Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools, which also allows the existing schools to crank costs to astronomical levels (“don’t worry, you’ll make enough to pay it back”).
One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things. Dentists, a similar profession, is going apeshit that states are trying to let specially licensed assistants (but non-DMDs) do slightly more advanced work like fill cavities.[0]
The entire health system from top to bottom would benefit immensely from free market forces.
> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools
They do not. You may be confusing the AMA (which less than 25% of doctors even belong to) with the AAMC. The latter does cap the number of medical school positions nationwide, but they've also made a concerted effort over the last ten years to increase that number steadily.
But even if they eliminated that cap entirely, it wouldn't matter, because the number of medical school slots isn't a bottleneck for the number of practicing physicians. The number of residency slots is, and the funding gap for that comes from Medicare, which is responsible for funding them.
Unless more residency programs are funded, increasing the number of medical school positions would simply increase the number of people who have medical school debt and aren't licensed or trained to practice medicine, which would be even worse,
> which also allows the existing schools to crank costs to astronomical levels (“don’t worry, you’ll make enough to pay it back”).
Hardly - in fact, there's already been significant downward pressure on these, because the debt level is already at the tipping point. Today, the typical person who enters medical school can expect to pay off their medical school debt in their 40s. That level of debt load is already having a negative impact on qualifications for medical school applicants (who wants to be past child-bearing age by the time they've paid off their debt, when they can just go into another better-paying field without any of that)?
> In recent years, the number of medical residents has become so restricted that even the American Medical Association is pushing to have the number of slots increased. The major obstacle at this point is funding. It costs a teaching hospital roughly $150,000 a year for a residency slot. Most of the money comes from Medicare, with a lesser amount from Medicaid and other government sources. The number of slots supported by Medicare has been frozen for two decades after Congress lowered it in 1997 at the request of the American Medical Association and other doctors’ organizations.
I was confused by that part too because the article goes on to say teaching colleges "have an incentive to offer residencies in specialties from which they can get the most revenue per resident."
My guess is the 150K number ignores the revenue contribution of the residents (which must be significant because they carry out a significant amount of the work that requires a doctor at a hospital)
I did a google search and found one article that seems to confirm this: "Whether the programs are ultimately costs or moneymakers for hospitals is mostly unknown. Expenses tied directly to the programs are tracked, but overall cost-benefit accounting that would take into account such things as savings or lower medical bills for patients from the use of lower-paid residents instead of practicing physicians isn't done." http://www.modernhealthcare.com/article/20150719/news/307199...
The argument that federal funding is the only way to create more educational "seats" for doctors seems strange since the article claims they are paid much more than other fields, and is not really laid out well in the article.
> but overall cost-benefit accounting that would take into account such things as savings or lower medical bills for patients from the use of lower-paid residents instead of practicing physicians isn't done
This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital. From an accounting or business perspective, it's pretty clear that residency programs don't make money for hospitals.
An easy way to reason about this is to remember that nothing's stopping hospitals from opening up residency slots that they self-fund. If residency programs predictably broke even, you'd expect them to do that. Except, almost no hospital does this, because the programs don't predictably break even - in fact, they pretty predictably lose money.
It's not that strange. Medicare has a physician fee schedule (PFS). Hospitals don't receive a PFS payment for services provided by a resident, unless a teaching physician is physically present during the key portions of the service, or under certain primary care exceptions. I'm not sure how private insurance companies do it, but I wouldn't be surprised if their rules weren't similar.
A similar thing is happening in the legal field. Clients wont pay for work done by first or second year lawyers, so large firms are cutting back entry level hiring and many smaller firms have stopped hiring entry level lawyers entirely. Thus you have a bizarre situation where there is a huge oversupply of JDs, but private-practice associate salaries continue to go up because there is a limited supply of experienced attorneys.
They don't receive the PFS payment, but they certainly do for room fees, imaging, labs and other diagnostics, not to mention medications.
And the patient is still tended to by nurses, who do absolutely generate revenue for the hospital.
While they don't get a PFS payment, we also can't provide that Medicare pays for the residency and then everything else is a charity case for the hospital.
That argument doesn't respond to whether it's "strange" that residents are unprofitable. It's just the unsupported assertion that certain unquantified ancillary payments will exceed the unquantified costs of employing and supervising a resident. But clearly they don't, or else hospitals would create more resident positions.
The charge is that hospitals are not creating more residencies in order to collude to drive up doctor salaries. Even if residents were profitable, but less profitable than experienced physicians, it would still be a rational business decision—rather than improper collusion—to hire physicians instead of residents.
That explanation makes sense (except partially for the sibling comment's point) but there is still something strange there.
In market terms, this is clients saying entry-level workers with lots of education provide zero value, or the risk outweighs the benefits. If that's true, it means that people need training until 30-somethings before they are valuable to society. Or our education system is broken.
Or it's not true and it's market manipulation. Given the choice between "no service" and "pay a fair entry-level price", many people will pay something.
And if/when they cann't get a job, the state then revokes their credentials. Hilarity ensues.. Oh did I say hilarity? I meant the spiral of loss of job/homelessness/garnishment/destitution. And it's then illegal to use the credential to try to make money to recover from.
Talk about being sold a bill of goods - Come get a degree from here, and if you can't find a job, we'll garnish you and remove your ability to use the degree you're being garnished for.
Not if the government already pays for it. Why open up self-funded slots and show that the government doesn't need to pay for it? If you make a small profit, you are just putting the other pure profit slots at risk...
> Not if the government already pays for it. Why open up self-funded slots and show that the government doesn't need to pay for it? If you make a small profit, you are just putting the other pure profit slots at risk...
I somehow doubt Hospital A, which has zero residency slots and receives zero residency funding from Medicare, cares if Hospital B down the road somehow loses their subsidies.
There is no "pure profit slot". Residency programs do not make money for the hospital. If they did, hospitals that do not have residency programs would open self-funded residency programs, and/or hospitals that already do have residency programs would expand theirs.
It is possible that if the AMA or others is intentionally restricting the supply then any hospital that started its own residency could have trouble hiring regular doctors. I am not claiming this is the case, but it is one reason that hospitals might avoid something that the free market would indicate.
Hospitals do not do their accounting in a normal way. When you or your insurance gets a bill, the doctors are often listed separately. In other words, patients pay for them directly for services, they are not paid as employees of the hospital. That means for residents, someone's got to pay for them. They are not seen as lower cost labor because doctors are not accounted for as high cost labor. I'm not sure how it's done, but it's not the same as interns in engineering.
> Are you sure it's not just a case of Hollywood style accounting?
Yes, for the reason I said:
> An easy way to reason about this is to remember that nothing's stopping hospitals from opening up residency slots that they self-fund. If residency programs predictably broke even, you'd expect them to do that. Except, almost no hospital does this, because the programs don't predictably break even - in fact, they pretty predictably lose money.
Even if you don't trust the accounting numbers, you have to trust the overall (lack of) incentive for hospitals to create self-funded programs.
I agree with this logic about "if residency programs predictably broke even" but I don't see any concrete support for that in the article. They don't have an accounting of revenue per doctor or at least the article has not shown one.
Saying the benefit is social benefit doesn't help here, obviously it is it's a hospital, there needs to be revenue numbers in the mix to talk about breaking even.
re-reading your comment "This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital." I think perhaps you do not understand what residents do. Residents handle a portion of the patient workload. They provide direct economic benefit to the hospital by handling patient workload at a lower salary than more senior doctors. There is a hierarchical system by which work is reviewed by more senior doctors but this is used in all hospitals regardless of whether there are residents. The economic benefit to the hospital is that residents do the work for lower salary than doctors. Putting that into dollar terms is what this article has failed to do, likely because the data to do so is not there.
> I think perhaps you do not understand what residents do.
Given my background, I understand exactly what residents do.
My point still stands. Even if you don't trust the accounting numbers, you have to look at the end result.
Let's assume that residency programs are, at the margin, profitable for hospitals. Let's also assume that hospitals like profit.
