How Being a Doctor Became the Most Miserable Profession(thedailybeast.com)
thedailybeast.com
How Being a Doctor Became the Most Miserable Profession
http://www.thedailybeast.com/articles/2014/04/14/how-being-a-doctor-became-the-most-miserable-profession.html
21 comments
I hate to make this a common refrain, but I make this same comment every time I see a comment like yours:
The supply of doctors is not restricted by the AMA. The supply of doctors is determined by the number of residency spots available to new graduates; that number is entirely determined by the Centers for Medicare and Medicaid (CMS). Thanks to the Balanced Budget Act of 1997, Graduate Medical Education (GME) was dramatically slowed due to decreases in Medicare funding of residency positions. [1]
As long as we require physicians to be US trained and to have completed a US residency, the bottleneck will be GME funding. To fix that, the AMA or any other concerned citizen can lobby Congress for an increase.
[1]: http://jama.jamanetwork.com/article.aspx?articleid=182532
The supply of doctors is not restricted by the AMA. The supply of doctors is determined by the number of residency spots available to new graduates; that number is entirely determined by the Centers for Medicare and Medicaid (CMS). Thanks to the Balanced Budget Act of 1997, Graduate Medical Education (GME) was dramatically slowed due to decreases in Medicare funding of residency positions. [1]
As long as we require physicians to be US trained and to have completed a US residency, the bottleneck will be GME funding. To fix that, the AMA or any other concerned citizen can lobby Congress for an increase.
[1]: http://jama.jamanetwork.com/article.aspx?articleid=182532
Why exactly must the government pay for it? It seems obvious if it's a net cost it really should be paid for by the students.
Also, if you could go to med school without an undergraduate degree you can increase the number of years a doctor could work thus lowering costs and increasing supply at the same time.
Also, if you could go to med school without an undergraduate degree you can increase the number of years a doctor could work thus lowering costs and increasing supply at the same time.
Well, someone has to pay the salaries of medical trainees. Who would you suggest do it?
Since the establishment of Medicare/Medicaid, CMS pays hospitals a set amount per year per resident. I suppose you could mandate that teaching hospitals be forced to foot the bill themselves, but most teaching hospitals have disproportionately high Medicaid and uninsured patient populations, so they aren't exactly swimming in cash.
Note: I'm editing my post, as you have edited yours.
Well, if you make students pay additional tuition / take loans for living expenses during residency training, then you can kiss goodbye the thought of ever fixing the doctor shortage. Think about what you're advocating here: Someone who just took out a $160k unsubsidized loan at 5.4% (variable) interest now has to increase his/her loan burden just. to. eat. for another 3-7 years while interest is accruing on that initial medical school balance. Does this seem like a sustainable system to you?
Man, I thought HN/Silicon Valley/Tech Industry was all up in arms at the unjustness of the unpaid internship...
Since the establishment of Medicare/Medicaid, CMS pays hospitals a set amount per year per resident. I suppose you could mandate that teaching hospitals be forced to foot the bill themselves, but most teaching hospitals have disproportionately high Medicaid and uninsured patient populations, so they aren't exactly swimming in cash.
Note: I'm editing my post, as you have edited yours.
Well, if you make students pay additional tuition / take loans for living expenses during residency training, then you can kiss goodbye the thought of ever fixing the doctor shortage. Think about what you're advocating here: Someone who just took out a $160k unsubsidized loan at 5.4% (variable) interest now has to increase his/her loan burden just. to. eat. for another 3-7 years while interest is accruing on that initial medical school balance. Does this seem like a sustainable system to you?
Man, I thought HN/Silicon Valley/Tech Industry was all up in arms at the unjustness of the unpaid internship...
If there doing useful work that offsets the need to supervise them then the patents should foot the bill for the net benefit. If there not doing useful work then there is no need to pay them.
Edit: As to fixing the shortage IMO remove the need for undergraduate education and you add 3+ years to a doctors career and lower costs. However, my point is you can have a sliding scale where they might make nothing for 3 months, minimum wage for 3 months, on up to full pay at year 7. Or however the cost/benefit equation works out such that there is no need for a subsidy.
Edit: As to fixing the shortage IMO remove the need for undergraduate education and you add 3+ years to a doctors career and lower costs. However, my point is you can have a sliding scale where they might make nothing for 3 months, minimum wage for 3 months, on up to full pay at year 7. Or however the cost/benefit equation works out such that there is no need for a subsidy.
Removing the need for undergrad does nothing to increase the supply. I also fail to see how it reduces costs. Everything is bottlenecked at the residency step.
Current billing rules do not allow for additional reimbursement just because a trainee took care of a patient. You're basically saying the hospital should foot the bill. Fine. That's a valid argument, but then you've got the problem of convincing hospitals to open up residency slots to train more doctors (and pay for them) instead of just hiring a PA/NP or two.
Current billing rules do not allow for additional reimbursement just because a trainee took care of a patient. You're basically saying the hospital should foot the bill. Fine. That's a valid argument, but then you've got the problem of convincing hospitals to open up residency slots to train more doctors (and pay for them) instead of just hiring a PA/NP or two.
Granted, it's not going to make a difference for ~30 years but by allowing doctors to start younger means some of them will work as a doctor for longer periods of time. Most importantly your adding time at the end of their career when there most capable. (Perhaps add a specific associates degree as an acceptable alternative as even 1 or 2 years times a few 100k doctors adds up.)
As to reducing costs, undergrad is not free so if you reduce/remove that cost students can afford to spend more on other things. Start med school with less debt and being unpaid for the ~first year of Residency is more reasonable which means you could have more slots open for the same subsidy.
Still, I would also suggest modifying the billing rules. This may create some perverse incentives but it balances the costs between Medicare and private insurance while paving the way for increasing the number of available slots.
As to reducing costs, undergrad is not free so if you reduce/remove that cost students can afford to spend more on other things. Start med school with less debt and being unpaid for the ~first year of Residency is more reasonable which means you could have more slots open for the same subsidy.
Still, I would also suggest modifying the billing rules. This may create some perverse incentives but it balances the costs between Medicare and private insurance while paving the way for increasing the number of available slots.
you're not required to get an undergraduate degree. you are only required certain courses and the MCATS.
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> Well, someone has to pay the salaries of medical trainees. Who would you suggest do it?
Our options are: government, students, and hospitals. Government has demonstrated an inability to manage the market. Hospitals don't have a good reason to pay students. Therefore, it has to be the students.
> [paraphrasing] But then students will have to borrow even more! Costs will spin out of control!
You're assuming the inflated education costs that are a direct consequence of the government paying for graduate medical education will persist indefinitely when the government stops paying for graduate medical education. Medical schools currently sell an artificially scarce commodity. Prices will decrease if we allow supply to increase. New schools will be built to handle the influx of students if necessary.
If college grads find the cost of medical school + graduate medical education unappealing, medical schools will have to look for customers earlier in the pipeline (college + med + grad might be too much, but med + grad won't be).
> [anticipating an argument] But it's still an awful deal for current college grads.
Easy: pass a bill saying the government will stop paying for GME in 10 years. If GME funding was an actual roadblock and not just an excuse, AAMC will announce lifting the supply controls in 10 years (I personally suspect they would have to be strong-armed into this, but that's another argument). Medical schools will anticipate the ability to increase supply of seats in 10 years and will build out as necessary so that when the deadline hits, the new pipeline will be ready to go.
New grads of 2024 wouldn't be screwed because they would have already had a chance to price the new policy into their decisions. For instance, if they wanted to be a doctor they might have worked (perhaps in a medical-related job) for 4 years in anticipation of accelerated direct-to-med-school programs opening 4 years after their high-school graduation.
Yes, there would be a market shakeup with winners and losers, but nobody would get the rug yanked out from under them in a way they could not have anticipated and planned for. Realistically, that's the best we can ask for.
> [another anticipated argument] But then our doctors won't be as good.
Give certificate-granting entities partial liability in malpractice cases. Then they'll be forced to price their actual opinion on the matter into their admissions policies.
I'm not qualified to determine where the lard should be cut, but I find it difficult to believe that there isn't a lot of it in the lucrative monopoly we see today.
Our options are: government, students, and hospitals. Government has demonstrated an inability to manage the market. Hospitals don't have a good reason to pay students. Therefore, it has to be the students.
> [paraphrasing] But then students will have to borrow even more! Costs will spin out of control!
You're assuming the inflated education costs that are a direct consequence of the government paying for graduate medical education will persist indefinitely when the government stops paying for graduate medical education. Medical schools currently sell an artificially scarce commodity. Prices will decrease if we allow supply to increase. New schools will be built to handle the influx of students if necessary.
If college grads find the cost of medical school + graduate medical education unappealing, medical schools will have to look for customers earlier in the pipeline (college + med + grad might be too much, but med + grad won't be).
> [anticipating an argument] But it's still an awful deal for current college grads.
Easy: pass a bill saying the government will stop paying for GME in 10 years. If GME funding was an actual roadblock and not just an excuse, AAMC will announce lifting the supply controls in 10 years (I personally suspect they would have to be strong-armed into this, but that's another argument). Medical schools will anticipate the ability to increase supply of seats in 10 years and will build out as necessary so that when the deadline hits, the new pipeline will be ready to go.
New grads of 2024 wouldn't be screwed because they would have already had a chance to price the new policy into their decisions. For instance, if they wanted to be a doctor they might have worked (perhaps in a medical-related job) for 4 years in anticipation of accelerated direct-to-med-school programs opening 4 years after their high-school graduation.
Yes, there would be a market shakeup with winners and losers, but nobody would get the rug yanked out from under them in a way they could not have anticipated and planned for. Realistically, that's the best we can ask for.
> [another anticipated argument] But then our doctors won't be as good.
Give certificate-granting entities partial liability in malpractice cases. Then they'll be forced to price their actual opinion on the matter into their admissions policies.
