care. And this is for educational purposes only, not medical advice. And you should always seek the advice of a physician if you have a problem. And today I have a phenomenal guest, Dr. Marion Moss, who is a practicing pediatrician. And as a retired OBG went, I love pediatricians. So always happy to talk to pediatricians. And she's trained at Duke and Northwestern. And she's a prolific writer. And she's also produced something very interesting: Free to Care, which is an organization that she co-founded, which is a physician-led organization. And she wrote a wonderful white paper. And that white paper has lots of good ideas in there. We're going to reference that in the show notes. But Marion, could you talk to me us a little bit about free to care's shopping and price transparency, why that's so important?

SPEAKER_01 2:30

Sure. Like, you know, listen, I don't understand what the big deal is. Like if we had transparent prices and patients could uh compare, like going to an independent doctor's office versus going to a hospital-owned clinic for something, um, when we have uh prices that are not transparent in the hospital setting, because only 21% of hospitals are being compliant with the price transparency rules. I mean, like, look, we're asking them to do the most basic thing, and I'm sure we'll discuss in the show, our government's giving them a lot of like goodies, right? So they're supposedly nonprofit. Yes. But when you take a look at the fact that 40% of Americans are in medical debt, I believe about half of that comes from emergency room debt, and another 30% of that comes from hospitalizations. When you have twenty only 21% of hospitals, and most of our hospitals in our country are nonprofit, getting the goodies from the government, right? Uh and uh when when we have that setting that like 80% of hospitals aren't doing the most simple thing, which is providing the prices, and we know that when you shop for things, when you can shop around, you can drive prices down. Well, it just seems to me that the hospitals are hiding something. And usually when someone hides something, and especially when it's someone that's making a lot of money, they're hiding something because they have something to hide.

SPEAKER_00 3:55

Absolutely. You know, it is a great point because a lot of people say, and you've seen this on X and social media, they say, Oh, are you supposed to shop for care when there's an emergency? And most of medical care is non-emergent. And as Mark Cuban said, if you could schedule it, you can shop for it. And the other thing is, you know, what I would do, I'm living in Jacksonville if I had complete price transparency, you could shop around ahead of time. You know, you're gonna have a baby, you could say, what's it gonna cost me? What's my out of pocket gonna be at the different hospitals if it was easy to find? But but you're 100% right. It's very difficult. The hospitals have resisted this call for price transparency. And I think that would be a game changer because if you saw that you could get a CAT scan at your hospital for $10,000 or $350 in a freestanding imaging center, you would never go back to the $10,000 CAT scan.

SPEAKER_01 4:48

Exactly, 100%. Actually, um, one of the great groups that's really pushing on the price transparency, in fact, leading the way, the patient rights advocate group uh led by Cynthia Fisher, um, they have put out all kinds of reports. You know, this this group is all over the price transparency issue. They did a 2020 report. I think it's always great to give like an example, right? So within one of their 2020 reports in just Colorado, they were talking about one of the university hospitals in Colorado, and they were um pointing out that what the hospital does is it sends either attorneys or bill collectors after the patients. And some of the patients were sharing their stories. There was one gentleman that uh was charged more than 10 times the standard amount for a simple single x-ray. I think he was charged like nearly $700, and the x-ray should, you know, at a at a freestanding center, it would have been 60 bucks. So if a hospital is charging that much, and then when you have hospitals that you realize are non-transparent, you know, like look, if you twist your ankle and you think you you need an x-ray to make sure that you're not broken, maybe you wouldn't go to a hospital, maybe you would pick a different center. I mean, there's plenty of examples of care that um, you know, that I think the patients deserve to know. And furthermore, once these examples are out there, I hate to use the word shame, you know, like ring the bell, right? Like shame, shame, shame. I have the feeling we'll be doing that all through this episode with the ringing of the bell with shame. But, you know, these these hospitals, yes, these hospitals might be shamed into dropping their prices.

SPEAKER_00 6:31

Absolutely. You know, 100%. I mean, the sunlight really does do that. And the other thing that I want to talk a little bit about is there's a lot of misunderstanding of what a nonprofit hospital is. And I see a lot of people say, we need healthcare to be nonprofit. That's gonna solve everything. And they think that these nonprofit hospitals, which are the majority of hospitals now, are run by Mother Teresa and are given free care. And of course, there's no difference in the business practice between nonprofit or for-profit hospitals. The only difference is that you don't have shareholders and you're not paying taxes, and you're not paying federal state, you're not paying property taxes. And I want people to start thinking, you know, if you go downtown in a big city center, you know, if you go to the UPenn or any of the big city centers, there's tremendous real estate holdings at these hospitals and they're paying no taxes. That means everybody else is paying those taxes. So it's a big burden on the community. And there's been lots of studies, and you dealt with that in Free Two Care about are the hospitals given the charity care that they're supposed to for the tax exemptions that they get. And the tax exemptions are worth billions of dollars a year. And there is a slide, and it's always hard to know exactly, but the last episode I saw estimate was $37.4 billion that they're getting for all these. And the idea is that then they would give enough charity care to make up for that. But a lot of times they don't do that.