- The statement "residency programs are profitable (at the margin) for the hospital" is logically equivalent to "increasing the number of residency slots (or programs) would be profitable for the hospital".
- If increasing the number of residency slots (or programs) would be profitable for the hospital, there would be more of them.
- However, there aren't - the number of self-funded residency programs has been (essentially) zero for decades.
Therefore, one of our two assumptions must be wrong. Either residency programs are not, at the margin, profitable hospitals, or hospitals just like turning down profit.
"residency programs are profitable (at the margin) for the hospital"
No, there are many options between 'profit' and 150k costs.
The question is can Medicare increase the number of residency's without increasing Medicare's costs. And because of the excessive number of specialists with higher associated costs the answer to that is clearly 'Yes'.
Thus, the cost of a residency slot is not inherently negative 150,000$/year. It's very possible for residency's to break even without hospitals to have any incentive to implement them, further that 150k/year provides profit even with the current mix.
> No, there are many options between 'profit' and 150k costs.
Why are you bringing $150,000 into this? That's the median debt load of a resident - it has nothing to do with what a hospital makes.
> The question is can Medicare increase the number of residency's without increasing Medicare's costs. And because of the excessive number of specialists with higher associated costs the answer to that is clearly 'Yes'.
I... don't even understand what point you're trying to make here. The point is that hospitals cannot generally provide self-funded residency programs, because they lose money on those programs.
Yeas, it's true that not all residency programs cost the same amount - some fields are more expensive than others. But it's not like we're trying to optimize for the total number of residents in the system at any time; the reason we have more expensive programs like neurology is because we need neurologists. Yeah, we could "save money" by training them in EM instead, but then that'd just mean an even greater shortage of neurologists (and even higher market wages for neurologists).
Because 150k/year is the current subsidy per resident. People may reasonably not want to spend more money on this, but it's hard to argue with spending money more efficiently.
You're demonstrating that hospitals do not consider residency programs to be worth funding, but you aren't helping us understand why, which is the far more interesting question.
There are multiple factors at work, only one of which is funding.
Residents are required to handle a minimum number of a large variety of cases by the time they graduate, in order to guarantee that they've seen a representative sample of cases in their field and have knowledge of all of them. E.g. a neurosurgery resident might need to do (completely fabricated numbers) 30 open vascular cases, 50 spine fusions, 40 tumors, etc. This is probably the primary limiting factor for specialist surgery residencies; these residents are profitable (they can handle the bulk of most simple cases fairly autonomously once they're a couple years into their training, and they stick around for 5-7 years), so many hospitals would like to hire more of them, but there are simply not enough patients with the necessary conditions for them to add more trainees.
For non-surgical residencies, the residencies are much shorter (so you have less time from highly-skilled residents), and the residents are less profitable, so funding is a significant limitation.
It's also important to note that residents are competing with mid-levels in the "less expensive practitioners" category, and mid-levels are a far better deal for the hospital in most specialties. They're somewhat more expensive in terms of raw salary, but they remain mid-levels, which means they have the time to develop near-perfect competence at the things they do handle, and they don't leave just when you've trained them up. A few good mid-levels make all the difference in keeping a department running smoothly.
> You're demonstrating that hospitals do not consider residency programs to be worth funding, but you aren't helping us understand why, which is the far more interesting question.
Because they... don't make money if they do?
I don't know how to make it any clearer. The costs of providing additional residency slots (paying resident salaries, paying additional attending salaries, paying taxes, paying insurance, etc.) don't bring in enough additional revenue or offset enough other costs to be worthwhile.
It's not particularly complicated math - it's the same arithmetic a McDonald's franchise owner has to do to decide whether to hire another person to flip patties, just with bigger numbers attached to it.
The way to make it clearer would be to discuss specifically why the services rendered by residents are not valuable enough to cover their costs.
A concrete example: I've had a resident do a checkup while I was in the hospital. If they hadn't done it, a fully trained doctor making a lot more per hour would have needed to. Did the hospital lose money on that checkup? If so, wouldn't they have lost more money if the fully trained doctor would have done it? If they make money on that sort of thing, what kinds of things are the opposite?
I don't know how it works, I've only ever been a patient. It seems like you might know, so I'm asking you how it works. Do you see how "they don't make money" is really not an answer?
> A concrete example: I've had a resident do a checkup while I was in the hospital. If they hadn't done it, a fully trained doctor making a lot more per hour would have needed to.
You're assuming that, in the absence of the resident, they'd be hiring an additional attending physician. In reality, they'd just have a smaller staff, and you'd have to wait longer, the doctor would have to work longer/harder/faster, etc to cover the same patient load.
Hiring a resident doesn't bring in additional revenue. Insurers don't reimburse more per patient just because an additional physician was involved. Hiring a resident doesn't bring more patients in the door, because that's not the bottleneck for hospitals anyway. It does increase costs, because it's an additional person on staff - they have to pay them an extra $51,000/year, plus 25% of the cost of an additional attending physician to supervise them (and three other residents), plus taxes, plus health insurance, plus insurance to practice medicine, plus licensing fees, and so on.
> Did the hospital lose money on that checkup?
Probably not, unless you're on Medicare or Medicaid - in which case, yes, they do lose money on you on a per-patient, per-service basis.
Great point about how it isn't a question of the same service at a different price but of avoiding poor service which would otherwise have to be accepted because of the distorted market for health care that makes it hard to effectively punish poor service.
Are residents that much less effective? Do they require so much supervision?
If residents are just cheaper doctors, then hospitals would optimize for a high resident:attending ratio.
So what is it? As far as I know, in hospitals residents are really cost effective doctors. Yes, sure, they don't do the big fancy operations, but they are very capable.
It might be that hospitals have other parameters to factor in. Maybe if there would be too many residents compared to regular doctors, people would flock to other hospitals. And so on.
Oh nice! This is what I'm interested in! What kinds of things can they and can't they do without supervision? What is common in practice? Is there a good place to read about how this all works?
Then ... that means the supervision of residents is not working. That basically means, it's useless. (Since it'd make sense to apply the maximum amount of supervision when a resident is new and as the resident gains trust, decrease it.)
Or of course it means, that attending doctors do a constant amount of (insufficient) supervision, or they ramp up supervision after someone screws up... :|
Residents are cheaper doctors, but they are cheaper because they are less trained, less experienced doctors. They aren't equally-capable doctors with lower salary demands.
Sure, but lots of real problems require more than the skill level expected of residents, if nothing else to have reasonably justified confidence that the problem isn't one which requires more specialized attention.
Some hospitals especially teaching hospitals are non-profits. So I don't think the profit motive is sufficient justification. I think it is more likely a capacity problem.
> Some hospitals especially teaching hospitals are non-profits. So I don't think the profit motive is sufficient justification. I think it is more likely a capacity problem.
Once again, "non-profit" or "government agency" doesn't mean "no profit motive". The profit motive affects all players.
This is not-even-wrong levels of reasoning here. Personally, your comments on this subthread, and the confidence with which you've delivered them, will stay with me for a long time, and whenever I find myself nodding along with something that is facilely convincing and authoritatively stated, I'll think back to your posts and remember to be a bit more skeptical, a bit more discerning. For that, I thank you.
For the rest, well, I can't be as laudatory.
>This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital. From an accounting or business perspective, it's pretty clear that residency programs don't make money for hospitals.
"Medicare pays for services furnished in teaching settings through the Medicare Physician Fee
Schedule (PFS) if the services meet one of these criteria:
1 They are personally furnished by a physician who is not a resident
2 They are furnished by a resident when a teaching physician is physically present during the critical
or key portions of the service
3 They are furnished by a resident under a primary care exception within an approved Graduate
Medical Education (GME) Program"
Crucially, there is no distinction between how much a hospital can charge for services an attending working alone has delivered (1), and how much it can charge for services a resident has delivered, as long as the attending signs off on it (2). You might naively suppose that the "physically present" part of (2) means that both attending and resident are in the room for the dx differential, and through a Socratic back and forth they jointly treat the patient, and you'd be mistaken. And of course, if you're in your final year of residency, or you're a Chief Resident, the oversight an attending will choose to exercise will be perfunctory. Read more about just how much (or little) it take to technically comply with these rules: http://www.hcpro.com/HIM-283624-8160/Coding-billing-and-docu....