I'm not qualified to determine where the lard should be cut, but I find it difficult to believe that there isn't a lot of it in the lucrative monopoly we see today.
1. New schools are being built and they aren't cheaper. Quinnipiac University is the newest medical school to open (accepted its first class in 2013) and it is just as expensive as any other private medical school.
See: http://www.quinnipiac.edu/academics/colleges-schools-and-dep...
2. Inflated education costs are the result of easy access to loan money that is not dischargeable. Most university education cost increases follow from this. I'd argue we should make schools hold the loans for their graduates at the bare minimum, and then allow them to be discharged in bankruptcy again.
Or, even more radically, I'd argue we should make medical education free, but require tuition for residency. That way, if you want to specialize, you owe more years of tuition, but supposedly will make more money later and can pay it off. This way, you actually have a strong incentive for people to consider primary care specialties, as it will lead to a much lower total-loan-burden.
Or even more radically, let's lop off a year of residency for the primary care specialties. Canada seems to do fine with GPs only completing a 2 year residency. That's gaining a whole year of attending earning power. That could be huge.
I do not see medical education costs responding to general market forces so long as educational debt is easy to obtain.
3. Again, American medical school operates typically as a 2 + 2 system, where the first two years are spent heavily in class learning the basic science of medicine and the last two years are spent clinically learning the fundamentals of history taking, physical exam, differential diagnosis, and medical decision making.
The premedical requirements actually are useful for establishing a common foundation of knowledge which allow for us to only need 2 years to cover all the pre-clinical coursework. If you lop that off, you will simply transition to the non-US systems of medical training, which are only 1-2 years shorter in total duration. Mexico has a 6 year system. Chile is 7 years. UK grad entry is 4 years + 2 foundational years + residency, so at minimum 6 years before residency begins. Fine, there's some cost-savings in 2 years of undergrad removed, but most undergrad tuition is cheaper than medical school tuition. I think there will be no net savings.
4. Again, you are fundamentally misunderstanding things. The AAMC has no supply controls. They can only control how many students a medical school has. They have zero say in the amount of residency spots. Those are created by hospitals and accredited by the ACGME. Most hospitals only create as many spots as they receive CMS funding for. They could create spots and fund them themselves, provided they meet the minimum standards set by the ACGME for each trainee (sufficient case volume and teaching). If the government were to stop paying for GME funding in 10 years, either the hospitals would start paying or they would begin charging tuition, but in EITHER CASE, you've got to create quality residencies to train people. You can't just open a residency at random hospital because you want to.
See: http://www.quinnipiac.edu/academics/colleges-schools-and-dep...
2. Inflated education costs are the result of easy access to loan money that is not dischargeable. Most university education cost increases follow from this. I'd argue we should make schools hold the loans for their graduates at the bare minimum, and then allow them to be discharged in bankruptcy again.
Or, even more radically, I'd argue we should make medical education free, but require tuition for residency. That way, if you want to specialize, you owe more years of tuition, but supposedly will make more money later and can pay it off. This way, you actually have a strong incentive for people to consider primary care specialties, as it will lead to a much lower total-loan-burden.
Or even more radically, let's lop off a year of residency for the primary care specialties. Canada seems to do fine with GPs only completing a 2 year residency. That's gaining a whole year of attending earning power. That could be huge.
I do not see medical education costs responding to general market forces so long as educational debt is easy to obtain.
3. Again, American medical school operates typically as a 2 + 2 system, where the first two years are spent heavily in class learning the basic science of medicine and the last two years are spent clinically learning the fundamentals of history taking, physical exam, differential diagnosis, and medical decision making.
The premedical requirements actually are useful for establishing a common foundation of knowledge which allow for us to only need 2 years to cover all the pre-clinical coursework. If you lop that off, you will simply transition to the non-US systems of medical training, which are only 1-2 years shorter in total duration. Mexico has a 6 year system. Chile is 7 years. UK grad entry is 4 years + 2 foundational years + residency, so at minimum 6 years before residency begins. Fine, there's some cost-savings in 2 years of undergrad removed, but most undergrad tuition is cheaper than medical school tuition. I think there will be no net savings.
4. Again, you are fundamentally misunderstanding things. The AAMC has no supply controls. They can only control how many students a medical school has. They have zero say in the amount of residency spots. Those are created by hospitals and accredited by the ACGME. Most hospitals only create as many spots as they receive CMS funding for. They could create spots and fund them themselves, provided they meet the minimum standards set by the ACGME for each trainee (sufficient case volume and teaching). If the government were to stop paying for GME funding in 10 years, either the hospitals would start paying or they would begin charging tuition, but in EITHER CASE, you've got to create quality residencies to train people. You can't just open a residency at random hospital because you want to.
1. New != cheaper, but that's never what I was arguing. I argued that if the bottleneck (legal or organizational) were removed, enough new capacity would be built to reduce costs (the word "enough" is key).
2. Easy access to loan money increases demand for degrees, yes, but you're forgetting the supply side of this equation. Supply will increase to compensate unless there's a barrier to creating more supply (such as accreditation or actual economic demand for prestige, which only becomes significant when the degree itself doesn't suffice for employment).
Why would government funding of medical school not fall victim to a similar fate to GME? What if someone offered the compromise "government pays for tuition, but then government gets to set the salaries." How appealing would that be?
3. I'm familiar with what IS done, but I would be astounded if the "we can't possibly cut expenses" line continued once competition started to kick in.
4. No supply controls? Xodarap's evidence looks awfully damning: http://skeptics.stackexchange.com/questions/4561/does-the-am...
5. Yes, the point is to have students pay for their education, so that the supply of medical education can scale with the demand for it. It's not reasonable to expect the U.S. government to manage the supply of doctors at this time or in the near future.
2. Easy access to loan money increases demand for degrees, yes, but you're forgetting the supply side of this equation. Supply will increase to compensate unless there's a barrier to creating more supply (such as accreditation or actual economic demand for prestige, which only becomes significant when the degree itself doesn't suffice for employment).
Why would government funding of medical school not fall victim to a similar fate to GME? What if someone offered the compromise "government pays for tuition, but then government gets to set the salaries." How appealing would that be?
3. I'm familiar with what IS done, but I would be astounded if the "we can't possibly cut expenses" line continued once competition started to kick in.
4. No supply controls? Xodarap's evidence looks awfully damning: http://skeptics.stackexchange.com/questions/4561/does-the-am...
5. Yes, the point is to have students pay for their education, so that the supply of medical education can scale with the demand for it. It's not reasonable to expect the U.S. government to manage the supply of doctors at this time or in the near future.
This doesn't have to be a theoretical discussion. Dentistry residencies to specialize require tuition from the residents. Only a few provide salary.
Dentists make more money and work less than doctors. Simply forcing medical students to pay to be residents won't make things cheaper.
Dentists make more money and work less than doctors. Simply forcing medical students to pay to be residents won't make things cheaper.
I am a doctor, an anesthesiologist. I don't like AMA. But to blame AMA is a complete nonsense. (AMA really is just an insurance and loan agency, just like AARP.)
The real problem is government regulation of our profession, of the whole clinical process, and of devices and medications.
Those of you who go up in arms when government sticks its nose in your internet business, should imagine how it is to deal with the government that is there all the time for us. For example, how about trying to bill Medicare for a surgery, when one phrase--one phrase-- is missing from the documentation, and I don't get a penny for a 4 hour surgery?
The real problem is government regulation of our profession, of the whole clinical process, and of devices and medications.
Those of you who go up in arms when government sticks its nose in your internet business, should imagine how it is to deal with the government that is there all the time for us. For example, how about trying to bill Medicare for a surgery, when one phrase--one phrase-- is missing from the documentation, and I don't get a penny for a 4 hour surgery?
I don't believe you.
I am a physician too and you are repeating a lot of the falsehoods that are perpetuated among those that don't understand the billing process or aren't actually physicians.
AMA is an insurance and loan agency? I... I... don't know what to say to this. How about start by reading this (poorly written, but summary nonetheless):
http://en.wikipedia.org/wiki/American_Medical_Association
and one of their most influential functions:
http://en.wikipedia.org/wiki/Specialty_Society_Relative_Valu...
It's true that insurers set up arbitrary requirements (for sentinel effect, mostly) to try and refuse reimbursement, but often a simple change and resubmission will result in payment. These are issues that are dealt with in your contract with the insurer--have you read this contract? If not, then you can't complain! Even the CMS has a contract with its physicians.. and contrary to popular belief, they pay pretty well for most anything. It's Medicaid that is atrocious... especially since it covers children/poor and will often limit their access to healthcare.
I am a physician too and you are repeating a lot of the falsehoods that are perpetuated among those that don't understand the billing process or aren't actually physicians.
AMA is an insurance and loan agency? I... I... don't know what to say to this. How about start by reading this (poorly written, but summary nonetheless):
http://en.wikipedia.org/wiki/American_Medical_Association
and one of their most influential functions:
http://en.wikipedia.org/wiki/Specialty_Society_Relative_Valu...
It's true that insurers set up arbitrary requirements (for sentinel effect, mostly) to try and refuse reimbursement, but often a simple change and resubmission will result in payment. These are issues that are dealt with in your contract with the insurer--have you read this contract? If not, then you can't complain! Even the CMS has a contract with its physicians.. and contrary to popular belief, they pay pretty well for most anything. It's Medicaid that is atrocious... especially since it covers children/poor and will often limit their access to healthcare.
Sure it's true. If I do two cases, and my billing times overlap even by one minute, I am not going to get paid for either one of them by Medicare. If I place an epidural in Medicaid pt, I get paid something like $36 for the placement, and I don't get a penny for watching this pt for next 18 hours.
The question is why medicine is becoming the most miserable profession (with polling data to back it up) while the gov't interference in it is at all time's high and going higher and higher all the time.
The question is why medicine is becoming the most miserable profession (with polling data to back it up) while the gov't interference in it is at all time's high and going higher and higher all the time.
