[faangFar]

There seems to be a lot to unpack, so sorry if this is jumping around but I tried to provide lots of details.

My wife has worked at those places and the difference in patient outcomes is night and day. Sure some people will get better regardless, but there's something special about people saying a 3 year old injury has 0/10 pain. At a big name company, they get people "good enough".

She's one of those people that would prefer to be a Physical Therapist rather than a business owner.

As a side note, many of her patients came from that 60$/hr insurance because most places don't accept it. It seems like it's a stepping stone. Knowing her, they will be grandfathered in.

Something I didn't mention is how often she does free work/eat the cost because insurance will deny payment for services that were approved but later deemed "not necessary". (Despite the person being unable to work) It's complicated because a phone call, or Physician, or patient can sometimes fix this.

[gen220]

I think there is a lot to unpack here, yes! Thank you for responding :)

I wonder how much of the outcome difference is due to selection bias, so to speak.

For example, your patients are more likely to have better outcomes, because the fact that they are willing to pay OOP for your services implies that they are bullish regarding the valuation of their physical health, which means they are likely proactive in seeking preventative care, solving health problems earlier rather than letting them fester, etc.

Similarly, I'd imagine that the better doctors probably self-select into your wife's situation, because they want to work with active patients and they want to capitalize on their skills and passions. It's a feedback loop where good-follows-good.

Good income -> good outcome, if you will.

But tragically, this implies that good doctors are less likely to be found in the big hospitals, where the people who need healthcare "most" are in need of them. "Most" used here in a marginal sense, where the needy, insurance-using patient receiving 1 hour of your wife's attention provides 10x value in terms of QoL-adjusted life expectancy, than the average proactive OOP patient.

So, we're kind of bound to have a two tier system, with this set of incentives.

In your wife's case, it seems that the price cap of insurance will prevent 10x patients from seeking her out, exacerbating the tiers. But, you can't really blame any of the individual actors in this equation (payer, patient, or provider), it's the incentives that are wacky.

I know of some doctors who "volunteer" some of their time working at a hospital/clinic, in addition to their private practice. Like, one day a week or something like that. If your wife feels guilty about her role in this dance, she might consider doing this, in addition to grandfathering-in the insured folk.

Anyways, I don't really have a point, just thinking out loud. Thank you for your perspective, curious to hear anything more on this topic you'd like to share.

[faangFar]

Just to clarify, all patients currently are accepted. There's no selection yet.

There is a difference between hands on care for 1 hour, and 1 hour being divided between 9 people (seriously, there are some clinics that do that).