Then reread this short, moving piece published in the NYT mag for an illustration: https://www.nytimes.com/2017/10/24/magazine/the-rules-of-the.... As a resident in his third year out of medical school, how was it that the author was able to essentially run his own service if residents are really just stumps of malformed medical errata, all but useless unless they have their hands held by an attending?
Or just ask yourself: how is it that you can give a hospital a senior resident in radiology, or anesthesiology, or dermatology, who is just months away from demanding 350k+ on the job market, cap the resident's salary at 60k or less, and have the ability to work them for up to 80 hours, how is it that a hospital fails to make money here?
Sure, you can go through all the malpractice costs that have to be priced in, the free cafeteria food, the upkeep of the residents lounges. Sure, and Google spends a ton on the great insurance and fun perks it offers too. Somehow they manage to make sure they don't lose money on their employees.
>An easy way to reason about this is to remember that nothing's stopping hospitals from opening up residency slots that they self-fund. If residency programs predictably broke even, you'd expect them to do that. Except, almost no hospital does this, because the programs don't predictably break even - in fact, they pretty predictably lose money.
An even easier way to see you're making things up is to realize that medical residents can earn up to $100+/hr by moonlighting[0], all while they're apparently causing their home institutions to "predictably lose money" while earning an 10% hourly rate.
[0] https://www.staffcare.com/medical-moonlighting-for-residents... and the doctors discussed in this article aren't getting these opportunities after some long rigorous period. One of them was in his second year of residency once he decided to start moonlighting, literally a year out of med school. Again, this goes to show residents are pretty valuable right off the bat, are (overall, generally speaking) a bargain for their home institutions, and only get more financially profitable as time goes on.
> This is not-even-wrong levels of reasoning here. Personally, your comments on this subthread, and the confidence with which you've delivered them, will stay with me for a long time, and whenever I find myself nodding along with something that is facilely convincing and authoritatively stated, I'll think back to your posts and remember to be a bit more skeptical, a bit more discerning. For that, I thank you. For the rest, well, I can't be as laudatory.
Look, I could respond to each of the points you bring up in turn, and explain how it's actually quite easy for those individual statements to be true but still impossible for most residency programs to turn a profit.
But I've been on Hacker News long enough to know that, when someone begins a lengthy comment with an insult that underhanded and that personal, there's no way that they're in the mood for a good-faith discussion, and attempting to engage further in a reasoned debate is a recipe for frustration.
I see you're a relatively new commenter here, so I'll just say: on the off-chance that this interpretation is wrong, and you were looking to have a good-faith discussion on the topic, I'd recommend next time leaving off the personal insults.
Hmm I don't read the quoted text as a personal attack (snarky, okay fine) and I certainly don't see anything "underhanded" about what I posted, but if you think I'm posting in bad faith (all too endemic online, unfortunately), I don't think you can be faulted for not wanting to engage. That's certainly fair. And honestly, if you felt it was personal, I can apologize. Sorry.
That being said, you've made ~15 comments itt, in which you're variously appealed to your own authority ("Given my background, I understand exactly what residents do". Actually, I don't know any medical resident who could make such a statement, given how broad and diverse the fields that postgraduate medical training encompasses are, but sure.), and made repeated statements about what residents are and aren't capable of, all seemingly without citation or reference.
All of which is to say, I think if you could have made the case that the facts and figures posted above, and in this thread, are perfectly compatible with your contention about medical residents being a net financial drain for hospitals and academic centers, you would have done it by now. In that sense, I agree further debate would probably not be very productive.
I was confused by that part too because the article goes on to say teaching colleges "have an incentive to offer residencies in specialties from which they can get the most revenue per resident."
One way this makes sense is how Medicare pays teaching hospitals. A hospital gets $X for a procedure code. If they are a teaching hospital, they get $X+2% (can't remember the exact bump but it's relatively small).
The more expensive the procedure, the bigger the bump for being a teaching hospital. That's the incentive to get residents practicing expensive specialties.
Does it cost $150k/yr of actual concrete costs or does it cost $150k/yr because that's what they're used to receiving and they want the gravy train to continue?
> Does it cost $150k/yr of actual concrete costs or does it cost $150k/yr because that's what they're used to receiving and they want the gravy train to continue?
There's no "gravy train" - residency programs are not self-sufficient without this money from Medicare. It costs a lot to train a doctor, and that's even paying doctors less than minimum wage in many areas[0].
If they were, hospitals would be free to open as many residency programs as they wanted without Medicare's subsidies, except they generally don't. There are very few non-Medicare funded residency positions, and they tend to be very special cases in obscure regions.
[0] The average resident salary comes out to $12.25/hour, which is literally less than minimum wage in some areas.
The fact that residents aren't paid much by the hospitals doesn't mean that the hospitals aren't making a net profit, it would normally be evidence that it is profitable for the hospitals. Even working 100 hour weeks all year that salary would only come to $65k leaving another $85k to be accounted for. Some of that is benefits and some is the time used by doctors to train the residents and by hospital administrators to oversee them. But the residents also do work for the hospital that would otherwise have to be done by doctors or nurses. So I'd expect that they are profit centers for the hospital but I'm willing to be convinced otherwise if someone can come up with numbers.
The hospital doesn't directly receive money for work done. In many cases they get paid for a procedure done by a doctor, but don't get paid for the exact same procedure done by a resident, so it matters who does the work because that directly affects revenue.
They still bill a healthy profit on the procedure done by the resident by way of room fees, equipment fees, lab fees, imaging fees, diagnostic fees, nursing care fees, PT fees, and so forth.
> You have too much faith in the free market. There are all kinds of things that could cause hospitals to not hire more residents.
So far, in this entire thread, nobody has been able to offer one explanation that doesn't ultimately boil down to either "hospitals don't actually want to increase their profit".
Here's a purely economic argument: if there is an expected profit from self-funding but it is less than that from receiving the Medicare funding, and there is a perception that the Medicare funding only exists because the argument has successfully been made that self-funding is not profitable, then making the smaller profit from self funding would put at risk the possibility of receiving the larger profit through Medicare funding, and administrators might determine it is not worth the risk.
Here's a practical argument: perhaps combined with the uncertainty of the above calculation, administrators are humans, for whom the inertia of the status quo "this is just how it's done" is powerful.
That's all speculation, just like your purely economic argument is just speculation. What would provide actual insight would be some understanding of why residencies are unprofitable, if it's true that they are.
> Here's a purely economic argument: if there is an expected profit from self-funding but it is less than that from receiving the Medicare funding, and there is a perception that the Medicare funding only exists because the argument has successfully been made that self-funding is not profitable, then making the smaller profit from self funding would put at risk the possibility of receiving the larger profit through Medicare funding, and administrators might determine it is not worth the risk.
No, that doesn't add up. Hospitals only receive $80,000 per resident from Medicare. If residency programs were profitable at level P, they could increase them from N residents to M residents, where (80000 + P)N < P M[0].
Furthermore, hospitals that currently don't receive any money from Medicare would simply expand self-funded programs, because they wouldn't be losing anything by doing so[1].
There's also no way that hospitals would be doing so much to preserve a mere $80,000 stipend, because increasing the number of physicians is in their best interest - it allows them to decrease their expenses (physician salaries) in the long run.
> That's all speculation, just like your purely economic argument is just speculation.
No, it's not speculation; it's exactly what hospitals, government employees, elected officials, and industry analysts have pretty much all been saying for decades. And it's supported by the actual evidence at hand, including all of the financial figures that they publish.
[0] Of course this doesn't work if P is a decreasing function of either N or M, which is the entire point - it is decreasing, and in fact, is already negative for the current value of N.
[1] Except, of course, if P is negative - which it is.