"If I place an epidural in Medicaid pt, I get paid something like $36 for the placement, and I don't get a penny for watching this pt for next 18 hours."
Wuh? I'm not a physician. But I do work for an ambulance service. And my day job has involved working with insurance reimbursement algorithms for Hospital and Insurance Administrators.
But "$36 for epidural and not a penny for the next 18 hours?"
You might want to look into that. Medicaid allows a Maximum Fee of $1.16/minute for an anesthesiologist's time.
"Essentially, hospitals will be reimbursed at $669.90 for the epidural procedure performed in the hospital setting; whereas, in office setting, after removing the portion designated for the physician professional fee, office practice expense will be reimbursed at $30.28 to $34.36 a whopping 2,315% to 2,668% with SGR cut and 1931% to 2312% without SGR cut more in the hospital setting."
Yes, epidurals are cut - but under what circumstances are you monitoring a patient bedside for 18 hours in a non-hospital setting?
And for every one of these examples, there's a flip-side:
Wisdom teeth under general anesthesia.
"Hi, I'm Mr X and I'll be your anesthesiologist today. How you doing? Now, to confirm, no allergies, right? And it says you weigh 180lb? Great, see you in theater!"
Bill:
"Pre-operative anesthesiologist consultation: $662"
For about 90 seconds. Now, I know the principles of anesthesia, though I'd never claim my knowledge was within orders of magnitude of that of a specialist, but I routinely perform RSI for ET intubation, and I know all about "the charge isn't for the time, it's the knowledge", but nonetheless.
Wuh? I'm not a physician. But I do work for an ambulance service. And my day job has involved working with insurance reimbursement algorithms for Hospital and Insurance Administrators.
But "$36 for epidural and not a penny for the next 18 hours?"
You might want to look into that. Medicaid allows a Maximum Fee of $1.16/minute for an anesthesiologist's time.
"Essentially, hospitals will be reimbursed at $669.90 for the epidural procedure performed in the hospital setting; whereas, in office setting, after removing the portion designated for the physician professional fee, office practice expense will be reimbursed at $30.28 to $34.36 a whopping 2,315% to 2,668% with SGR cut and 1931% to 2312% without SGR cut more in the hospital setting."
Yes, epidurals are cut - but under what circumstances are you monitoring a patient bedside for 18 hours in a non-hospital setting?
And for every one of these examples, there's a flip-side:
Wisdom teeth under general anesthesia.
"Hi, I'm Mr X and I'll be your anesthesiologist today. How you doing? Now, to confirm, no allergies, right? And it says you weigh 180lb? Great, see you in theater!"
Bill:
"Pre-operative anesthesiologist consultation: $662"
For about 90 seconds. Now, I know the principles of anesthesia, though I'd never claim my knowledge was within orders of magnitude of that of a specialist, but I routinely perform RSI for ET intubation, and I know all about "the charge isn't for the time, it's the knowledge", but nonetheless.
I don't think your example is very strong. It's not exactly clear what you mean by government "sticks its nose in your internet business" but for most that probably means regulation. But in your example Medicare is just a really big insurance company; if a private sector insurance company denied your claim for some stupid reason would you complain about the private sector? I'm sure there are examples of onerous regulations that would make a better example?
> But in your example Medicare is just a really big insurance company
I agree that there are better examples of government regulation directly impacting medical practice, but this example illustrates the power of a monopsony[0].
To overgeneralize, the same way that monopolists (single suppliers) can exercise power over purchasers in ways that we might deem unfair, monopsonists (single consumers) can exercise power over suppliers in ways that we may also deem unfair or harmful.
These effects are not limited to Medicare patients or providers, by the way. It's not hard to make the case that customers who can choose between Comcast and Verizon FiOS are harmed by the fact that cable companies are regional monopolies in most other markets.
Similarly, even if you have a private insurance plan, there are a number of ways that you are affected by Medicare's policies indirectly, in ways that you would not if they weren't such a big player.
[0] https://en.wikipedia.org/wiki/Monopsony
I agree that there are better examples of government regulation directly impacting medical practice, but this example illustrates the power of a monopsony[0].
To overgeneralize, the same way that monopolists (single suppliers) can exercise power over purchasers in ways that we might deem unfair, monopsonists (single consumers) can exercise power over suppliers in ways that we may also deem unfair or harmful.
These effects are not limited to Medicare patients or providers, by the way. It's not hard to make the case that customers who can choose between Comcast and Verizon FiOS are harmed by the fact that cable companies are regional monopolies in most other markets.
Similarly, even if you have a private insurance plan, there are a number of ways that you are affected by Medicare's policies indirectly, in ways that you would not if they weren't such a big player.
[0] https://en.wikipedia.org/wiki/Monopsony
The Association of American Medical Colleges (www.aamc.org) sets number of medical students, and not AMA.
The number of medical students is wholly irrelevant to the conversation at hand. We currently have more residencies than medical students, so spots are filled by foreign medical grads.
However, in about 2-3 years, there will be more American medical students than there will be residency spots. Still have the same problem: the bottleneck in training is the residency.
So, blaming the AMA or AAMC for keeping medical student numbers down is pointless. They are not the final gatekeeper for the creation of doctors. Residency training is that gatekeeper.
However, in about 2-3 years, there will be more American medical students than there will be residency spots. Still have the same problem: the bottleneck in training is the residency.
So, blaming the AMA or AAMC for keeping medical student numbers down is pointless. They are not the final gatekeeper for the creation of doctors. Residency training is that gatekeeper.
last year there were more grads than residency spots.
http://www.scpr.org/programs/airtalk/2014/04/15/6508/ can you comment on this radio segment please?
Bet you're pretty happy to have the government there with barriers to entry for your profession tho, keeping supply down.
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It would be interesting to see some data and in depth analysis on this subject to tell apart unfounded conspiracy claims from an actual problem that needs to be addressed.
I disagree. The problem is frankly that we've come to expect too much from modern medicine. Doing a triple bypass surgery on a 90-year-old is expensive, plain and simple. Yes, we can save his life, but we have to be willing to pay the cost—and we aren't.
Medicare is a monopsony. They represent such a large share of patients for many practices that they set their own prices. And when people expect medicare both to pay for their triple bypass and not to go broke at the same time, what we get bankrupt hospitals and over-worked doctors.
Being more responsible about the way we apportion healthcare is the only reasonable option.
Medicare is a monopsony. They represent such a large share of patients for many practices that they set their own prices. And when people expect medicare both to pay for their triple bypass and not to go broke at the same time, what we get bankrupt hospitals and over-worked doctors.
Being more responsible about the way we apportion healthcare is the only reasonable option.
I don't know any cardiologists who would perform that kind of surgery on a 90yo.
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Phil Ochs - A.M.A. Song
https://www.youtube.com/watch?v=6lkvswrSRAE
https://www.youtube.com/watch?v=6lkvswrSRAE
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From a demand/supply perspective involving only patients and doctors, it seems correct. I actually have the similar thought. But can anyone provide more dimensions of this "market"?
Coming from the healthcare marketing field, I can tell you there are many doctors who are looking for more patients. Especially specialists.
could you expand
The worst part about this set up is that increasing the number of doctors won't actually reduce healthcare costs, but paradoxically, increase them. This is because doctors in the USA make money through ordering tests and exams, rather than just spending face time with patients, as the article points out. There was an excellent Time [1] article on this phenomenon.
To make matters worse, Canada is suffering the effects of the American system. Doctors licensed in Canada are encouraged to go to the USA (particularly specialists), by the allure of much higher salaries. In order to prevent a vicious brain drain, the Canadian Medical Association must pay doctors as much as they can to stay and practice in the country. As such, Canadian healthcare costs have been skyrocketing due to specialist salaries soaring ever higher to compete with American rates.
Comparing physician salaries in the US and Canada with other commonwealth countries like Australia and the UK provides a clearer picture as to what is going on. The American healthcare system is completely and utterly FUBAR. It needs to be torn down and rebuilt based on a functioning healthcare system from another country.
1. http://time.com/198/bitter-pill-why-medical-bills-are-killin... (Unfortunately, it is now paywalled)
To make matters worse, Canada is suffering the effects of the American system. Doctors licensed in Canada are encouraged to go to the USA (particularly specialists), by the allure of much higher salaries. In order to prevent a vicious brain drain, the Canadian Medical Association must pay doctors as much as they can to stay and practice in the country. As such, Canadian healthcare costs have been skyrocketing due to specialist salaries soaring ever higher to compete with American rates.
Comparing physician salaries in the US and Canada with other commonwealth countries like Australia and the UK provides a clearer picture as to what is going on. The American healthcare system is completely and utterly FUBAR. It needs to be torn down and rebuilt based on a functioning healthcare system from another country.
1. http://time.com/198/bitter-pill-why-medical-bills-are-killin... (Unfortunately, it is now paywalled)
There's a million fixes for that. Ultimately it needs to be the patients that are in charge of the payment.
As it stands there are no published prices (or they're bogus, if your published prices are 3x what insurance companies pay it's not a real price) for anything so nobody can shop around. That means there is no competitive pressure on the non-critical, non-life-threatening things that are expensive-ish but possible to pay out of pocket. And that means that nobody can circumvent insurance. And that means that doctors have to keep spending $58 to process a form that will net them a $20 to $30 copay and maybe another $50 worth of reimbursement? So the doc nets between $30 and $40. Call it $35 and multiply by 5 (12 min per patient) and the doc is billing out at $175 per hour provided he teleports from one exam room to the next.
There are a great many people who could afford to pay $100 cash (or equivalent) for a doctors visit, for say 30 minutes with a doctor. So that's $200 per hour.
Major medical plans (for big stuff) coupled with health savings accounts will empower patients to ask "do I really need this" with a price sheet in hand and a real conversation about the benefits vs the costs. Right now that happens approximately zero.
