[tdees40]

The biggest problem is just the AMA. They limit the number of doctors in America, so there are just too few. This drives up the salaries for the few doctors who live the tell the tale (but certainly don't want to go into primary care, when other more lucrative jobs are on offer), and drives up the hours for everyone.

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).

[riahi]

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

[Retric]

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.

[riahi]

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...

[Retric]

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.

[riahi]

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.

[Retric]

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.

[jjoonathan]

> 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.

[riahi]

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.

[jjoonathan]

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.

[mudil]

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?

[Shinkei]

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.

[mudil]

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.

[FireBeyond]

"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.

[thecage411]

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?

[chimeracoder]

> 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

[mudil]

The Association of American Medical Colleges (www.aamc.org) sets number of medical students, and not AMA.

[riahi]

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.

[autokad]

last year there were more grads than residency spots.

[sizzle]

http://www.scpr.org/programs/airtalk/2014/04/15/6508/ can you comment on this radio segment please?

[GFK_of_xmaspast]

Bet you're pretty happy to have the government there with barriers to entry for your profession tho, keeping supply down.

[zavi]

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.

[araftery]

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.

[karmajunkie]

I don't know any cardiologists who would perform that kind of surgery on a 90yo.

[pessimizer]

Phil Ochs - A.M.A. Song

https://www.youtube.com/watch?v=6lkvswrSRAE

[LiweiZ]

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"?

[rdmcfee]

Coming from the healthcare marketing field, I can tell you there are many doctors who are looking for more patients. Especially specialists.

[wehadfun]

could you expand

[FD3SA]

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)

[msandford]

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.

[SapphireSun]

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.

[msandford]

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.