As we've gone on in this thread, you've provided an increasing amount of actual details on how this works (thanks!) and now express knowledge of external sources that back this up (though citations to those would be useful). Your initial claim read to me as just, "it's simple free market incentives", which is not the same as the more full picture we've gotten as we've gone on, which now includes more analysis of how the Medicare incentive might play out for different decision makers. I feel like that was peoples' point (at least it was mine): an indirect "follow the money and don't worry about why it works the way it does" argument was not sufficient. So thanks for taking the time to fill in a bunch of gaps!
I still think you may be downplaying the impact of the risk calculation hospitals have to make regarding their ability to receive the stipend now or in the future. It may be only 80k, but clearly that 80k is enough to incentive many hospitals to have residents, so it must be material to them to some extent.
Your point about increasing supply of doctors being in hospitals' interest in the long run is interesting, but this is the same training conundrum everyone has: it is often difficult to make the decision to invest in the near term when the payoff is not realized until much later.
I'm sure you're right about all this in general - training people is a tricky and expensive problem for every industry.
Not really, it's just that most people here are simply relying on the very good heuristic that most markets, government (mis-)managed or free, are chock-full of perverse incentives.
In this case, the likely culprit is that accepting residents for less than $150k/yr in sponsorship sabotages their ability to claim that the fair market value of residency training is $150k/yr, and they've calculated that the marginal benefit from accepting a single resident at a lower cost does not outweigh the risk of being forced to provide the same discount to their existing residency positions.
> In this case, the likely culprit is that accepting residents for less than $150k/yr in sponsorship sabotages their ability to claim that the fair market value of residency training is $150k/yr, and they've calculated that the marginal benefit from accepting a single resident at a lower cost does not outweigh the risk of being forced to provide the same discount to their existing residency positions.
So you're saying that hospitals which receive no funding from Medicare eschew this potential profit center (a residency program) so that their rival hospitals can keep receiving funding from Medicare and make an even larger profit?
This makes even less sense than the other theory being proposed, which is that hospitals are eschewing short-term profit in order to increase the expenses they have to pay in the long-term.
> they've calculated that the marginal benefit from accepting a single resident at a lower cost does not outweigh the risk of being forced to provide the same discount to their existing residency positions.
only holds up for schools with existing residency positions, which there are many without. If a residency were profitable without the subsidies, one would expect to see those non-teaching hospitals launching residency programs. Especially so because they don’t have to worry about threatening the subsidies which they aren’t receiving.
> So far, in this entire thread, nobody has been able to offer one explanation that doesn't ultimately boil down to either "hospitals don't actually want to increase their profit".
My wife is in med school, here's my argument based on what I see in her education.
Training doctors is fucking hard.
Profits and business and all of that jazz plays a part, sure.
What I've seen is none of that really matters because hospitals can't even get enough qualified staff to support more residency positions. It takes a lot of work for a senior physician to include a medical student or resident in their daily activities. On top of already having a stressful job, dealing with naivety and inexperience of young doctors makes it very unattractive for doctors to want to participate in the process.
> Training doctors is fucking hard. What I've seen is none of that really matters because hospitals can't even get enough qualified staff to support more residency positions.
Yes, and I don't mean to discount the challenges in finding and compensating enough physicians properly for even agreeing to do this in the first place!
Put another way, what I was saying before is that, even if the costs were linear, hospitals couldn't pay for it (without external funding). But as you point out, the costs aren't linear, which makes it even harder.
Or put yet another way, we can't easily increase the number of residents we train to practice medicine, because we don't have enough people trained to practice medicine in order to train them.
This isn't unique to medicine; we have the same problem with law too[0]. Heck, I even know startups that have complained that they don't have the bandwidth they need to hire and train more people.
In other words, doctors salaries are so extreme because it saves the state government a few bucks when training doctors.
This is pretty common knowledge among doctors of course, who starting at least a decade ago, have started clamoring for more and cheaper places in education programs. These it's tough finding any doctors at all who aren't asking for more doctors in training.
But systematic decisions to defund education, starting a long time ago (like 30 years ago or so) and have continued under every government since. That is the root cause here.
Or you know, hospitals with residency programs could just use of the massive insurance money they make to fund residency positions. It's not like the residents aren't employees or something.. Even the medicaid/medicare procedures are reimbursable.
Medical stuff is incredibly complex. Hospitals aren't making massive amounts of money -- overall the situation is that there are too many hospital beds as insurers push more and more procedures into outpatient settings with better outcomes and lower shared cost.
That's why medical networks are forming -- they put the GPs on a salary, cram in more nurse practitioners and PAs, avoid union contracts that are more common in hospital settings and extract more money from those settings.
So you have lots of implicit and explicit subsidy. Hospitals lose money on Medicare and some medicaid patients, and on no-pay patients who lack insurance. When my wife had my son, the unplanned c-section cost over $40k, largely because of those insane overheads that require subsidy.
i think one of the most interesting things about healthcare is how local it is. Most hospitals around the country are struggling, but there is a subset of large powerful hospitals that are making money hand over fist. They are basically buying physician networks so that 1) they can charge more for the same services by getting facility fees and higher negotiated rates and 2) they can control patient flow from primary care all the way to the hospital. And often that means treating a patient in the most profitable setting to the health system
Sutter is a shining example of this type of health system -- get huge regional scale, vertically and horizontally integrate, control patient flow, and crush payers at the negotiating table. Their prize is having some very profitable hospitals, including the second most profitable in the nation (almost $300M / year in profit at one hospital). And this profit is after paying their execs handsomely
Hospital spending is the biggest driver of cost, in no small part because of practices like the above
Oh totally. These networks engage in all sorts of unethical and self-dealing practices as well.
The Catholic hospital and medical network in my region was swallowed up with Trinity Health, which is a national medical network. Your interaction with a doctor or hospital is entering a sales funnel, where each additional interaction is engineered to generate more revenue for the network.
A family member had a stroke, which was debilitating and had a bunch of after affects. Prior to hospital discharge, the social worker (aka salesperson) drops a packet of nursing homes in the room and demands that it gets filled out by the end of that day. (which is illegal) That packet doesn't include acute rehab facilities, which is contrary to their physician's guidance. The list is sorted by available beds and exclusively consists of nursing homes owned by the medical network.
> Their prize is having some very profitable hospitals, including the second most profitable in the nation (almost $300M / year in profit at one hospital).
Yea, but this is on over $12 billion in revenue. That's less than 2.5% margin.
the article i saw said that the $270M profit was for a single hospital, sutter memorial hospital in sacramento, which does revenue of $3B per a separate article i found.
it is interesting that sutter's overall system-level profit is $370M. i think they have a few other very profitable hospitals as well. they must spend a lot on corporate sg&A and executive salaries (their CEO has a $7-10M salary IIRC)
I think sutters CEO is in the top 3 or so highest paid non profit CEOs, and sutter may be the biggest / second biggest non profit health system in the country, so I don't know that there are many industry comparables
I'd love to see a breakout of corporate g&a vs provider level g&a at sutter vs a set of comparable systems. All that "non-profit" profit has to go somewhere
> Even the medicaid/medicare procedures are reimbursable.
Medicare reimburses rates below-cost. About 7% below COGS, which means they lose money per-patient, even before they have to pay doctors, nurses, janitorial staff, etc.
> Or you know, hospitals with residency programs could just use of the massive insurance money they make to fund residency positions.
The "massive insurance money" is used to subsidize the losses that hospitals make on Medicare patients.
> It's not like the residents aren't employees or something
Great point. And that's why companies generally don't hire employees unless they work they do is profitable for the company. As it turns out, residents are not profitable for hospitals, which is why hospitals don't "just hire more of them".
> As it turns out, residents are not profitable for hospitals, which is why hospitals don't "just hire more of them".