As it stands there are no published prices (or they're bogus, if your published prices are 3x what insurance companies pay it's not a real price) for anything so nobody can shop around. That means there is no competitive pressure on the non-critical, non-life-threatening things that are expensive-ish but possible to pay out of pocket. And that means that nobody can circumvent insurance. And that means that doctors have to keep spending $58 to process a form that will net them a $20 to $30 copay and maybe another $50 worth of reimbursement? So the doc nets between $30 and $40. Call it $35 and multiply by 5 (12 min per patient) and the doc is billing out at $175 per hour provided he teleports from one exam room to the next.
There are a great many people who could afford to pay $100 cash (or equivalent) for a doctors visit, for say 30 minutes with a doctor. So that's $200 per hour.
Major medical plans (for big stuff) coupled with health savings accounts will empower patients to ask "do I really need this" with a price sheet in hand and a real conversation about the benefits vs the costs. Right now that happens approximately zero.
That's a popular theory, but it doesn't help much because a) we want universal access (poor people just won't use it if they have to pay) b) non-professionals don't review metrics critically and don't have enough knowledge to (and the metrics are hard to interpret for experts) and c) laymen just don't have enough knowledge to make good decisions with their money, they'll just use price as a signal of quality regardless of the underlying quality.
For some ordinary, understandable things, we can get people to pay if they have the means and understanding to do so, but we need to pay for outcomes (indexed for the base sickness of the population) for more complex cases. However, paying for outcomes forces the financial risk onto the doctor, so what we really need is some mixture of "pay for performance" and "fee for service" to keep them in business, but focused on adapting their practices to evidence and modernity over the decades.
One way to reduce bureaucracy and paper work is simply "Medicare for everyone" which reduces the number of forms, data links, and creates a massive negotiating position for the payer which is needed in an inelastic market such as medicine.
To give an example, if the patients are directly on the hook and grandpa is sick, they'll just send him to the "highest quality hospital" as determined by a mixture of patient reviews ("The rooms were well lit and people smiled!") and price ("This is the most expensive and therefore best hospital in the area!"). It might even have the best metrics (the sickest and (correlated) poorest will go to the cheaper hospital and tank their metrics). They'll then pay basically anything to keep grandpa alive regardless of what the hospital asks, maybe raising money if they need to.
Hence, inelastic complex market without where transparency can actually hurt.
The other thing to note is that if people of means pay $100 cash to obtain better healthcare and jump the line, it's kind of like paying more to get gas during hurricane Sandy. You're not creating more or better resources for the people, but merely rearranging them at high cost to the benefit of the affluent. This TED talk has some interesting points about this trend:
http://www.ted.com/talks/michael_sandel_why_we_shouldn_t_tru...
Aside: I used to work in the healthcare billing industry.
For some ordinary, understandable things, we can get people to pay if they have the means and understanding to do so, but we need to pay for outcomes (indexed for the base sickness of the population) for more complex cases. However, paying for outcomes forces the financial risk onto the doctor, so what we really need is some mixture of "pay for performance" and "fee for service" to keep them in business, but focused on adapting their practices to evidence and modernity over the decades.
One way to reduce bureaucracy and paper work is simply "Medicare for everyone" which reduces the number of forms, data links, and creates a massive negotiating position for the payer which is needed in an inelastic market such as medicine.
To give an example, if the patients are directly on the hook and grandpa is sick, they'll just send him to the "highest quality hospital" as determined by a mixture of patient reviews ("The rooms were well lit and people smiled!") and price ("This is the most expensive and therefore best hospital in the area!"). It might even have the best metrics (the sickest and (correlated) poorest will go to the cheaper hospital and tank their metrics). They'll then pay basically anything to keep grandpa alive regardless of what the hospital asks, maybe raising money if they need to.
Hence, inelastic complex market without where transparency can actually hurt.
The other thing to note is that if people of means pay $100 cash to obtain better healthcare and jump the line, it's kind of like paying more to get gas during hurricane Sandy. You're not creating more or better resources for the people, but merely rearranging them at high cost to the benefit of the affluent. This TED talk has some interesting points about this trend:
http://www.ted.com/talks/michael_sandel_why_we_shouldn_t_tru...
Aside: I used to work in the healthcare billing industry.
I agree that the emergency or otherwise time sensitive stuff is harder to fix up but it's still doable.
I am not suggesting that the rich be able to spend $100 to see a doctor and all the cattle should be left to fend for themselves. What I am suggesting is that it's not outside the realm of possibility for people to fund their own care.
Right now the way insurance is structured they lump together "maintenance" with "serious" and "catastrophic" all in a single insurance policy. That is unfortunate because most regular human beings can self-fund "maintenance" and many can even self-fund "serious" but only very wealthy folks have the capacity to pay for "catastrophic"
The reason we want individuals to pay for "maintenance" and even some "serious" stuff out of pocket is two-fold. First we want competitive pressure on doctors to not jack their prices up. Second, it will help encourage a culture of "do I really need this?" among patients and they will ask their doctors about more than "will it help" but more like "is it worth it" and while some doctors might lie to enrich themselves most that I have met aren't the type.
Why do we want competitive pressure on doctors not to jack their prices up? Because right now the way things work is that the insurance companies have a pretty good idea of what things cost and they negotiate doctors down very aggressively on that. They will of course let the docs make a little money, but nothing crazy. Let's say 10% as an example. If you can only make 10% on your costs then the easiest thing to do is to work on increasing your costs, which then makes a bigger pie for you to earn 10% of. Furthermore there is no incentive for doctors to come up with cost-savings because if they do, it simply reduces the size of their pie to earn 10% of. The unfortunate side effect is that even though medicine has more and more technology and that technology is getting cheaper and cheaper, the cost of medicine is rising.
I realize that I don't have the answers to everything but competitive pressure and rewarding innovation are sorely lacking in medicine today. Other forces are also necessary, like publishing outcome statistics in addition to prices. But I find it very difficult to believe that for the mundane stuff that makes up a lot of a person's exposure to medicine until something serious or catastrophic happens (or late in life) would go a long way towards reshaping people's expectations as well.
I am not suggesting that the rich be able to spend $100 to see a doctor and all the cattle should be left to fend for themselves. What I am suggesting is that it's not outside the realm of possibility for people to fund their own care.
Right now the way insurance is structured they lump together "maintenance" with "serious" and "catastrophic" all in a single insurance policy. That is unfortunate because most regular human beings can self-fund "maintenance" and many can even self-fund "serious" but only very wealthy folks have the capacity to pay for "catastrophic"
The reason we want individuals to pay for "maintenance" and even some "serious" stuff out of pocket is two-fold. First we want competitive pressure on doctors to not jack their prices up. Second, it will help encourage a culture of "do I really need this?" among patients and they will ask their doctors about more than "will it help" but more like "is it worth it" and while some doctors might lie to enrich themselves most that I have met aren't the type.
Why do we want competitive pressure on doctors not to jack their prices up? Because right now the way things work is that the insurance companies have a pretty good idea of what things cost and they negotiate doctors down very aggressively on that. They will of course let the docs make a little money, but nothing crazy. Let's say 10% as an example. If you can only make 10% on your costs then the easiest thing to do is to work on increasing your costs, which then makes a bigger pie for you to earn 10% of. Furthermore there is no incentive for doctors to come up with cost-savings because if they do, it simply reduces the size of their pie to earn 10% of. The unfortunate side effect is that even though medicine has more and more technology and that technology is getting cheaper and cheaper, the cost of medicine is rising.
I realize that I don't have the answers to everything but competitive pressure and rewarding innovation are sorely lacking in medicine today. Other forces are also necessary, like publishing outcome statistics in addition to prices. But I find it very difficult to believe that for the mundane stuff that makes up a lot of a person's exposure to medicine until something serious or catastrophic happens (or late in life) would go a long way towards reshaping people's expectations as well.
I don't get why overworked personnel aren't regarded as a dire safety issue. There's a reason the FAA restricted the number of hours commercial pilots are allowed to fly per week without rest.
http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot...
I met a resident the other day, and they routinely get four hours of sleep or less and worked for shifts that are insanely long that are basically dictated by patient demand. Why not just hire more doctors, maybe lower salaries by increasing supply, and give them a healthier lifestyle? Maybe medical school prices would go down with additional scale.
http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot...
I met a resident the other day, and they routinely get four hours of sleep or less and worked for shifts that are insanely long that are basically dictated by patient demand. Why not just hire more doctors, maybe lower salaries by increasing supply, and give them a healthier lifestyle? Maybe medical school prices would go down with additional scale.
It's extremely difficult to study the effects of sleep deprivation on the rate of medical error, but several studies have shown that the highest numbers of medical errors occur during handoffs between shifts. Reducing the frequency of those handoffs by increasing shift length reduces the total number of detectable medical errors.
Additionally, the work hour restrictions placed on residents over the last few years appear to have done nothing to reduce the overall number of medical errors.
(I am in favor of reducing medical work hours myself, but these are some of the data-driven reasons that it will be very difficult, not to mention the structural reasons inherent to the current system of medical training.)
Additionally, the work hour restrictions placed on residents over the last few years appear to have done nothing to reduce the overall number of medical errors.
(I am in favor of reducing medical work hours myself, but these are some of the data-driven reasons that it will be very difficult, not to mention the structural reasons inherent to the current system of medical training.)
By having more doctors working less intensely for overlapping shifts, they can take more time to complete handoff documentation and conversations properly, and have fewer handoffs (by taking on fewer patients after the first half of their shift)
Longer shifts does not mean that doctors can't have longer sleep that 4 hours. Let doctors have 16 or even 18-hour long shifts interleaved with days without shifts at all, for sleeping and some [light] paperwork.
This is, I believe, how firefighters work: long shifts of oncall where they live in the firehouse, separated by longer periods of non-work (rest, sleep, whatever).