SPEAKER_01 8:01

Well, no, and as they mentioned before, they're they're hiring the debt collectors and sending them back out after the patients after they weren't transparent about their care. Um, I think uh Gee Bai, who is a professor of um economics at Johns Hopkins University, she did a 2020 study. A lot was happening in 2020. I guess maybe we were all locked up. People were starting to like look under the hood and see where the money was, right? But uh I think she did a study, and it looked like to me, the more that the hospital was pulling in revenue, the less the percentage of charity care that they were giving. Um, at least that's how I read the study. You know, we should look into that. And I I think um one of the things that most Americans might want to know is that for these nonprofit entities, you can just type in the name of the nonprofit and type 990, and you get like a really great uh really great bunch of information as to how much some of the people who run these nonprofits are making, because dang, some people are really profiting, right? You know, I I put up a post on X a couple weeks ago and it stimulated me to write an article. You know, if we can we roll through that one real quick.

SPEAKER_00 9:13

Sure, absolutely.

SPEAKER_01 9:14

Yeah, so the post was um one of my favorite sites to look on is something called perplexity, because when you go on perplexity AI, you can dig up a lot of information. So I didn't actually have to go to each of the, you know, uh what I thought were going to be the heftiest paid CEOs in the nonprofit hospital world, but I simply asked Perplexity, which American hospital CEOs are paid the most? And I got this like stunning like answer. And so I took a screenshot of it. It was really useful, and I put it up there, and there were multiple uh hospital CEOs making uh 33 million dollars. That was like the top. Well, I shouldn't say multiple making 33. The top was 33 million in a calendar year. Some of it gets hidden from the 990, and I can't figure that out because I guess what they have is the deferred compensation, so they're getting stopped. So if you look at the 990, it's less. But um, I did a repost of that because each of these really handsomely paid CEOs are surrounded by what we call a C-suite, right? You know, the C-suite is like all the little hospital henchmen that also are pulling in a big salary. And so um, when you went to that top hospital CEO salary of 33 million, you could see that there was a C-suite of people making, you know, 4 million, 5 million, you know. And you could like re redo this for nearly every big nonprofit hospital across America. I mean, you know, we should actually talk in some um pretty good terms about Kaiser, which is based out of Oakland, California, you know, and their top CEO, I believe, was making over 15 million. But then I I kind of lost count. I think they have an additional, um, I took some notes here, um additional 15 people making over 2 million, and then another whole cadre of people making um a million or more. I mean, so it's it's not just like look at the top guy. You know, the top guy has a lot of friends, and then of course, all of those people can become impactful in places like their state capitals in Washington. How can they become impactful? I mean, like, well, ask Willie Sutton why does he rob banks? They're where the money is, right?

SPEAKER_00 11:29

Absolutely. And now it was kind of interesting because that I had one of those slides just to go through that. Sintera Healthcare is where Howard Kern made that $33 million in 2021. So that that's unbelievable. And then there was another uh New Vance health. The CEO made $30 million, and then RWJ Barnabas Health in New Jersey made $70,300,000. But interesting there, that was a big cadre of people, like you just talked about. There was a couple people in eight figures, then there was another group of people in six uh seven figures, and then there's like 51 people in six figures. It is an army of people. And this kind of gets back to what happens with hospitals. And they get so many special programs that I didn't know about until probably the last year or two, and the public doesn't know. You know, and Dutch had done a great job. And I I put a slide up from the Rojas report, which I recommend everybody follows. And he kind of looked at 275 billion. He, you know, added up all the costs of these special programs, but they're getting $275 billion worth of goodies. And a lot of these really are to the detriment of physicians. And do you know what happens? You know, we get paid very little under Medicaid. We get paid so little as an independent practicing physician that you really can't afford to see those patients. But the hospitals get so many supplementary payments, like state directed payments. And in North Carolina last year, they were getting paid at commercial rates for Medicaid. And then, of course, that leads to one of our favorite topics is why are hospital costs so high? Because of consolidation. And could you talk to us about how these special programs that pay the hospitals lead to consolidation?