This isn't quite in line with reality. If you familiarize yourself with specific hospital system figures, you find gems like this: Of Beaumont Hospital's 395 residents, 91 are not covered by Medicare and so are paid for by Beaumont. The $57 million for GME represents 4.73% of Beaumont's net patient revenue in 2013, or about $189,368 per resident. [0]
> The 91 residents that are trained within the hospital system without medicaid funding speaks to the fact that residents are in fact employees
...nobody ever said that residents weren't employees? The point is that they are and hospitals aren't going to go out and hire more unless it's profitable for them to do so. (Which it isn't, or else they would have done so, and that article even says as much).
For profit hospitals and doctors do not have to accept medicare or medicaid patients. Non-profits are required to to get non-profit tax exempt status. Some providers are more efficient then others so a statement that medicare reimburses below cost is not accurate. Maybe some procedures reimburse below cost but not all do. It is also not rational for these profit seeking doctors/hospitals to accept medicare patients but they do which directly conflicts with your statement that hospitals only do profitable things. One could argue that medicaid and medicare patients are sicker and there are more of them than most so they provide a larger revenue stream than private insurance covered patients (and they also require more procedures). If you didn't have these patients then your utilization would be lower and therefore your COGs would be higher as well. Also you might not be able to scale your hospital to take on the profitable procedures. Residents are also lower paid which give the hospital greater incentive to have them treat the medicaid/medicare patients as well. So logically it is better to employ more residents if you have sufficient patient load since it would reduce COGs.
> Some providers are more efficient then others so a statement that medicare reimburses below cost is not accurate. Maybe some procedures reimburse below cost but not all do.
I never said all do - I said that in aggregate, Medicare reimbursements are 7% less than COGS. "Efficiency" doesn't really enter the
picture, because COGS isn't driven by efficiency (ie, overhead); it's driven by upstream costs.
> So logically it is better to employ more residents if you have sufficient patient load since it would reduce COGs.
Nope, none of the stuff you mentioned falls under COGS.
> One could argue that medicaid and medicare patients are sicker and there are more of them than most so they provide a larger revenue stream than private insurance covered patients (and they also require more procedures)
This is the classic "we'll lose money per customer, but make it up in volume" argument.
You keep giving me the sense (like with your "7% below COGS" statistic) that you do actually know why residencies aren't profitable, but you keep making an indirect economic argument instead of talking about that directly.
All anyone in this thread is trying to figure out is why folks getting paid poorly to do work that we know costs tons of money (because we see the bills) would incur net negative profit.
> All anyone in this thread is trying to figure out is why folks getting paid poorly to do work that we know costs tons of money (because we see the bills) would incur net negative profit.
Because hospitals have to pay:
- residents' salaries
- attendings' salaries
- health insurance
- residents' insurance (for practicing)
- licensing fees
- taxes
It turns out, that all comes out to a lot of money. And hiring additional residents doesn't really save them much money, or bring in much additional revenue. The costs are greater than the revenue or savings. So, it's not profitable.
> to do work that we know costs tons of money (because we see the bills)
That's a question of medical billing, which is a whole other separate topic. In short: hospitals don't receive anywhere near the sticker amount for those bills, and a massive chunk of reimbursements from privately-insured patients goes towards recouping the losses that Medicare and Medicaid patients incur (as explained elsewhere, hospitals lose money on a per-patient basis for publicly-insured patients).
It seems to me that all of that (both the fully loaded costs of an employee, and the complexity of medical billing) applies equally to any other doctor, with a single exception. The exception is the portion of the attendings' costs that can be "charged" to each resident.
Is it that the additional cost in attendings' time, along with the reduced ability to earn larger sums for complex unsupervised procedures, outweighs the lower salary?
> Or allow people to do internships with normal, non-ER doctors.
Huh? What does that even mean? The only people who do their residency training with EM physicians are residents training in... EM.
> Or eliminate the residency requirement completely.
So... have people who aren't qualified to practice medicine be allowed to practice medicine?
Residency isn't just some arbitrary requirement - it's how neurosurgeons actually train in neurosurgery[0], and so on.
[0] Well, to be pedantic, neurosurgery also requires a post-residency fellowship. But you'd be hard-pressed to make the argument that neurosurgery fellowships could somehow eschew the residency requirement - it's a prerequisite for a reason.
> Well, to be pedantic, neurosurgery requires a post-residency fellowship.
Doubly pedantic: further specialization within neurosurgery (complex spine, vascular, tumor, peripheral ...) is done via fellowship, but plenty of practicing general neurosurgeons ended their training with residency. Source: wife is in her final year of neurosurgery residency. Of the folks in her program who have graduated while she's been around, about 1/2 did a fellowship, the other half went straight into practice.
(I hesitate to post this extremely minor correction, because everything you've said in this thread is absolutely spot-on and a very welcome dose of facts.)
Now that we are discussing facts... please tell us how many doctors you have personally visited that have been required to perform neurosurgery on you? I can't think of a single incident where that has been necessary in my own experience, and yet every doctor I have seen has been required to have residency experience. Rather counterintuitively, most of the time that has seemed unnecessary, and the work was done by a low-paid nurse or technical staff with the doctor waltzing-in at the end to "sign-off" on the results in order to fulfill the requirements of the insurance companies and ensure the hourly-billing rate was well-above what it would have cost to pay a private clinic staffed by the same nurses to do the same work.
So please enlighten me instead of just slamming what seems a fairly obvious point without adding anything of actual substance to the discussion. Because from the perspective of an actual patient it seems rather silly that a nurse can't take a blood test, and a paediatrician-in-training can't study with a family doctor or another paediatrician in a private practice. And it seems absurd that extensive state funding is now accepted as necessary simply to certify someone to oversee tasks like prescribing antibiotics, or signing-off on STD tests, or allowing patients to get blood test results.
No-one is suggesting that neurosurgery should be done by people without specialized training (I would actually think that "residency" is a poor way of measuring competence in that field as well, fwiw). And by reducing the complaints to this rather silly level all you are really suggesting you have no practical answer to the question of why "residency" is a reasonable bottleneck blocking the certification of doctors and keeping the costs of general medical care far above what is actually needed to deliver the vast majority of it that doesn't involve cutting into people's brains.
EDIT: I love the downvotes people, but you would be better off answering the question since I have karma to burn and enough experience with the US medical system to know that "residency" hasn't been necessary for almost any of the medical care I have received.
Residency at an ER isn't necessary for someone to become a pediatrician. Pediatricians do a pediatric residency. You seem to be very, very confused.
> Why have you elevated some bottleneck guild requirement into a general license to write prescriptions? Or sign-off on an STD test? Or allow patients to get blood tests? Or to inform them of said test results?
Literally everything you listed here can be done by a mid-level (i.e. non-MD), and commonly is (though the scope of prescriptions they can write is limited by states, IIRC).
> by reducing the argument to this level you are only suggesting you have no adequate response to the actual problem
I have no idea what you're talking about; I posted a minor factual correction to someone else that has nothing to do with this point. Again, you seem to be very, very confused.
----
In your edit you say:
> I would actually think that "residency" is a poor way of measuring competence in that field as well
Residency is not a tool for measuring competence. It is the means by which that competence is acquired[1]. You demonstrate competence by passing the written and oral boards in your specialty.
> "residency" hasn't been necessary for almost any of the medical care I have received.
May this continue to be true. If everyone were so lucky, the medical system would be much, much simpler.
[1] Foreign doctors who may already be competent are required to go through residency in the US as well; there probably should be a way to short-circuit that and allow them to demonstrate competence.
> Residency at an ER isn't necessary for someone to become a pediatrician.
You may simply be talking past each other here. All of my (now doctor) friends who went through residency pulled at least one, and usually more than that, rotations through ED. I can't imagine all 3 hospitals had wildly different residency programs than the rest of the nation, so I imagine 3-6mo of ED rotation is quite common during residency.
Yes, a 3-6 mo ED rotation is quite common for medicine docs (so is an ICU rotation for surgeons), but that's wildly different from an actual emergency medicine residency.
> In recent years, the number of medical residents has become so restricted that even the American Medical Association is pushing to have the number of slots increased.
This does not sound like a system where students can fulfill their residency requirements working at general care facilities with trained doctors who have years of experience.