One solid reason is the same reason sleep deprivation is used in basic training. Most doctors, will, at some point in their life, have to make life and death decisions when they're operating far from 100% ... or at least that was true back in the days when they'd take calls at any hour of the day (as late as the '70s). Less dire, they have office hours they must keep unless they're really sick, and they certainly won't be at 100% every day.
So this is useful training, albeit at a cost. Although if they make a mistake that kills a patient during residency and learn they can't deal with the consequences of that, I suppose the earlier the better. They can of course move to less life and death specialties.
So this is useful training, albeit at a cost. Although if they make a mistake that kills a patient during residency and learn they can't deal with the consequences of that, I suppose the earlier the better. They can of course move to less life and death specialties.
I get that deprivation training can be helpful, but to be deprived nearly 100% of the time in a safety critical, fast paced environment? That's crazy. These guys aren't special forces (who I assume have in-field careers similar to pro-sports players), they're normal people trying to work at this for many decades.
If your goal is to reduce medical errors, create systems that don't depend on a single person's fluctuating energy level (e.g. have two doctors responsible for each patient, keep patient loads low enough that they can deal, automate as much as possible with computer systems (e.g. billing), and delegate to e.g. PAs for mundane diagnoses). Exhausted people make mistakes, can't work or think as quickly, are less creative, and are generally less happy. All the technology in the world won't help you if the key decision makers screw up at the wrong time.
After all, coffee does exist for those times when your natural energy level won't do it for you. ;)
If your goal is to reduce medical errors, create systems that don't depend on a single person's fluctuating energy level (e.g. have two doctors responsible for each patient, keep patient loads low enough that they can deal, automate as much as possible with computer systems (e.g. billing), and delegate to e.g. PAs for mundane diagnoses). Exhausted people make mistakes, can't work or think as quickly, are less creative, and are generally less happy. All the technology in the world won't help you if the key decision makers screw up at the wrong time.
After all, coffee does exist for those times when your natural energy level won't do it for you. ;)
A nit, in the military this is not limited to "special forces", and I'm just talking about the stresses of peacetime. Look at e.g. https://en.wikipedia.org/wiki/Watch_system which doesn't list the 4 hours on, 4 hours off system the US Navy used, at least in the '50s when my father was First Lieutenant on a North Atlantic radar picket ship. He still remembers it being very hard.
This is interesting. Thanks for the link!
Nonetheless, I don't think these guys are getting 4 on 4 off... I think they just work basically straight through for 12-16 (or more) hours and get maybe a day a week off.
I can completely sympathize though that 4 on 4 off would be incredibly hard in and of itself. I'm not sure I could do it for weeks let alone months on end.
Nonetheless, I don't think these guys are getting 4 on 4 off... I think they just work basically straight through for 12-16 (or more) hours and get maybe a day a week off.
I can completely sympathize though that 4 on 4 off would be incredibly hard in and of itself. I'm not sure I could do it for weeks let alone months on end.
So... possibly put real patients at risk on a regular basis in order to train doctors for hypothetical situations that they may face at some point in their career? That doesn't sound like a solid justification to me.
Not sure why you were downvoted, but this is the exact reason that a couple of my relatives in medical profession gave when asked why their training involved 24-36 hour shifts routinely with very few sleep breaks.
I think it makes sense in training (under supervision), it's just doing it as an all encompassing lifestyle that I think makes no sense.
Well, the downvoting didn't stick.
I learned this primarily from my mother, who was a RN nurse anesthetist, and a doctor who became my father's primary hunting partner about the time I was old enough to start actively hunting.
I learned this primarily from my mother, who was a RN nurse anesthetist, and a doctor who became my father's primary hunting partner about the time I was old enough to start actively hunting.
It is a logical argument but it's far from "solid" given today's realities. Humans simply don't adapt to sleep deprivation and organized, constant sleep deprivation clearly is going to make decisions worse over time.
There's no justifiable reason to give a large, urban hospital an organization system fit to the battle field.
There's no justifiable reason to give a large, urban hospital an organization system fit to the battle field.
> Maybe medical school prices would go down with additional scale.
It seems like a bit of a chicken and egg problem. Medical school is already so expensive that the salaries are necessary in order for newly minted doctors to have the same disposable income after loan payments that, say, a programmer or chemical engineer who's 7 years younger has (4 years medical school + 3 years residency minimum). Who would make the sacrifices necessary to become a doctor, taking out massive loans, only for an income that won't sustain them comfortably?
It seems like a bit of a chicken and egg problem. Medical school is already so expensive that the salaries are necessary in order for newly minted doctors to have the same disposable income after loan payments that, say, a programmer or chemical engineer who's 7 years younger has (4 years medical school + 3 years residency minimum). Who would make the sacrifices necessary to become a doctor, taking out massive loans, only for an income that won't sustain them comfortably?
So, Apple suppressing engineer wages indirectly made the medical profession more attractive for doctors!
This is completely a story of industry structure and bad incentives, and how people react to them.
Currently, in the United States, we believe all of the following things: (1) Human physicians, are the only qualified parties to diagnose, treat, and/or recommend courses of action related to health (not nurses, physician's assistants, computer programs, etc.), (2) everyone has a fundamental right to healthcare, (3) health professionals must undergo expensive, lengthy, difficult courses of study and training, and (4) we reimburse for procedures, not pay for outcomes.
Given these incentives, it's not hard to see why doctors are some of the most overworked, stressed-out, and generally miserable professionals out there. They're at the nexus of a crushing conflict between keeping people healthy, a management system that demands more revenue (and remember that revenue=procedures, because we reimburse for procedures, so the only way to increase "productivity" is to do more, faster, with fewer breaks and longer shifts), and a legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study.
I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. I believe this outcome is inevitable, but will take a decade or more to surface, because it requires major shifts in how doctors and insurance companies think about billing, greater human trust in computers and recommendation systems, and a collective realization that the current state of healthcare is untenable.
Currently, in the United States, we believe all of the following things: (1) Human physicians, are the only qualified parties to diagnose, treat, and/or recommend courses of action related to health (not nurses, physician's assistants, computer programs, etc.), (2) everyone has a fundamental right to healthcare, (3) health professionals must undergo expensive, lengthy, difficult courses of study and training, and (4) we reimburse for procedures, not pay for outcomes.
Given these incentives, it's not hard to see why doctors are some of the most overworked, stressed-out, and generally miserable professionals out there. They're at the nexus of a crushing conflict between keeping people healthy, a management system that demands more revenue (and remember that revenue=procedures, because we reimburse for procedures, so the only way to increase "productivity" is to do more, faster, with fewer breaks and longer shifts), and a legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study.
I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. I believe this outcome is inevitable, but will take a decade or more to surface, because it requires major shifts in how doctors and insurance companies think about billing, greater human trust in computers and recommendation systems, and a collective realization that the current state of healthcare is untenable.
> greater human trust in computers and recommendation systems
I am an MD and have a degree in CS. Expert systems are not remotely there yet for this purpose. On no planet would I trust care of my patients to a computer. Far too many subtleties involved in accurate diagnosis and treatment that are not encoded in a machine-readable format.
> legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study
Good reasons for this - it actually takes that lengthy course of study to safely perform many procedures, and, more importantly, to fix things when they go wrong.
NPs and PAs are helpful but based on the quality of care that I personally observe they should not function without physician oversight.
There is no escaping that medicine is an extremely complex field, and it is only getting more so. Not long ago, many of the people who today are restored to their usual state of health would simply have died. The sicker a patient is, the more complex and difficult to manage they are. By definition a doctor is the one who is able to do so.
I am still waiting to meet a patient who comes to the hospital and prefers to have their care rendered by non-physician providers over physicians, or would even settle if there were an option.
I am an MD and have a degree in CS. Expert systems are not remotely there yet for this purpose. On no planet would I trust care of my patients to a computer. Far too many subtleties involved in accurate diagnosis and treatment that are not encoded in a machine-readable format.
> legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study
Good reasons for this - it actually takes that lengthy course of study to safely perform many procedures, and, more importantly, to fix things when they go wrong.
NPs and PAs are helpful but based on the quality of care that I personally observe they should not function without physician oversight.
There is no escaping that medicine is an extremely complex field, and it is only getting more so. Not long ago, many of the people who today are restored to their usual state of health would simply have died. The sicker a patient is, the more complex and difficult to manage they are. By definition a doctor is the one who is able to do so.
I am still waiting to meet a patient who comes to the hospital and prefers to have their care rendered by non-physician providers over physicians, or would even settle if there were an option.
It's not that simple. A society cannot afford the triple-A gold standard of everything for everybody. Not everybody can live in a McMansion and not everybody can afford to have an MD/CS for their every single health need, no matter how minor or how routine. Tradeoffs have to be made.
US medicine has been very successful at creating a guild system that's prevented lower-cost provision of care for decades, all under the concern of "it'll lower the standards of patient care." End result has been millions of people who can't afford medical care at all.
One anecdote: for a time I was splitting living in the UK and the US and had health care experiences in both places. It was fascinating to see the differences in treating my (very ordinary) health issues. One time I came down with a mild rash that rebounded a few times before it finally went away. In the UK, the GP looked at the rash, punctured the pustules with little pokey thing so they'd drain, and they cleared up in a few days. In the US, the dermatologist wheeled in a big machine filled with liquid nitrogen and froze the pustules; they went away in a few days after that too. End result the same; cost to administer - orders of magnitude different. In the US, it seems like there's no medical treatment that we can't make more expensive by requiring more specialists with more years of training, using ever more expensive machines and medications.
I love modern medicine. My dad's a retired doctor and I almost became an MD myself. But the system we've created has costs out of control while simultaneously creating worse societal health outcomes than other countries.
US medicine has been very successful at creating a guild system that's prevented lower-cost provision of care for decades, all under the concern of "it'll lower the standards of patient care." End result has been millions of people who can't afford medical care at all.