SPEAKER_01 13:22

Oh, well, sure. So um, and actually let me just point out like we talked about all those big C-suites.

SPEAKER_00 13:27

Sure.

SPEAKER_01 13:27

Um, you know, when when the price transparency, I just have to really get this in there because we were all on transparency. When the price transparency rules came out, it was uh stemmed from an executive order the Trump administration did, I believe, in um 2018 or 2019, and they went into uh effect in 2021. And as I've said before, like only 21% of hospitals are fully compliant. Um, the hospitals complained, oh, we we can't do that. It's too much work for us. Well, good God, you know, you're saying that your CEOs deserve this much money. Like, if if they're not capable of doing the most uh essential thing, telling the patients what the price is, like what good are you? Why are you earning that money anyway? And why is the government giving you uh so many goodies? But then what you can do when you earn all those goodies from the government, you can do what uh Kaiser Permanente did. Kaiser took seed money of five billion and started something called RisenHealth. And RisenHealth has bought two hospital systems. One of them is Geissinger, right here in Pennsylvania. You know, whenever we hear about hospital uh or any kind of consolidation, we're told it's going to streamline the care. Well, how you're streamlining care between California and Pennsylvania should be a mystery to all of us. And it it now that people know about the goodies that they get from the government, not paying any taxes, you know, we can talk more about 340B, um, getting paid more for Medicare patients, all of the things, right? It's no mystery how they have the five billion to form Risen Health. Um, and then they bought up not just Geissinger here in Pennsylvania, but a uh hospital system in North Carolina called Cone Health. So, as mentioned, you know, there's Kaiser in California, in Oakland, California, with the $15 million CEO and plenty of like people in his C-suite behind him, who takes their five billion in seed money and creates something called Risen Health. And then uh they also built a gigantic building in Washington, D.C. I didn't even know about it until my like trip two times ago to Washington, D.C. So I'm walking down the street and I see this giant building. I should look up how many stories it is. Look like it's about seven or eight, and it says Kaiser on it. I'm like, holy crud, they have a big, gigantic. I mean, that that that building had to cost a lot of money to build. So, like, you can tell what they're doing with some of the money that they create. But there they create Rosent Health with a $5 billion bid of seed money, and Cone Health is five hospitals and 120 physician practices in North Carolina with two retirement homes. That's not inconsequential, you know. So now you have Kaiser, and they, I guess, functionally have integrated and created that big system. And then here in Pennsylvania with Geissinger, 10 hospitals, and I believe over a hundred and uh 130 clinics is the number. So we want to talk about consolidation. Now you have Kaiser out in California, and then you have these other two places. And actually, if you go to the price transparency report put out by Patient Rights Advocate, you can go click on California and you can go look at all of the hospitals that Kaiser has out there. Not a single one of them is fully compliant with the price transparency rule.

SPEAKER_00 16:48

And Kaiser is over $100 billion worth of revenue and is nonprofit, which doesn't make any sense.

SPEAKER_01 16:54

Yes, and they own their own insurance company too.

SPEAKER_00 16:56

Yeah, I mean they're they're fully integrated. They have the whole suite of everything. And the other thing this brings up when you're talking about the physicians and the Cone Health is that physicians are not allowed to own hospitals as part of Obamacare Section 6001. But hospitals can own physicians. And obviously it's a huge conflict of interest because when you work for a hospital, you are pressured or encouraged to send people to the specialists in the hospital, the labs, x-rays, everything, you know, the labs. And it's a lot more expensive to do that. So you have this perverse incentive. And the other thing is the hospitals get the facility charges for physician services. So it's going to increase it. It depends on the service, but like echo is up 300% of what it would be in a physician's office. So it's this feedback loop that makes no sense where the physicians are driven out of private practice by being underpaid by Medicaid and Medicare. And then the hospitals gobble them up and then they turn around and they charge a lot more for the same exact services, and we get into more debt. It doesn't make any sense.

SPEAKER_01 18:04

Oh, 100%. You know, like there's like the whole self-dealing part. You know, I mentioned how many hospitals and how many physician practices both Cone Health and Geissinger owned, but they're incentivized to buy up those physician practices because when once the hospital owns it, you can bill more for the same care provided at that outpatient practice if the hospital owns it. So, for instance, if you're a rheumatology practice and you're independent and you're uh giving an infusion in your you know, rheumatology independent practice, and then all of a sudden you decide you're gonna sell out to the hospital because you you can't deal with the billing, maybe you're getting ready towards retirement, you know, all of the things, the hospital buys you the very next week, Medicare gets to charge much more for the very same care that you got the week before when you were in independent physician practice. I mean, it in part explains um the fact that we don't have what we call site neutrality in Medicare is just one reason why they get to do that and then add in the facility fees, which the hospitals collect much more for. And no wonder we don't have independent practices. So, you know, you're you're dipping into all like the the money that was meant for our Medicare patients. Isn't it fiscal folly to spend much more? And then, of course, like you bring up that we want site neutrality. Now you have all those hospital CEOs, all those hospitals, and for the nonprofit hospitals, the American Hospital Association, who lobbies with what, $33 million a year, something like that, you know? So they're gonna lobby. No, no, we can't have site neutrality. You need to keep paying us at the nonprofit hospitals more. Crazy.