> The major obstacle at this point is funding. It costs a teaching hospital roughly $150,000 a year for a residency slot.
So why exactly is there a slot shortage if people can literally fulfill their residency requirements pretty much anywhere? There are plenty of hospitals that could easily use the labor.
Scroll up, Stephen. These quotes are in the thread at the heart of this discussion, and they are pulled directly from the article.
I mean... I appreciate getting downvoted for reading the article and addressing it directly, but if there are indeed adequate residency spots then you are disagreeing with the article and would be better served to focus on what it gets wrong instead of attacking me for making rather rudimentary observations that follow from its core premise.
Right, but I never said there were adequate residency spots. In fact, I think that there aren't[1]. So again, why are you replying to this thread in particular?
[1] however, from what I've seen it isn't a critical issue for US healthcare; we need more mid-levels and to expand their scope of practice more than we need residents. For residents, it would be far more effective to reduce the span of pre-residency training somehow, so that people aren't starting residency with $300k in debt.
I think it is correct. They pushed for a cap, but are now pushing for an increase. ...the AAMC is now calling for an annual increase of 3000 Medicare-funded slots.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978854/
According to the above article, new programs are not capped. However, the bureaucracy hurdles you are required to jump to establish such a residency program is huge.
Restricting access to medical education (certification) is only one way to restrict supply.
Another way is to require certification for more kinds of activities in the first place.
If Americans want access to less expensive healthcare, why not make it so that some kinds of medical treatment are available from people with ~2 years of education instead of 10? (Yes, the treatment would be inferior, but also much less expensive.)
Also, when IBM's Watson becomes the world's best diagnostician (Any Day Now), what will its legal status be? Probably IBM would be happy with a special exception to the law that makes it hard for other computer companies to enter the market?
> If Americans want access to less expensive healthcare, why not make it so that some kinds of medical treatment are available from people with ~2 years of education instead of 10? (Yes, the treatment would be inferior, but also much less expensive.)
We already have. It turns out that patients generally don't want this. When given the choice, they generally opt for the practitioner with more training (the physician) over the one with less (an NP or PA).
Sure, we can (and do) pass these costs on to the patient, or (in some cases) force them to use the cheaper option, but at that point, you're literally talking about either:
(A) forcing patients to assume the costs of their care directly, either entirely or in proportion; or
(B) forcing patients to use the lower-cost, lower-quality option
Politically, people don't like (A) because it means patients' access to quality medicine is restricted by their ability to pay. And people don't like (B) because nobody likes to be told that they can't have access to the top level of quality (whether or not they're expected to pay for it themselves).
Man, pro tip- always go with a PA over an actual doctor for most general purpose visits. Doctors are waaaaaaaaay harried and checked out of the process. PA all the way. Honestly, even for hard problems I'm half inclined to go with a PA first, just because getting through to a doctor is so difficult, and there's always an easier solution they're going to try to make you prove won't work (to save themselves a little trouble).
> We already have. It turns out that patients generally don't want this. When given the choice, they generally opt for the practitioner with more training (the physician) over the one with less (an NP or PA).
That's because there's no price consequence for the majority of people in that circumstance. If the doctor costs $500 to see, the 2 year example costs $50, and the person actually has to feel that cost, it's very obvious which one they will choose.
Most working Americans get heavily subsidized insurance from their employer; most of the rest get almost entirely subsidized coverage from the government. Accordingly, very few Americans ever directly touch the cost of care. The majority of all Americans never get anywhere near that in fact. That's one of the big reasons why we're spending a trillion dollars per year beyond what we should be.
> Hardly - in fact, there's already been significant downward pressure on these, because the debt level is already at the tipping point.
Yeah, by my calculations, my SO is currently taking home around $-1 per hour in residency. Some reasons: ~50k/year, expensive area, ~400k in loans, 8% interest rate.
I took a slightly more comfy route, career-wise (Ph.D.). Her bank account will likely surpass mine when she's ready to retire (around 55-60).
A bit offtopic, but 8% interest rate on a loan you can't default on sounds bonkers. I'd rather expect something like 0.5 percentage points over the current interbank offered rate.
At the time she's licensed, she'll be over a million dollars behind where she would have been if she went straight into industry. Break even is something like 25 years down the road - even with "high doctor salaries"
I based it on her Biochem degree. Many of her peers who decided against medical school went into medical related fields like pharma and medical engineering.
Every time the topic comes up, you bring up the Medicare funding issue. Every time I explain why that doesn't seem to make sense:
If there are more aspiring doctors than can fill the subsidized slots (there are), you can balance demand and supply by passing some of the costs on to the resident[1]; many will still gladly accept this because of the extreme returns to becoming a doctor.
The fact that they don't allow that happen is not a funding issue.
You can further massively increase the supply at little cost to doctor quality by getting rid of the pointless four-year degree pre-requisite. (vindicating the blame placed on the AMA)
More generally, if demand vastly exceeds supply (as it does here), subsidies can't be the bottleneck. To reiterate the analogy (from the past copies of this exchange), it would be like saying the musical Hamilton can't come to LA because the TSA won't pay for the plane tickets to get the cast down there. No: there is enough demand to cover the cost of airfare. And there is enough demand to cover the shortfalls in resident subsides.
[1] Concretely: instead of funding 100,000 slots at 100%, fund 120,000 at 80% or something like that.
> Every time the topic comes up, you bring up the Medicare funding issue. Every time I explain why that doesn't seem to make sense: you can balance demand and supply by passing some of the costs on to the resident[1]; many will still gladly accept this because of the extreme returns to becoming a doctor.
And every time, I've explained that there aren't "extreme returns" to becoming a doctor. After accounting for all the expenses that physicians are required to pay out-of-pocket (which are not tax-deductible, due to AMT), the expected take-home pay is lower than what a mid-career engineer at Google or Microsoft makes, And the debt load is already high enough that it's discouraging people from entering the field[0][1][2], due to both the size and the risk..
Making medicine an even riskier bet (by taking on an even larger debt load with a longer time horizon) isn't going to solve any of that; it'll just lower the overall quality. At that point, it's more efficient to talk about NPs and PAs than piling on more debt to physicians.
You're citing marginal[1] cases of people that got disincentivized away. That doesn't change the fact that the demand vastly exceeds the supply and has a well-trod solution.
Also, the returns aren't simply monetary, but the fact that you have much higher social status in general that outweighs a lower net salary, even if it got to that point.
>Making medicine an even riskier bet (by taking on an even larger debt load with a longer time horizon) isn't going to solve any of that; it'll just lower the overall quality.
They still have to meet the med school and residency requirements.
>the expected take-home pay is lower than what a mid-career engineer at Google
The typical doctor would not qualify to work at Google.
>At that point, it's more efficient to talk about NPs and PAs than piling on more debt to physicians.
Or, as I said before, lifting the pointless requirement to have an unrelated four year degree. Or applying a whole host of QA feedback loops to the process. That doesn't change the fact that Medicare funding cannot reasonably be called the bottleneck here, for the same reason a subsidy can never be called a bottleneck when there is excess demand.
[1] marginal in the economic sense; not saying they are rare just that they're not common enough to affect the logic
> The typical doctor would not qualify to work at Google.
The top ones absolutely would. In fact, math and statistics (which includes CS, in their categorization) is the second-highest performing undergraduate major for medical school matriculants.
You're kidding yourself if you think that the top students aren't making career decisions between medical school or finance and STEM and factoring in the massive difference in both risk and reward in the process.
> Or, as I said before, lifting the pointless requirement to have an unrelated four year degree.
There is no requirement to have an unrelated four-year degree - or any degree at all. Medical schools could accept someone straight out of high school. Except they don't, because the top-performing matriculants are those with a degree in the humanities, followed by those with a degree in the social sciences. Pre-med, amusingly, comes in dead last.
> the fact that you have much higher social status in general that outweighs a lower net salary
This may be the funniest thing I've read in this thread. No, compared to the other options available for a bright, qualified college student, going into medicine is probably the worst option if you want to optimize for either wealth or social status.