One anecdote: for a time I was splitting living in the UK and the US and had health care experiences in both places. It was fascinating to see the differences in treating my (very ordinary) health issues. One time I came down with a mild rash that rebounded a few times before it finally went away. In the UK, the GP looked at the rash, punctured the pustules with little pokey thing so they'd drain, and they cleared up in a few days. In the US, the dermatologist wheeled in a big machine filled with liquid nitrogen and froze the pustules; they went away in a few days after that too. End result the same; cost to administer - orders of magnitude different. In the US, it seems like there's no medical treatment that we can't make more expensive by requiring more specialists with more years of training, using ever more expensive machines and medications.
I love modern medicine. My dad's a retired doctor and I almost became an MD myself. But the system we've created has costs out of control while simultaneously creating worse societal health outcomes than other countries.
> It's not that simple. A society cannot afford the triple-A gold standard of everything for everybody.
The society in question has not realized it.
> US medicine has been very successful at creating a guild system that's prevented lower-cost provision of care for decades, all under the concern of "it'll lower the standards of patient care." End result has been millions of people who can't afford medical care at all.
Even the bottom rungs of the doctors in the "guild system" are not very good - lowering standards even more is very hard to agree with when push comes to shove. Especially there is no guarantee that this will actually lower costs to society.
But I guess this is what will have to happen, at least in primary care, because that is a miserable field that I am incredibly glad I didn't go into. I hope that at least some kind of care turns out to be better than none at all.
The society in question has not realized it.
> US medicine has been very successful at creating a guild system that's prevented lower-cost provision of care for decades, all under the concern of "it'll lower the standards of patient care." End result has been millions of people who can't afford medical care at all.
Even the bottom rungs of the doctors in the "guild system" are not very good - lowering standards even more is very hard to agree with when push comes to shove. Especially there is no guarantee that this will actually lower costs to society.
But I guess this is what will have to happen, at least in primary care, because that is a miserable field that I am incredibly glad I didn't go into. I hope that at least some kind of care turns out to be better than none at all.
I like people from the US who want to cut out people poorer from being helped by an MD because it's "impossible"; when so many other developed countries seem to manage with it just fine.
I'm still amazed some want to go back to a system that charged them more for marketing it to themselves than actual care-- boggles the mind.
> I am still waiting to meet a patient who comes to the hospital and prefers to have their care rendered by non-physician providers over physicians, or would even settle if there were an option.
Attach a price tag to each and find out. Maybe someone who couldn't afford a $500 consultation with an MD could settle for a $250 or $100 consultation with a PA, or an expert system. You really don't know until you experiment, and find out.
Attach a price tag to each and find out. Maybe someone who couldn't afford a $500 consultation with an MD could settle for a $250 or $100 consultation with a PA, or an expert system. You really don't know until you experiment, and find out.
True, that is the experiment to do.
It is not without ethical concern though. Unfortunately, most patients are not sufficiently informed about medicine to make a rational market choice. (Indeed, outside my specialty, I am not really either, and would seek the advice of a trusted physician friend, which is a luxury most don't have.)
For example, the PA and expert system would not reliably know when they are in over their heads and require an MD. Some subset of people would suffer serious injury or death through no fault of their own other than not having had the information necessary to allocate their funds in a manner most benefiting their interests.
It is not without ethical concern though. Unfortunately, most patients are not sufficiently informed about medicine to make a rational market choice. (Indeed, outside my specialty, I am not really either, and would seek the advice of a trusted physician friend, which is a luxury most don't have.)
For example, the PA and expert system would not reliably know when they are in over their heads and require an MD. Some subset of people would suffer serious injury or death through no fault of their own other than not having had the information necessary to allocate their funds in a manner most benefiting their interests.
There's some research that at least some expert systems("decision support system") implemented in the right culture do improve medical services[1].
But still due to huge resistance by doctors, who like the autonomy of the job, such systems are rarely used.
I could only imagine how rapidly such systems would improve if the backbone of medicine would be dependent on them, and enough revenue would be shifted towards them.
[1]http://www.ncbi.nlm.nih.gov/pubmed/24573664
But still due to huge resistance by doctors, who like the autonomy of the job, such systems are rarely used.
I could only imagine how rapidly such systems would improve if the backbone of medicine would be dependent on them, and enough revenue would be shifted towards them.
[1]http://www.ncbi.nlm.nih.gov/pubmed/24573664
give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles.
They are not tried and true. A friend of mine worked as a QA engineer at my city's most prominent children's hospital (a minor power on the world stage). His thankless task was to find ways to improve communications between departments and curb the errors. It was simply not possible - every doctor had their preferred provider, sometimes from merit, sometimes because they liked the shiny goodies that the sales reps brought.
All the individual systems interoperated very poorly, and none of the physicians would budge, and the hospital administration could not force their hand. Any time admin tried to regularise something, the affected physician would just state "If we make this change, children will die". It didn't matter that everyone at the table new that this was a total lie, because the official authority for that department (or speciality) was that specialist. They got their 'free market', being able to use their preferred products for each individual specialist, for personal preference at the cost of better overall treatment. The whole was very much less the sum of its parts.
Another friend became a sales rep for a pharma company. The rep she took over from was a fairly standard rep, but she was quite ethical, and would only allow her 'freebie' budget to be used on things that developed the practise. Some doctors already do this. Others were more like "ah, well, the ride is over with this rep". Some were absolutely outraged that she should dictate to them what this 'extra income' was spent on - how dare she suggest medical charts instead of football tickets?
I myself have personally seen a specialist in a field report on some clinical studies so badly that we technicians had to go to other specialists and get them redone. That specialist didn't get any more of that kind of work at our practise, but his utter incompetence was never followed up beyond "don't hire him again".
I guess the moral of the stories are that freedom to run practises as you see fit does not mean ethical (or even ethically neutral) behaviour, and that an environment where every physician uses their preferred products does not mean better care is delivered.
They are not tried and true. A friend of mine worked as a QA engineer at my city's most prominent children's hospital (a minor power on the world stage). His thankless task was to find ways to improve communications between departments and curb the errors. It was simply not possible - every doctor had their preferred provider, sometimes from merit, sometimes because they liked the shiny goodies that the sales reps brought.
All the individual systems interoperated very poorly, and none of the physicians would budge, and the hospital administration could not force their hand. Any time admin tried to regularise something, the affected physician would just state "If we make this change, children will die". It didn't matter that everyone at the table new that this was a total lie, because the official authority for that department (or speciality) was that specialist. They got their 'free market', being able to use their preferred products for each individual specialist, for personal preference at the cost of better overall treatment. The whole was very much less the sum of its parts.
Another friend became a sales rep for a pharma company. The rep she took over from was a fairly standard rep, but she was quite ethical, and would only allow her 'freebie' budget to be used on things that developed the practise. Some doctors already do this. Others were more like "ah, well, the ride is over with this rep". Some were absolutely outraged that she should dictate to them what this 'extra income' was spent on - how dare she suggest medical charts instead of football tickets?
I myself have personally seen a specialist in a field report on some clinical studies so badly that we technicians had to go to other specialists and get them redone. That specialist didn't get any more of that kind of work at our practise, but his utter incompetence was never followed up beyond "don't hire him again".
I guess the moral of the stories are that freedom to run practises as you see fit does not mean ethical (or even ethically neutral) behaviour, and that an environment where every physician uses their preferred products does not mean better care is delivered.
I worked in a hospital, and saw similar things, but I think the moral of the story is that huge organizations operate internally more like a feudal oligarchy. They crystallize, regardless of the external market.
This one certainly was. Another story of my friends was sitting in on a meeting, where one of the old-school specialists of nearly 30 years experience made a snide remark about 'newcomers not understanding how things are done'. The target of the remark responded 'I've been here 17 years...'.
The point remains the same, though - letting physicians choose whatever they want is not a magic bullet given by 'the free market', and can make things worse in practise. And it's not like 'the free market' has shown us that comms protocols are followed with any particular veracity in the software world, for things that have no regulation on them. Do we have an open video codec yet that runs on all browsers, for example?
The point remains the same, though - letting physicians choose whatever they want is not a magic bullet given by 'the free market', and can make things worse in practise. And it's not like 'the free market' has shown us that comms protocols are followed with any particular veracity in the software world, for things that have no regulation on them. Do we have an open video codec yet that runs on all browsers, for example?
Healthcare has been such a regulated industry in every aspect that anecdotes like these do little to discredit free markets.
People who have to solve problems in the pragmatic world, like my QA friend above, are poorly served by your ideology. At least anecdotes are a reference to a real-world event; blindly sticking to ideology is pure fantasy.
Point of clarification: physician assistants are qualified to diagnose, treat, and recommend courses of action related to health care.
Per the American Academy of Physician Assistants: "PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling and make rounds in hospitals and nursing homes. All 50 states and the District of Columbia allow PAs to practice medicine and prescribe medications."
http://www.aapa.org/the_pa_profession/what_is_a_pa.aspx
Disclaimer: I work for the Physician Assistant Education Association.
Per the American Academy of Physician Assistants: "PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling and make rounds in hospitals and nursing homes. All 50 states and the District of Columbia allow PAs to practice medicine and prescribe medications."
http://www.aapa.org/the_pa_profession/what_is_a_pa.aspx
Disclaimer: I work for the Physician Assistant Education Association.
Interesting. This seems like a step in the right direction. What can't PAs do, that MDs can?
Just FYI nurse practitioners (NPs) can also diagnose/prescribe/refer. I happen to know this because my mom's finishing up school to become one. When she's finished, she'll get a huge pay bump, and have quite a few options open to her. A clinic at Walgreens, for example, is often staffed by a nurse practitioner. Cheaper than a doctor, but with their general prescriptive abilities.
http://en.wikipedia.org/wiki/Nurse_practitioner
http://en.wikipedia.org/wiki/Nurse_practitioner
> give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles
I agree completely, but you forgot to add under what we believe: (5) "government has the solution for everything." At least that's what it feels like lately.