SPEAKER_00 19:46

It is crazy. I mean, the hard part is, and it's it's bad for patients, but and it's bad for taxpayers because we're running all this money, and it's really going through when you're a nonprofit hospital, you don't want to show profit. And there's two ways you don't show profit. The first way, which we talked about, is you overpay massively your CEOs and your C-suite and administrators, and that's what they do. They're very top-heavy. And the second way is you build. They're always building, they're always buying, like you said with Kaiser, they're buying, and that's where their money is going. So there's profit, they're just hiding it from you. And there's you know, and that's the hard part. And the thing is, there's no way these nonprofit hospitals could compete with physician-led care. And that's why they push for that ban on physicians-owning hospitals, because physician-owned hospitals are less expensive and offer higher quality of care. And so they're like, we don't want to compete with them. And it's so it's kind of crazy, you know, with that. But the other thing I did want to touch base on the 340B program and go through that. And that was a program that sounded well-intentioned. We're gonna go ahead and we're gonna get lower-priced pharmaceutical drugs for the needy. So you're like, oh, that's a good idea. So, what they're gonna do is we're gonna have a big stick and we're gonna say the pharmaceutical companies, you have to discount these drugs significantly. And then you have to provide them to the hospital lower rate. But of course, things get loosened over time, and it goes from the impoverished areas to suburban areas, and you loosen the rules, and all of a sudden you have a program where there's $90 billion worth of money flowing through to the hospital. And I saw it when I was practicing in Wisconsin, it was really hurting the oncologist because the uh free the freestanding oncology centers didn't get the discounted meds that the hospital did. And I was reading the other day that when a hospital buys, and if they have a 340B program, when they buy an oncologist, they make a million dollars a year in profit just on a 340B program. And this money, again, was supposed to go help the neediest people, and it doesn't, it goes into the general ledger of the Health system, which means I can spend it on whatever. So you know, that's where all these programs start. They sound good, but they have so many unintended consequences. And you know, because you've been in Washington C a lot and you're very savvy with politics, it's almost impossible to get rid of a program once it gets in there.

SPEAKER_01 22:19

Oh, yes, I always say like the hardest thing to get done is to reverse something. Yes. Like if you try getting a congressional act across the line, that's already hard. But reversing one is enormously hard.

SPEAKER_00 22:32

Right. Because we would like them to reverse essentially every major piece of healthcare legislation since 1970, and we would be much better off. Our cost of care would be a lot lower.

SPEAKER_01 22:43

So I believe like the number was 5 billion is the amount of um money that was flowing, you know, to the hospitals from the 340B in 2010. And then all of a sudden they increased the number of um hospitals that could qualify or they loosened the rules, as we said, right? And so now we're like, what what number did you give? 90 billion, 80 billion?

SPEAKER_00 23:03

Yes, 90 billion. 90 billion.