But sure, if you want to propose an incredibly convoluted process for filtering away the top prospective doctors (incentivizing them towards finance and STEM instead, for the better pay and respect), replacing them instead with less-qualified, middle-of-the-pack, independently-wealthy people who are willing to take on an extremely large and risky debt load because they can afford to and they don't have any other well-paying options... fine, go ahead, I won't stop you. If you think that that's the answer, then that means there's no policy solution needed. Nothing's stopping you from finding those people and going to them and encouraging them to take on that debt load themselves and apply to medical school today. They can take out those loans themselves, or use their own money to pay their own way.
But then please stop derailing these conversations by talking about lifting non-existent requirements, or making rather pedantic quibbles about terminology. When we're talking institutional policy, it's perfectly fine to say that an existing subsidy is "the bottleneck", in the sense that, ceteris paribus, increasing it would alleviate the problem and decreasing it would exacerbate it.
>> The typical doctor would not qualify to work at Google.
>The top ones absolutely would.
I was referring to the typical one.
>Medical schools could accept someone straight out of high school. Except they don't, because the top-performing matriculants are those with a degree in the humanities, followed by those with a degree in the social sciences. Pre-med, amusingly, comes in dead last.
But they're not even considering those without a four-year -- that's another cause of low supply.
>This may be the funniest thing I've read in this thread. No, compared to the other options available for a bright, qualified college student, going into medicine is probably the worst option if you want to optimize for either wealth or social status.
You're saying the typical doctor has lower social status than the typical CS job or finance?
>But sure, if you want to propose an incredibly convoluted process for filtering away the top prospective doctors (incentivizing them towards finance and STEM instead, for the better pay and respect), replacing them instead with less-qualified, middle-of-the-pack, independently-wealthy people who are willing to take on an extremely large and risky debt load because they can afford to and they don't have any other well-paying options...
That's a strawman -- the comparison was to doing e.g. 10% more residencies by having them 10% less funded. Still no requirement for independent wealth.
>But then please stop derailing these conversations by talking about lifting non-existent requirements, or making rather pedantic quibbles about terminology. When we're talking institutional policy, it's perfectly fine to say that an existing subsidy is "the bottleneck", in the sense that, ceteris paribus, increasing it would alleviate the problem and decreasing it would exacerbate it.
When you talk about "the bottleneck", has a precise meaning: "this is the limiting factor that must be relaxed for any growth". If that criterion doesn't hold, it's just one of many factors and one of many options to consider.
When you say that Medicare subsides are "the" bottleneck, you're claiming it's literally impossible to have more doctors unless a government agency spends more tax money on it. That's every bit as false as the equivalent claim about Hamilton in LA and the TSA: if the private market is already willing to pay, and to be paid, enough for it to happen, the problem can't be insufficient subsidies, but a refusal to implement well-trod solutions (or the regulations that prevent that well-trod solution).
That is definitely not a pedantic quibble, but the difference between "this needs more money" and "this only needs more money because they're adhering to harmful practices" (like rejecting qualified students who don't yet have a four year degree, which they're apparently doing even if not required).
Iirc residents are a profit center for hospitals, meaning that if they really wanted to, residency slots could be self funded by the host institution without federal funding. That line of reasoning sounds like an attempt at obfuscation (not necessarily by you, but by the hospitals and medical profession in general).
> Iirc residents are a profit center for hospitals, meaning that if they really wanted to, residency slots could be self funded by the host institution without federal funding. That line of reasoning sounds like an attempt at obfuscation (not necessarily by you, but by the hospitals and medical profession in general).
They're not. If they were a profit center, there would be more of them, unless you think that hospitals would willingly refuse to do something that's clearly profitable for them.
There are plenty of reasons to eschew short term profitability for long term profitability and prevent flooding the market. Fwiw my information is gleaned from "An American Sickness" where the Harvard MD writer claims that a resident costs something like 180k but makes the hospital 300k.
If it is the case that the author has intentionally neglected to mention other factors that contribute to a resident being a cost center, I would sincerely be interested to learn about this.
> There are plenty of reasons to eschew short term profitability for long term profitability and prevent flooding the market.
That's not what we're talking about.
What people are proposing here is literally that hospitals are eschewing short-term profit in order to increase the expenses they have to pay in the long-term (physician salaries).
> There are plenty of reasons to eschew short term profitability for long term profitability and prevent flooding the market.
Pretty much in any industry, participants could collude to reduce supply to keep up prices. In practice, such arrangements are highly unstable, because individual participants have huge incentives to break rank and seek short-term profitability. What makes you think hospitals are different?
> Pretty much in any industry, participants could collude to reduce supply to keep up prices. In practice, such arrangements are highly unstable, because individual participants have huge incentives to break rank and seek short-term profitability.
In addition to everything you said (which is true), in this case, the hospitals and doctors have opposing incentives. I can't imagine why hospital administrators would collude to increase their expenses (ie, their employees' salaries).
When Apple, Google, etc. were found to be fixing wages, they were trying to keep salaries down, not bring them up.
> unless you think that hospitals would willingly refuse to do something that's clearly profitable for them.
The original claim you were responding to was that a doctors guild artificially limits the number of doctors available by capping the number of medical schools, the implication being that it leads to higher a demand for doctors and thus higher prices.
Granted that it's a lack of residencies and not medical schools that creates the demand, is creating artificial demand not a reason why hospitals might willingly refuse to do something that's clearly profitable for them?
Are you disagreeing with the OP only on who is creating the artificial demand?
> The original claim you were responding to was that a doctors guild artificially limits the number of doctors available by capping the number of medical schools, the implication being that it leads to higher a demand for doctors and thus higher prices.
That's a pretty fundamental misunderstanding of economics, then. Capping the number of medical schools can't cause higher demand for doctors. It can restrict the supply, which means that the prices will be higher, but it doesn't affect demand at all.
> Granted that it's a lack of residencies and not medical schools that creates the demand, is creating artificial demand not a reason why hospitals might willingly refuse to do something that's clearly profitable for them?
Even if this premise were correct: why would hospitals refuse to do something that's profitable for them, just so that they could pay more in expenses (salaries) in the long run?
> That's a pretty fundamental misunderstanding of economics, then. Capping the number of medical schools can't cause higher demand for doctors. It can restrict the supply, which means that the prices will be higher, but it doesn't affect demand at all.
My lord, that clearly means an excess of demand over supply.
> Even if this premise were correct: why would hospitals refuse to do something that's profitable for them, just so that they could pay more in expenses (salaries) in the long run?
Because they expect revenues to outpace those expenses??
> Well the alternate is capacity. They only have so many doctors on staff to supervise which limits the slots. Think of it as a management problem.
First: residents are doctors.
Second: Yes, they ratio of residents to attendings is fixed, by law, as is the number of hours that they're allowed to work per week. Both of those were fixed because we found that working residents 100-120 hours/week and without enough attendings resulted in mistakes and people dying.
Since this ratio is fixed, it means that hiring 4 more residents also means hiring an additional attending, and you only get an additional 320 resident-hours/week from them. It turns out that this isn't profitable, because if it were, more hospitals would do it.
Yes, obviously, residents are doctors. By "doctors on staff" I meant supervising doctor. The phrase "on staff" usually means permanent staff vs the residents who are temporary.
> the typical person who enters medical school can expect to pay off their medical school debt in their 40s. That level of debt load
Does how long it takes someone to pay a debt off say anything at all about how big the debt load was? You've juxtaposed these sentences as if it does.
Many people pay off their student loans last, as they're usually very low interest. You could have a student debt into your 40s but not because you can't pay it off - rather because it's cheaper than your mortgage.
Why pay off a cheap debt to buy a new expensive one?
People probably pay off their student debts in their 40s as they part of pay off the last of the mortgages and look to finally get rid of other debts.
> Many people pay off their student loans last, as they're usually very low interest. You could have a student debt into your 40s but not because you can't pay it off - rather because it's cheaper than your mortgage.