The cynic in me says that the healthcare industry will continue to get worse for some time before it gets better, if ever. We may see complete nationalization because the government must swoop in and "save us" from the monster it has helped to create through misguided regulation.
I agree completely, but you forgot to add under what we believe: (5) "government has the solution for everything." At least that's what it feels like lately.
The cynic in me says that the healthcare industry will continue to get worse for some time before it gets better, if ever. We may see complete nationalization because the government must swoop in and "save us" from the monster it has helped to create through misguided regulation.
In countries with socialized healthcare systems, costs are much lower, as is the overall amount spent on healthcare.
Americans actually display stunning recalcitrance towards this fact, and as a result we have an incredibly polarized debate which has led to a bastardized and amalgamated system comprised of several other, and often conflicting, constructs.
Americans actually display stunning recalcitrance towards this fact, and as a result we have an incredibly polarized debate which has led to a bastardized and amalgamated system comprised of several other, and often conflicting, constructs.
I actually agree with this (wrote the GP). If we could have either whole-hog free market or public option, I believe either would be better than what we have now.
I think integrated systems could help, where the financial and operational sides of healthcare are combined (e.g. Group Health in Seattle, or Kaiser). The key thing is to remove the conflict between the payer and operator -- it's just madness that we have a system where one party has 100% of the incentive to control costs, and the other is completely responsible for outcomes, cost be damned.
I think integrated systems could help, where the financial and operational sides of healthcare are combined (e.g. Group Health in Seattle, or Kaiser). The key thing is to remove the conflict between the payer and operator -- it's just madness that we have a system where one party has 100% of the incentive to control costs, and the other is completely responsible for outcomes, cost be damned.
Not only that, many Americans seem to believe their system of having insurance companies as middlemen improves the system somehow.
My girlfriend is a doctor here in Europe (though she has worked in Mexico). As such she has worked with private and public systems (generally in Europe, you are automatically part of the public system. You can pay private yourself and generally have to wait less).
Anyway, both her and her boss pointed out that if you have anything serious, go to the public system. Why? Because insurance companies always want to pay the least for the cheapest drugs / treatment. The doctors don't enjoy working for the private, because too much of it is trying to justify using the more expensive treatment to the insurance companies.
At the end of the day the public healthcare system exists to help people get better. The private healthcare system exists to make money.
My girlfriend is a doctor here in Europe (though she has worked in Mexico). As such she has worked with private and public systems (generally in Europe, you are automatically part of the public system. You can pay private yourself and generally have to wait less).
Anyway, both her and her boss pointed out that if you have anything serious, go to the public system. Why? Because insurance companies always want to pay the least for the cheapest drugs / treatment. The doctors don't enjoy working for the private, because too much of it is trying to justify using the more expensive treatment to the insurance companies.
At the end of the day the public healthcare system exists to help people get better. The private healthcare system exists to make money.
International comparison: http://healthcarereform.procon.org/view.resource.php?resourc...
Administrative overhead of government vs private insurance: http://healthcarereform.procon.org/view.resource.php?resourc...
Administrative overhead of government vs private insurance: http://healthcarereform.procon.org/view.resource.php?resourc...
How do outcomes compare?
Here's some basics:
http://www.commonwealthfund.org/~/media/Files/Publications/I...
Essentially, we excel in a couple very specific things, like survivorship of breast cancer. We're middle of the pack in some things, like general cancer survivorship. And we're the worst by quite a bit in others, like chronic diseases. Basically, I would say we're not getting our $'s worth.
Here's some Commonwealth Fund info if you don't want to trust some random white paper.
http://en.wikipedia.org/wiki/Commonwealth_Fund
Oh, and if you want something from an organization with a known bias: http://www.rand.org/content/dam/rand/pubs/working_papers/201...
Key abstract quote: "But one key finding emerges – the US ranks poorly on all indicators with the exception of self-reported subjective health status."
http://www.commonwealthfund.org/~/media/Files/Publications/I...
Essentially, we excel in a couple very specific things, like survivorship of breast cancer. We're middle of the pack in some things, like general cancer survivorship. And we're the worst by quite a bit in others, like chronic diseases. Basically, I would say we're not getting our $'s worth.
Here's some Commonwealth Fund info if you don't want to trust some random white paper.
http://en.wikipedia.org/wiki/Commonwealth_Fund
Oh, and if you want something from an organization with a known bias: http://www.rand.org/content/dam/rand/pubs/working_papers/201...
Key abstract quote: "But one key finding emerges – the US ranks poorly on all indicators with the exception of self-reported subjective health status."
>I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles
Holy meaningless platitudes Batman. How do you have a system that is simultaneously profit driven and that allows everyone a fundamental right to healthcare? Short answer: you can't! You can either have a system that avoids treating the most expensive (free market), or you have a system that ensures a certain level of care for all (socialism), or you have some bastardized hybrid that costs ungodly amounts of money and does not serve the sick and poor well. (the system we have).
Holy meaningless platitudes Batman. How do you have a system that is simultaneously profit driven and that allows everyone a fundamental right to healthcare? Short answer: you can't! You can either have a system that avoids treating the most expensive (free market), or you have a system that ensures a certain level of care for all (socialism), or you have some bastardized hybrid that costs ungodly amounts of money and does not serve the sick and poor well. (the system we have).
I don't think it's either-or. Conditional and unconditional cash transfers [1] have many of the benefits of free-market competition (focus on efficiency and cost reduction) with many of the social benefits of an expanded welfare state. I could easily see a system where people get "medical vouchers" to spend on their most pressing care problems, and providers compete to supply care at the lowest possible price to either vouchered payers, or those paying in cash.
[1] http://en.wikipedia.org/wiki/Conditional_cash_transfer
See also: http://www.economist.com/news/international/21588385-giving-...
[1] http://en.wikipedia.org/wiki/Conditional_cash_transfer
See also: http://www.economist.com/news/international/21588385-giving-...
Also relevant: I wrote "Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school" (http://jseliger.wordpress.com/2012/10/20/why-you-should-beco...) based on watching the experience of my fiancée and her friends and peers.
EDIT: In the essay I describe why it can become so hard to leave medicine after one has invested more than a year or two in med school because of student loans; that may help explain the suicide issue: people who feel trapped may in turn feel like death is the only way out.
A surprisingly large number of doctors hit residency and realize they don't want to become doctors. In most professions that's not a tremendous problem, but in medicine the only way to pay back $100 – $250K in graduate student loans is by becoming a doctor.
EDIT: In the essay I describe why it can become so hard to leave medicine after one has invested more than a year or two in med school because of student loans; that may help explain the suicide issue: people who feel trapped may in turn feel like death is the only way out.
A surprisingly large number of doctors hit residency and realize they don't want to become doctors. In most professions that's not a tremendous problem, but in medicine the only way to pay back $100 – $250K in graduate student loans is by becoming a doctor.
A similar phenomenon is at work with law students. Granted law school is shorter than an MD program at only 3 years -- but can still result in $150k of student loan debt.
This is true of almost all terminal degrees today. Higher education is such a corrupt industry, feeding those at the top of the pyramid by making promises to prospective students they are fully aware are unrealistic.
With Pay As You Earn a debtor won't pay more than 10% of AGI to federal student loans. Note that's AGI, not gross income, meaning you can contribute to retirement and not have it counted. Loans aren't as big of a constraint on career options as people make them out to be. Debtors are also willfully ignorant of these sorts of options and choose to instead destroy their lives paying debts that don't need to be paid.
To be clear, it's a huge problem, and we shouldn't have this sort of debt loads on those who want to educate themselves. It also weakens the broader economy and drives up professional services costs. But to say people are killing themselves because of student loans is a mistake.
To be clear, it's a huge problem, and we shouldn't have this sort of debt loads on those who want to educate themselves. It also weakens the broader economy and drives up professional services costs. But to say people are killing themselves because of student loans is a mistake.
While it is true that PAYE is capped at 10% of AGI, if you have an average medical school debt and are making a resident's salary, your payment will be less than your interest accrued each month. PAYE does nothing to cap your interest.
Further, implying that Doctors are willfully ignorant of loan financing options is...interesting. All Federal borrowers are required to complete exit loan counseling upon graduation from medical school. That counseling includes discussion of the various repayment options (Standard, Extended, ICR, IBR, PAYE, and forbearance).
Further, implying that Doctors are willfully ignorant of loan financing options is...interesting. All Federal borrowers are required to complete exit loan counseling upon graduation from medical school. That counseling includes discussion of the various repayment options (Standard, Extended, ICR, IBR, PAYE, and forbearance).
Medicine is a very wide profession in itself, with lots of options for specialization in something that interests you somewhat. On top of that I am sure it is not too difficult to go into research that is only slightly related to medicine (I personally know a couple of people doing this).
Another explanation of the suicide rate: doctors have access to means and methods of completing suicide. They are also aware of techniques that make completed suicide more or less likely.
A consideration of the economics would suggest that any doc who trained in the last two decades isn't in it for the money - the ROI on an MD is far less than most other advanced degrees. If we wanted to be wealthy, with the grades and letters required to get into med school in the US, most of us could readily have chosen other professions. (Heck, some even walk away from startups, believe it or not).
My impression as someone in practice for more than a decade, who cares for a large number of docs, and has run a large clinic: It's really not the reimbursement. It's the combination of dealing with payers determined to deny treatment, massive requirements in terms of documentation and ongoing accreditation, and - in particular - constant pressure to spend less time with more patients. Then, we read posts like these which buy into conspiracy theories about how we're out to poison patients with expensive medications to line our pockets. The time problem in particular afflicts primary care docs the most, but even the surgeons complain about it.
As far as ACA and its impact, there's no question it's a hack (and not a good one) - most economists not on the far right agree single payer would be optimal - but under the political circumstances, it was probably the best we could get.
Regardless, we'll move to a system where the majority of care isn't delivered by docs. Then we'll complain about it. But, it will be more cost-effective.