SPEAKER_01 23:06

Yeah, so if you go from 5 billion to 90 billion from 2010 to today, once again, we're back at Willie Sutton. Right. Right. But what um what's like very what program for America to understand? Because first of all, they hear that the pharmaceutical companies are having to cough up the drugs at a reduced rate. And most Americans say to themselves, right from that point, three, four, oh, well, they should do it because those rich pharmaceutical companies. But you know, kind of news for everyone, what do you think the pharmaceutical companies are doing with the rest of the cost of drugs if you're coughing up the reduced rate? They're probably increasing them somewhere else, is my guess. And if those drugs go out of business or the drug companies go out of business, or the not the big ones, but the smaller ones, then you're not going to have the drugs at all. But you know, to give an example, um, what's what's going on here is that program, the program itself is not the problem. The problem is it's strayed away from its initial intentions. The initial intentions were the pharmaceutical companies are giving the money so the patients that are economically needy don't have to pay the exorbitant rates. And at first it was going to hospitals that uh had a big percentage of economically needy patients at them. You know, you could call them, I guess, disproportionate share hospitals. Um, and then when we had this big consolidation that I've described, the hospitals are now buying up all the practices, just like I described with the rheumatology drugs, like you pointed out with the oncology practices and such. So when they do that, now all of those sites qualify because of the way the rules were loosened. So they can take the drug that they get at Lord knows how much. I mean, I've heard, and I the only state that's actually, you know, looking into it, believe it or not, is Minnesota. They have a transparency bid on 340p. So let's give them some credit for that, and that's good news. But so most places don't know what the discount is. The hospital gets the drug at the discounted price, but then they can build what I call full freight for not just their flagship hospital, not just their disproportionate share hospital, not just the clinics that are in the needy areas, but they can build full full freight everywhere. So the New York Times did a um case of a drug that was, I believe, at $2,700 list price, a cancer drug, you know, just like you um you pointed out the oncology practices. Um $2,700 list price, the hospital billed $22,000 and the insurance company paid $10,000. So if the list price is $2,700, the hospital probably got it for, well, they definitely got it for less than that under $340B, but they were able to collect $10,000. Of course it's a profit for them. And then what can they do with the money? They can go and build another oncology center or they can go and coordinate their care. I believe um there's a big hospital system over in New Jersey, uh, Cooper, you know, like their big program now is uh working with a cancer center down in Texas somewhere, and they're building new stuff over in New Jersey. Well, of course they are, you know, like if you could get a $2,700 drug for let's just say $2,000 and then build health $10,000 for it, then you're probably gonna pay all of your, you know, CEOs and their friends in the C-suite, you know, their millions of dollars, and then you're gonna build another cancer center, and then you just recycle the money back in. And all the while, you know, you're collecting the goodies from the Washington, D.C. hamper of the uh we're not paying taxes on any of our voluminous properties, and we're getting more money from the 340B program because they're making us, and we're collecting more because we don't have site neutrality, and you know, we haven't even gotten into the fee schedule, and we can do that at some point too.

SPEAKER_00 26:51

Absolutely right. You know, those those are all excellent points. And then there was an article that just came out and it looked at from 2016 to now, and the hospital inpatient rates went up 30%, the outpatient rates went up 26%, and physicians went down 7%. And that was the Medicare fee schedule. And people don't realize this with that, is the commercial rates are based off the Medicare fee. So if the Medicare fee goes down, it's gonna affect you on the commercial rates as well. So it's it's a good thing for physicians. And 2,000 physicians have gone down roughly probably 33% adjusted for inflation with the Medicare fee schedule. And our physicians are at the amount that they can spend on, but the hospital are not. So we're we're treated differently than Apples are. And when you look at every bill, there's always two groups that are not represented. And that's why they always lose it's patents and physics. Nobody's representing it. And everybody thinks, well, AMA represents a different. And AMA doesn't represent physics needs like this, they actually sign down to a volume that they were in because they have to protect the CPT code, which I I know you've written about that extensively. And that's where they get most of their revenue from licensing the codes that we have to use for every physician visit. We have to put our code in and we have to license that. So that's what they want to protect. And I don't blame them. That's their incentive. But that's why I think you you wrote that free-to-care paper and started that organization because we do need someone to represent all physicians and get out of our specialty silos.

SPEAKER_01 28:37

Yo, a hundred percent. Um, you know, look, uh one of the very first pieces I published that uh, I guess maybe you'd use the word went big, you know, like, you know, I opened up my inbox the next day and I had like dozens of emails from people that I have never heard of or was contacted on social media. But I wrote uh a piece in the Philadelphia Inquirer in 2017, Who Stands for the Patient? Um, you know, Who Stands for the Patient was something along those lines. And I exposed the AMA's gigantic conflict of interest because, you know, when when we say that the AMA collects money through their CPT codes, they're collecting, I think it's something like four or five times more than they're collecting in membership dues. They don't really need the membership, right? And the other thing that I revealed in there, so and actually that the reason that's a conflict of interest is because the AMA is incentivized to have big insurance prosper. I mean, in in a way, maybe that's why they um they were pro-OMacare. Because it it was an insurance company bill, right? I mean, it insisted that everyone have to get uh insurance, and we can see that the the um the revenues of insurance companies were you know, they went up.

SPEAKER_00 29:54

It's a subsidy plan for insurance companies.

SPEAKER_01 29:56

Yes, it's a subsidy plan for the yeah. That's what it is.

SPEAKER_00 29:58

Then it makes sense when you look at that.

