Yeah, but when you pay for services you don't expect to have to write checks for every subcontractor your service provider users. They do that. You pay them. Everywhere but our messed up Medical System is like that.

Imagine if every time you went grocery shopping you had to pay for the people stocking the shelves, putting the carts back if you used one, the cashier, and each wholesale distributor. It's crazy and senseless. Just the way they like it so they can get away with so much more.

> Yeah, but when you pay for services you don't expect to have to write checks for every subcontractor your service provider users.

Well, yeah, that's true by the definition of “subcontractor”, which doctors in hospitals often are not.

OTOH, healthcare isn't the only place where you might pay a fee to a facility for use of the facility and a fee to a service providers associated with the facility for services they provide in the facility. It's perhaps an inconvenient arrangement, but by no means unique.

> OTOH, healthcare isn't the only place where you might pay a fee to a facility for use of the facility and a fee to a service providers associated with the facility for services they provide in the facility.

Where else does this occur?

> Where else does this occur?

Event facilities (for weddings, etc.) often have established partners for various event services that you pay directly rather than through the facility, which you also rent.

Dance studios where the dance instructor is affiliated but not an employee of the studio (especially where the affiliation is non-exclusive) will sometimes (especially for private lessons rather than group classes) charge a floor fee which you will pay to the studio, while the instructor is paid directly.

Fairs, etc., often charge you a gate fee, while you pay for goods and services inside to vendors directly (which vendors are also paying the fair for the privilege of being there, too.)

Arguably, residential real estate leases without included utilities is a closer analogy than any of those: there are a number of non-optional service providers you pay separately, on top of paying the landlord to occupy the premises.

Weddings: you pay the caterer directly, even if the facility dictates which caterer you use

That's a really obscure example. I have a lot of family around me and we have many weddings. Most of the time the venue is the caterer since that is what they charge for the venue.(500-900 people weddings, over 10 a year). Not always though.

BUT STILL, weddings are a really bad example here.

The people getting married get to chose from whom they want the table and chair covers, flowers, singer/band, catering, belly dancers/entertainment, lights people, AV people.

Those are choices you got to make and the bills will obviously come separate since there is clear distinction of entities. Heck, the venue and the singers might not even of said a word to each other, let alone have a billing agreement.

>in California, hospitals may not legally employ physicians to practice medicine

...why?

The sort answer is California Business and Professions Code 2417.5, but thats probably not exactly what you meant.

Most (all?) states forbid whats called the "Corporate Practice of Medicine." The idea is that profit motive of a corporation can lead the corporation to manage physicians contrary to the interests of their patients. To mitigate this, states only allow certain business models for physicians:

* Sole Proprietorships - they can work for them selves

* Professional Corporations - a restricted sort of corporation that requires all shareholders and executives to hold a license for the profession the corporation practices (ie, they all must be physicians)

* Some states have exceptions for research universities, public hospitals, non-profits, and other sorts of organizations.

The exact restrictions of course vary from state to state. Here's a state-by-state rundown: [1]

Its my understanding that analogous restrictions are common for other licensed professions such as law and accounting, but I know much less there.

[1]: http://archive.healthlawyers.org/google/health_law_archive/p...

How does this work with institutions like Kaiser? Are their hospitals not technically hospitals? Or are the physicians all technically contractors there?

California really makes it hard to have everything on one bill because no hospital can hire a doctor.

But businesses and some consumers do want things to be under one roof - no surprises on in vs out of network, they don't like separate bills from each doctor that sees them, easy referrals, etc.

Kaiser is sort of a funny workaround.

The Kaiser Foundation Health Plan, the Kaiser Foundation of Hospitals and The Permanente Medical Group = Kaiser Permanente

The win for the patient is everything in-network and under one roof. If you are in a Kaiser facility EVERYONE is basically in network (with the exception of some state mandated providers that have to go through their own state flows - yes, that's why sometimes you need to repeat info on forms even at Kaiser)

The win for doctors is you really don't have denied claims or the billing pain you might in private practice.

CMA I think has really fought these setups before, but now oddly (in part because of medical malpractice and EHR overheads etc) working for Kaiser isn't considered a dump job anymore.

Bad news, obamacare put demand through the roof at Kaiser (even though they are not the cheapest plan) so they are shortstaffed I think.

If you do or know anything about medical billing - medical providers probably hate it as much as you do. A patient with primary coverage through Kaiser and secondary through Medi-cal - just to bill Medi-cal for $40 - you could spend hours on that as you hoop jump.

They are all salaried employees, so Kaiser can work from a 'fixed cost' perspective ( as told to me by a surgical nurse ).

There are there different entities that all work together: Kaiser Foundation Health Plan provides medical insurance. The Kaiser Foundation of Hospitals owns all the hospitals. The Permanente Medical Group, Inc. employs all the doctors. The latter is a Professional Corporation, so its allowed to employ physicians to practice medicine, but it doesn't operate hospitals.

100% false! That would be totally illegal. California CLEARLY bans hospitals from doing this.

I mean, you can even google it like I did, from this page: https://www.ophthoquestions.com/posts/why-i-left-kaiser-and-...

"For those who are not familiar with the Kaiser system, here is a very abbreviated explanation. Kaiser Permanente is an HMO, and consists of the Kaiser Foundation Health Plan (the Kaiser insurance) and the Permanente Medical Groups (the Kaiser doctors). The patients buy the Kaiser insurance and they are only allowed to see Kaiser doctors. The Kaiser doctors are salaried from the pool of insurance premiums and provide service only to the Kaiser patients. In the Kaiser model, services are prepaid, so there is no financial incentive or penalty to providing or receiving medical care."