[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.

[autokad]

you're not required to get an undergraduate degree. you are only required certain courses and the MCATS.

[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.

[riahi]

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.