SPEAKER_01 30:01

Right. But uh so like if they're making all that money, they don't really need the members. The other thing I revealed in the article, and that was back in 2017, that less than 15% of practicing physicians were members. Now the AMA contests this, they say it's 25%. But you know, back in the 1960s, 85% of physicians were members, even if they're down to 25%. And the reason they get 25% is because they count the residents and the um medical students as members. And you know, they are members, I get that. But when the AMA collects its dues, if I wanted to be a member and I'm not, I would have to pay $400. If a medical student wanted to pay, they would be 20. If a resident wanted to pay, they would be 40. And guess who pays for a lot of those residents and medical students? The hospitals, right? So if they're coughing up the money, you're just a member, you're not gonna turn down your free membership. It doesn't really cost the hospitals that much money, especially when they're making everything they make. And, you know, people can also uh pull up the 990s and look under the hood of not just the AMA. And, you know, you can see that um their uh CEO and the EVP like made, you know, a good bit of money. But uh, you know, they they pay their board of trustees, they have um, you know, other lawyers and so on and so forth that they pay, not to the same rate that the hospitals get paid, but uh the AMA also has a foundation, and their foundation, they say, like, you know, they do a lot of do-gooding, but when you look under the AMA foundation 990, it's not the salaries that are going to the foundation, but um you can look back through history and you can discover that the foundation got a lot of its funding through insurance, through PBMs, through pharmaceutical companies, etc. etc. So I guess the big question is this is like when someone is paying you, who are you speaking for? And now if you go back to thinking about an independent physician, if you're not paid by the hospital, if you're simply paid by your patients, uh and we have examples of the kinds of physicians that do that, you know, our direct care patients. They're paid by their patients, they're only speaking for their patients. If you're paid by hospital, you may have to speak for the hospital. Some of us don't, unemployed. We're not saying who I'm employed by, and I don't speak for them, but um there's you know, you you kind of wonder if you're the if you're the employed person, if you're getting paid, if your foundation is collecting money through pharma, through PDM, if you're paid by CPT codes, you know, which is basically, you know, prospering by insurance, then if you're the AMA, aren't you really speaking for insurance, possibly hospital because they pay the medical student, you know, stuff? Aren't you possibly speaking for pharma? Aren't you possibly speaking for PDMs? It's like really wild in there.

SPEAKER_00 32:48

No, it is. And I know they're not speaking for independent clinical physicians at all. And that's been the frustration. And the problem is the pri the public really thinks they do. And they're always quoted, you know, everybody says you have the AMA. And you know, one of the things that it's hard for physicians, we're all in our specialties. And you know, everybody who's, you know, future OB, internal medicine, you know, ENT, whatever you're at, you kind of follow your own special society. And you there's not really not a big group of physicians, which I think just get picked off. Um like I said, the uh and we I know Doug has talked about this as well. It's uh it's certainly something we need to change with that. Because I think and I do love the direct patient care model because you're just outside the system, like I said, you're working for the patients, and then you can refer them to the best doctors in town. You don't have to refer them to somebody down the hall in your system. You can get them the best price on drugs and imaging and everything else. And then you have the time. And you know, there's this whole push, you know, people upset that they're 15-minute doctor visits and they're on the computer. Employee docs don't have any choice. They are not in control their schedule. They don't just decide which EMR they're gonna get. You know, where if you're direct patient care, you can take time with patients, get to know them. And I actually use direct patient care as my family does. And if I text or call my doctor, he knows who I am. You know, I don't have to explain who it is. And, you know. So it makes a huge difference. And that's what I think people are missing. I think the public doesn't know what's wrong in healthcare, but they know they miss having their own doctor, like they did in the 60s and 70s. And that's that's a big change.

SPEAKER_01 34:32

They miss the personal care. They do. And you know, what you're bringing up too, like, you know, um, honestly, it's very interesting because a lot of people know I do the advocacy work. So they reach out to me and they're they, you know, Marion, I like I just called to try to get an appointment with a specialist, and they told me it's like 12 months. What can I do? Or they can't even get in with a general doctor, or they get in with a general doctor and they have a 10 or 15 minute visit and they're very frustrated. And, you know, like it's actually easy for me. I I have a whole phone full of physicians and all kinds of specialists that I can reach out to that I can, you know, get um, you know, help or curbside consults, and I know the questions to ask, but the general public, you know, they can't go there and so they're frustrated. And I say again and again, you know, look for if you want if you need some help and you need like uh lengthy appointments and you need access where you need access to a physician right away and you want a relationship, look for like a direct primary care doctor.

SPEAKER_00 35:28

Absolutely.