A comment here mentioned the absolute number of physicians in the United States, so I did some Googling and found a convenient website showing the number of physicians per 10,000 population in different countries. (The primary source for these data is studies by the World Health Organization, but the WHO website is not quite as user-friendly.) Note that in some countries the level of training and clinical experience to become a physician is much higher than in other countries.
http://kff.org/global-indicator/physicians/
http://kff.org/global-indicator/physicians/
Suicide rates are about 17.7 per 100,000 for men and 4.5 per 100,000 for women, and 11.3 overall. There are about 535,000 male physicians in the U.S., and 234,000 female physicians, and 66,000 of unreported gender. So the expected number of suicides would be 113 rather than 300.
I don't have a citation handy, but it's my understanding that doctors attempt suicide at a rate less than the general population but when they do make a suicide attempt they are more likely to succeed.
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I like you. Isn't suicide also extremely rare among adults with more than a bachelor's?
> In fact, physicians are so bummed out that 9 out of 10 doctors would discourage anyone from entering the profession.
OP missed a perfect headline opportunity: "9 out of 10 doctors recommend not becoming a doctor."
But seriously, we wonder what's wrong with healthcare. I seriously believe it's because of the lawsuit-happy nature of patients nowadays. Yeah, something could go wrong during your surgery, or your diagnosis for that matter. But that's an inherent risk in having something wrong with you that you need checked out.
OP missed a perfect headline opportunity: "9 out of 10 doctors recommend not becoming a doctor."
But seriously, we wonder what's wrong with healthcare. I seriously believe it's because of the lawsuit-happy nature of patients nowadays. Yeah, something could go wrong during your surgery, or your diagnosis for that matter. But that's an inherent risk in having something wrong with you that you need checked out.
Anecdotally, nonpayment is a much bigger problem than lawsuits. I remember listening to the CEO of Carle, a large Central Illinois healthcare chain, talking about this, and saying that "we expect to collect 60 cents of every dollar we bill".
It's a revenue optimization problem -- the goal is to collect the most revenue overall. Set prices too high and people/insurance goes elsewhere, too low and you leave money on the table the org could use to cross-subsidize non-payers.
It's a revenue optimization problem -- the goal is to collect the most revenue overall. Set prices too high and people/insurance goes elsewhere, too low and you leave money on the table the org could use to cross-subsidize non-payers.
> "We expect to collect 60 cents of every dollar we bill"
you have to be careful with that statement since it can be a clever way of talking about what insurance agrees to pay with the chain versus the "retail" rate the doctors charge.
my father is a general practitioner and I was always amazed when he started saying about 25 years ago that he wouldn't let me become a GP if I had gone into medicine. and this article covers all of his concerns well.
malpractice is a big part of the issue and it varies state to state. for example, in pennsylvania malpractice insurance is amazingly expensive. and people sue all the time, which is sad unless it is gross incompetence, since every doctor I've met is trying their best.
you have to be careful with that statement since it can be a clever way of talking about what insurance agrees to pay with the chain versus the "retail" rate the doctors charge.
my father is a general practitioner and I was always amazed when he started saying about 25 years ago that he wouldn't let me become a GP if I had gone into medicine. and this article covers all of his concerns well.
malpractice is a big part of the issue and it varies state to state. for example, in pennsylvania malpractice insurance is amazingly expensive. and people sue all the time, which is sad unless it is gross incompetence, since every doctor I've met is trying their best.
so what you're saying is no matter how the healthcare system is designed, the healthy (or maybe just wealthy?) always end up paying for the rest?
In practice, this is exactly what happens. Many hospitals have a mandate not to deny treatment, so many people come to the hospital (especially to the emergency room, where care is known to be more expensive than non-emergent settings) and simply don't pay after the fact.
I don't know how to solve this, or whether it's fair, but it's pretty universal if you talk to people in healthcare billing.
I don't know how to solve this, or whether it's fair, but it's pretty universal if you talk to people in healthcare billing.
You'll find this is happening in many industries. Despite that it lowers productivity and increases costs.
The problem is that management is filled with perverse incentives. It looks good on the books to have fewer employees - until you realize you have highly trained specialists spending hours per week working on paperwork or rushing their actual job and increasing long-term costs.
The problem is that management is filled with perverse incentives. It looks good on the books to have fewer employees - until you realize you have highly trained specialists spending hours per week working on paperwork or rushing their actual job and increasing long-term costs.
In Canada our GPs are paid approximately $31 for a regular visit. They pay their overhead out of this $31 and still typically keep 65-70% of their billings.
It's amazing that the billing costs in the US are a factor of magnitude higher.
It's amazing that the billing costs in the US are a factor of magnitude higher.
I paid cash for a time for my medical care, and GP visits for regular illness or annual physical generally were $70 to $80.
I wonder how salaries for nurses and doctors compare in the US vs Canada. Do you happen to have any data on that (or know of a good government source for it in Canada)?
I know that compared to much of first world Europe, our nurses and doctors often make two to four times as much as their counter parts there. Wonder if that's true compared to Canada as well.
I know that compared to much of first world Europe, our nurses and doctors often make two to four times as much as their counter parts there. Wonder if that's true compared to Canada as well.
In my province of BC, all payments from the Medical Service Plan (MSP is our public insurance system which costs Canadians a maximum of $65/mo or as little as $0 for low income individuals) publishes all annual payments to physicians:
http://www.health.gov.bc.ca/msp/legislation/pdf/bluebook2012...
The average for Family Doctors is around $240,000 CAD and for specialists is about $430,000.
Average registered nurse salary in BC is about $61,000 CAD.
http://www.health.gov.bc.ca/msp/legislation/pdf/bluebook2012...
The average for Family Doctors is around $240,000 CAD and for specialists is about $430,000.
Average registered nurse salary in BC is about $61,000 CAD.
If you take away the need to pay back six-figure student loans and tens of thousands each year for malpractice insurance - then much more of that money stays in the doctors pocket.
Doctors in Europe live quite well, and don't have as ridiculous workhours as the numerous USA examples listed, or the suicide problem.
Doctors in Europe live quite well, and don't have as ridiculous workhours as the numerous USA examples listed, or the suicide problem.
Tuition at UBC med is $16,000 per year and many students qualify for up to $100,000 in bursaries. After 4 years of academics there is a paid residency. It's not a huge salary (~$50k) but enough to avoid going into debt.
What is the malpractice liability exposure for a Canadian doctor? In the US, malpractice insurance is a huge expense for most doctors, and for some specialties (e.g. obstetrics) it's very close to prohibitive.
Canadian doctors are protected taxpayer subsidized insurance called CMPA. Typical cost is 1/10th of what it costs in US.
http://en.wikipedia.org/wiki/Canadian_Medical_Protective_Ass...
http://en.wikipedia.org/wiki/Canadian_Medical_Protective_Ass...
Funny that the article links to http://www.dailymail.co.uk/news/article-2600319/Medicare-dat... which references the top paid doctors by medicare... I read an article last week saying that this data would be misinterpreted, as a lot of the "top paid" doctors actually are just like whole departments using the lead physician's billing code, and they don't actually get any of that money - and here we are.
There's no evidence that the profession causes doctors to commit suicide. It's not a stretch to hypothesize that people accepted to medical schools are self selecting for perfectionism and bipolar disorders.
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"Just processing the insurance forms costs $58 for every patient encounter, according to Dr. Stephen Schimpff, an internist and former CEO of University of Maryland Medical Center who is writing a book about the crisis in primary care."
I'm curious how the arithmetic on that works out. The median pay for medical assistants is $14.12/hour [1], which means that assuming the assistant is handling the insurance form, that works out to just over 4 hours per patient encounter. There might be some fixed costs (filing space, for instance, is not free), and some costs associated with communicating with the insurance company, but it's really not obvious to me how any of those can add up to $58/visit.
[1] http://www.bls.gov/ooh/healthcare/medical-assistants.htm
I'm curious how the arithmetic on that works out. The median pay for medical assistants is $14.12/hour [1], which means that assuming the assistant is handling the insurance form, that works out to just over 4 hours per patient encounter. There might be some fixed costs (filing space, for instance, is not free), and some costs associated with communicating with the insurance company, but it's really not obvious to me how any of those can add up to $58/visit.
[1] http://www.bls.gov/ooh/healthcare/medical-assistants.htm
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Cost of employing someone is more than just their hourly rate * hours worked. For example, at one job where I was paid $26/hr, my time was billed at $48/hr--- and this was for a government agency internally billing itself, so there was no profit margin involved, just the cumulative cost of wages, benefits, and associated overhead.
I'll bet that the half of doctors who want out of the profession, are the ones who are exploited by the other half. Naturally the profession wants us to see doctors as selfless workers saving our lives, not as rentiers who are ruining us.
did this article "borrow" from the air talk segment this afternoon on the radio: http://www.scpr.org/programs/airtalk/2014/04/15/6508/
And now that Medicare payments will be tied to patient satisfaction—this problem will get worse.
That just sounds crazy. Can you imagine if your car insurance had to pay less if you complained about your mechanic? Not to mention that medicare is for the elderly who tend to have a lot to complain about anyway.
Can I pay my taxes based on my satisfaction with the government?
That just sounds crazy. Can you imagine if your car insurance had to pay less if you complained about your mechanic? Not to mention that medicare is for the elderly who tend to have a lot to complain about anyway.
Can I pay my taxes based on my satisfaction with the government?
Friendly warning, the article quotes Malcolm Gladwell uncritically.
True, but amazingly enough this is one of the two times per day when Gladwell's stopped clock happens to coincide with the actual time.
For fun, reread this article with "doctor" universally replaced by "teacher", and note the similarities. Then note that the doctor is probably taking home 4-5x the cash.
There's also this: http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-sh...
There's also this: http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-sh...
After 1.5x-2x the schooling, 3x-5x the apprenticeship period, and around 6x the debt.
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Making it easier to become a doctor would improve things immediately (especially given the recent research that makes it clear that nurse practitioners do just fine).