SPEAKER_01 35:29

It's really hard to find a personal relationship in a big system setting. I also loved what you were uh bringing up when you were talking about the, you know, like that we're in our own silos. Um, you know, and I think about the surprise medical billing debacle that happened, you know, a couple years back. And, you know, there were a lot of um the first people that were going to be hit by that were gonna be the ER docs, the anesthesiologists, some of the specialty surgeons, you know, that sort of thing. But, you know, I remember looking at that and thinking to myself, okay, if we have a problem with the emergency room docs, because the insurance companies take over the billing and under underpay, underpay our anesthesiologists, underpay our specialists, it's gonna fall on, you know, primary care physicians out in the community because the patients aren't going to want to, they're not gonna be able to access, you know, the emergency room as easily if we have a shortage of ER docs or if we have a shortage of anesthesiologists, you know, there's there's gonna be a lot of problems in our system. And then when patients can't get care, they're gonna go to the first place they can. You know, I I work in emergent care settings, so they'll often forego the ER and come to me. I think we have to start thinking about the problems that are happening to our fellow physicians that are not in our specialty. But what I hear a lot, you know, I'm I trained in primary care. I guess I consider OB kind of a blend of the two.

SPEAKER_00 36:52

Yes.

SPEAKER_01 36:52

But you know, the primary care doctors blame the surgeons for making too much money and then they they claim that it's the surgeon's fault. I mean, honestly, as physicians, we should be banding together and we should be thinking about the suits that are making money and standing up for all the scrubs, and honestly, not even just the physicians, but our, you know, our nurses, our pharmacists, and other people that work in the healthcare system, you know, PTs, you know, OTs, RTs, all of the, you know, the people that actually lay the hand on the patient. Because if you want to take it out from a 30,000 foot view, the suits are sucking away the money and the scrubs are getting hurt, and then they don't have any time for the patients. And then similarly, the patients have to realize I better make sure that the people who are actually laying their hands on me, who have the capacity to help me, and not the people sitting in the C-suites pushing the paper around, I better make sure that the scrubs have the ability to be sustainable so that I can get care for the future. I want the money reallocated to scrubs. That's what the patient should be saying.

SPEAKER_00 37:53

No, I I agree 100% with that. The other thing is interesting. If you go to a hospital and you get a CAT scan for $10,000, if you go to imaging center and you get one for $350, the radiologist doesn't make any different money. That difference in that price, that delta, isn't going to the doctor. That hospital doctor is really doing well. It goes to some state suite that you never met. And it goes into probably is that that supplemental executive retirement plan that gets it to $33 million, which is a deferred compensation plan. And you know, all these sorts of plans. That's what ends up happening. And people have to start realizing that the $10,000 is not better than $351. You're just feeding the system. And if you look at it, it you'll be and you say, well, my insurance company covered it. I don't have to worry about it. You don't have to worry about it. That's why your rates are going to go up next year. We all have to worry about that. And I think, you know, there's in terms of solutions, because I always like to try to say we need to come up with solutions that just say there's a problem. And I think in the short term, hopefully there'll be more price transparency. That would be a game changer. And people could start looking now today and say, okay, which are the hospitals that are a good deal in our community? The second thing I would say is if you're lower income, look at the financial assistance programs in the different hospitals. They all differ. And some of them will forgive care if you are less than if you make less than 200% of the federal poverty level. Some of them will give you discounted care if you make less than 400%, some are 600% of the federal poverty level, but they're all different. So I would definitely do that. And then I would try to do is avoid hospitals for non-urgent things and go, like you said, to urgent cares that are freestanding, not owned by hospitals. And I think the more as we start talking, more people start realizing that the hospitals are an issue. Because right now we're just funneling lots of government money to hospitals that are nonprofit, and they just give that to the executives and it's not being used by the patients. And that's wrong. And we haven't even talked about the Super Bowl commercials by nonprofits or naming stadiums by nonprofits. I'm like, what are you doing? If you're you're like NYU Lingoni two years ago, the Super Bowl paid $8 million for a commercial. I'm like, that's insane. Where's CMS on that? They should have called them up and said, we're obviously overpaying you. It's crazy.

SPEAKER_01 40:28

Well, it it is their money. You know, one thing I think we actually absolutely have to say here is that we're neither of us, we both know that hospitals are necessary. Absolutely. You know, if you if if you have uh right lower quadrant pain, to develop a fever, you feel nauseous, you start puking, you need the hospital, you need the surgeon, you need the anesthesiologist, um, you know, to be able to take care of your probable appendicitis, right? You know, like you can't you can't just waltz into your doctor's office and you know have the whole thing done. You probably can't even get the ultrasound there. So we need our hospitals, you know, but if you think about all the care that happens there, um, it's not the building, the pretty building and the pretty uh you know lobby that you need. It's it's not the overpriced uh ultrasound that you need to diagnose the appbey, it's not the facility feed that you need, it's it's the uh it's the radiologist to do the ultrasound, it's the anesthesiologist to put you to sleep, and it's the surgeon to take out your um your appendix and it's the nursing care that's there, and you need whatever uh equipment is needed to do everything. But if we don't open up the books and look at where the money's going, and even if we have the insurance plan that pays for all of it, if the insurance plan is overpaying, just as you said, we're gonna be dealing with new premiums next year. And if we're paying a hospital that's a bunch of um led by a bunch of suits in a C-suite and they're getting handsomely paid uh by the, I guess it's the board of the hospital that makes the decision, you know, then um it's not really helping the patient down the road. And then we don't have sustainable care. So if the hospital is choosing to pay their physicians and their anesthesiologists less because they're hospital-owned, and if they're getting undercut and the C-suite is not, then you don't have sustainable care. And I think you know, America also has to take a look at the average age of various physician groups, it's really pretty abysmal. I mean, CT surgeons, I think it's in the high 50s. Same for orthopedic surgeons and urologists. I mean, look, the Medicare patients might want to take note of that because if these guys keep on getting undercut and not able to take care of the patients and forced into doing more and more and more, when they retire, it's really hard to replace a CT surgeon, a urologist, an orthopedic surgeon. It's not going to be pretty for the future.

SPEAKER_00 43:00

No, that's true. Well, I remember when I came to Wisconsin in a medium-sized town, 1995, and there were three hospitals. They were all independent. And I practiced mostly at two of them, and they each had their own hospital president. The hospital president was very in tune to the medical staff. He knew the doctors, they you know, really interacted with them quite a bit. The medical staff meetings were packed. Every physician went to work. The physicians were very involved. And fast forward a couple years later, those two of the hospitals emerged, and all of a sudden, new bylaws, you have more of a T-sweet feel. And then the physicians just weren't involved anymore because they were really excluded from any decision making. And that's the part that I don't think people that's where you know standalone hospitals used to be focusing on the physician. You could walk down, talk to the president at any time in the hospital, chat with them. But now all of a sudden, instead of being physician driven, even if it wasn't physician running, a bit Physician driven. Now it's really when a patient comes into the hospital, they're looking at how can we extract as much money from that patient? That's the metrics they're looking at. And it's not, I'm not saying they're evil people, but they're finance people. So that's how they're going to think. And we think differently because we've been trained to think about medicine, but that's how they think. So we're turning that over to the finance people to suits is a real cost. And I think that's what people start to need to look at. And I, you know, I think we have to break up these systems. When you have a lot of these metropolitan areas where you have one or two systems controlling it, you get what we had last year in Jacksonville. There was a big public fight between the Baptist hospital system and Blue Cross Blue Shield because they both really are the big powers in the area. And Blue Cross Blue Shield had to have Baptist Hospital on their network or they couldn't sell their plans. Baptist knows that and they get in a fight. And I'm not saying who's right or wrong. I don't know. But this is what happens when you get consolidation. You have to have these hospitals and the prices go up in the network. So I think we have to break these networks up. And I think we need complete and utter price transparency. Indiana has a website where you can go look, buy zip code, and you can compare procedures. And it's just in layman's terms. So I would look through there and look at a colonoscopy in one zip code, you can get it for $1,200 or $12,000. Can you imagine paying $12,000 if you're a self-funded employer? And then all of a sudden the next week that comes out and you're like, I could have paid $1,200. And, you know, that's the kind of stuff that's going to change the behavior. And I know that there's elites, I won't mention names, who's poo-poo, price transparency. I think that's the game changer. And incentivizing patients to shop for care, I think that changes the whole game. But I agree with you. We definitely need hospitals, but we need them to work for us and not for the C-suite.

SPEAKER_01 45:58

Well, especially if if we're, I keep on going back to it, but it's but especially if we are giving them all those goodies.

SPEAKER_00 46:05

Absolutely.

SPEAKER_01 46:05

All the tax breaks, you know, the the rules all you know skewed in their favor. If we're giving them all those goodies, then they better be earning them. And it it would be apparent that they're not.

SPEAKER_00 46:16

Absolutely.

SPEAKER_01 46:16

If they're if they're looking, if 80% of them are hiding their prices, well, it's probably because they have something to hide.

SPEAKER_00 46:23

Absolutely. No, and I agree. And I'm going to close it out. And thank you, Marion, for being here. It's an excellent job. And thank you to all my listeners. Please like and follow for more. Let us know in the comments what you think. And we'll see you soon.