As explained below, no, the debt load that doctors hold is not very low interest. It's in the line of 8-10%. For contrast, I have credit cards that have APRs within striking distance of those rates, and that's consumer debt.
You seem to be thinking of undergraduate student loan debt, which is heavily subsidized.
Yea, I'm 37 and have about $2,500 of student loan debt left. I could pretty much pay off the balance whenever, but the interest is low, the monthly payment is low, so meh.
> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools
>> They do not. You may be confusing the AMA (which less than 25% of doctors even belong to) with the AAMC.
Actually the AMA is the problem. They lobby to uphold the incredibly strict licensing requirements that doctors use to maintain the exclusivity of their job.
Doctor licensure requirements are stricter in America than most of Europe. For instance, why do doctors NEED to do a 4-year undergrad degree before medical school? Why do they NEED to go to a 2+ year residency after medical school? In Europe, students can go straight to medical school from high school.
Each additional licensure requirement to become a doctor decreases the supply of new doctors, increases the salary of current doctors, and increases the cost to consumers.
> For instance, why do doctors NEED to do a 4-year undergrad degree before medical school?
They don't. Medical schools can accept students straight out of high school, as long as they've completed the required pre-medical coursework. They don't, however, because those students drastically underperform their peers who received an undergraduate degree in a different field.
> Why do they NEED to go to a 2+ year residency after medical school?
Because without it, they literally have never been trained to practice medicine. Where do you get the idea that Europe is somehow different? Residency is required (and comparably long) in the UK, Germany, etc.
> Medical schools can accept students straight out of high school, as long as they've completed the required pre-medical coursework. They don't, however, because those students drastically underperform their peers who received an undergraduate degree in a different field.
I guess all those Australian medical schools will be interested in hearing how their graduates "drastically underperform" all these American doctors who did a postgraduate medical school.
Seems to work well enough, to me, as someone who has used physicians extensively in both countries, and worked in healthcare in both. "drastically underperforming" doesn't really fit that picture.
This. Residency is the bottleneck and is funded mostly by the Govt. I'm not a doctor but have worked in healthcare the majority of my career and have family members who are doctors. Doctors deserve what they are paid. Period.
What does "deserve" have to do with it? People who work at Walmart deserve a living wage and a financially secure retirement, too.
If there's an artificial restriction in the supply of doctors (because the government sets an arbitrary limit on the number of residency slots it will fund), then doctor salaries are inflated by government fiat. If we increase the number of residency slots to reduce the price of medical care --- which everyone seems to agree we badly need to do --- then doctor compensation will decrease. You seem to believe that's a bad thing.
Everyone deserves to be paid fairly. There is a difference between a doctor and someone who works at Walmart. You seem to discount the fact that there is infinite demand for doctors in specific and healthcare in general.
why aren't there more residency spots? Why can't people who need to do residency be forced to go to a (more) far away city that has a lack of doctors and be trained there?
Because residency programs are very difficult to operate and require a level of staff that not all hospitals have access to.
The issue isn't with the supply of graduating students, it's with the number of residency spots.
This year 95.3%[0] of graduating students matched to a residency program. Out of 18.5k applicants, only 17.5k matched to an available residency program.
That's an interesting theory. It seems to parallel the situation in the legal field. Unlike in medicine, there's no shortage of JD graduates--there are about twice as many graduates as there are legal jobs for them. But the bottleneck for the supply of trained lawyers is the number of opportunities to get real-world experience, which is limited by the underlying economy (the number of trials, the number of mergers, etc.).
> who wants to be past child-bearing age by the time they've paid off their debt, when they can just go into another better-paying field without any of that)?
doesn't matter if the non-debt income is substantially higher.. most would rather take 500k a year with 100k of debt repayment over 100k a year with none..
> One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things.
An alternative scenario is to train doctors more quickly and effectively for primary care positions. Currently, to become a family practice doctor, you need 4 years of undergrad, 4 years of medical school (much of it not geared towards primary care), and then 3 years of residency. Instead, students could be started earlier, with immediate exposure to primary care (working internships) and education focused towards practical medical aspects of primary care. It would take far less than 11 years and arguably give them much more exposure and training that's directly applicable. I'd wager you'd get both higher quality care and lower costs.
I can't agree more with this, especially with respect to undergrad. I've taught hundreds of undergrads about ohm's law so that they could go on to become doctors. And that was one of the more useful skills they learned. They also took classes on western legal theory and renaissance art and modern Russian literature.
Don't get me wrong: some doctors need hard science skills, but while I want my neurologist to understand ion channels I don't need that from my orthopedic surgeon.
As for the liberal arts base, personally I'd rather have a doctor who entered medical school 4 years earlier, and had a chance realize that med school wasn't for them 4 years earlier. With our current system, acing the MCAT means that you will be a doctor if you want to be one. And once you're in medical school you've sunk too much into education to back out and try something else.
It still makes sense to have a hierarchy of capabilities. You see this in many places in medicine, e.g. EMT, EMT-I, paramedic, with the RN-MD divide being one of the more notable gaps.
IMO the fact that RN's wind up with tacit approval to perform certain proceedures and make certain decisions that the MD is nominally supposed to, is a clue it would indeed be suitable.
I don't understand the requirement for the initial 4 years of undergrad before you enter medical school here. All it seems to do is increase the debt burden for doctors & their time it takes to get into actually practicing medicine.
My wife is a doctor. She is just over a year out of residency. She makes around $300,000 per year. It's a lot of money. She has to make that much money because the U.S. has stupidly decided to burden doctors with massive med school debt. Her debt is $400,000.
When she pays off her debt her salary won't go down. People expect to make more in successive years. Hence large salaries are going to be normative unless there is drastic change in the system. It would be much better for the country, and for my wife, if her debt were wiped out and she made a lot less money. We'd be happy for that.
Whatever system is going to be in place will require some form of rationing. Prior to Obamacare that rationing was done on the basis of money, and whether or not a person was lucky enough to have a job that had health benefits. Obamacare is an attempt at free market forces whilst providing care for most people. It's somewhat better now than in the past but not ideal. I think universal, government funded healthcare is the most moral and economical option.
Taxes and whatnot account for 50% of her salary. She does need to save for retirement and one must include more than just the federal income tax rate to calculate how much is taken out in taxes. There's FICA, state taxes, and state sales taxes and property taxes. There is also rent, food. She can not save put 50% of her salary toward her student loans. That said, she can pay it off relatively quickly.
However, after 4 years undergrad, 4 years med school, and 4 years of residency it's time to live, no? What's the point of it all if you don't actually make enough to live a little until you are 40? A way better system would be to just provide for higher education and not burden people with debt. Instead a large salary is needed to pay the large debt but the large salary is permanent and the debt is not. Save a lot more money buy just properly funding higher education.
Well, debt free at 40 leaves still 25-30 years of a pretty good career, no?
The downside of govt just paying for it is you'll get a lot more people who really aren't committed to the profession and it taxes everyone else - it's not free, it's done through higher taxes on everyone else.
It doesn't have to involve higher taxes on everyone else. We spend well over a trillion dollars a year on national defense/spying. Also, we spend way higher per capita on healthcare than any national healthcare system and those systems generally include paying for medical school. Thus the evidence is that it will involve less money spent. Perhaps there would be a tax reduction as a result.
I used to be a big believer in freer markets in these areas, but all the places that are cheaper appear to use monopsomy power to drive down costs which is kind of the opposite. Even if there is a widely competitive market you don't get to make informed choices, negotiate and leave for elsewhere when you have a bad hospital or surgeon in a priority case. It's also far easier for people to make irrational choices when dealing with their health. As far as filling cavities, many fillings literally amount to cutting a tooth open inserting a material and reattaching the piece that was cut. Common complications include hitting nerves. Allowing assistants to do this on fairly limited training seems to be a very poor idea -- I've changed dentists because of complications from a filing and the inability to fix it, and I wouldn't wish the complications on someone.
> The entire health system from top to bottom would benefit immensely from free market forces.
lolnope. Free market sooner or later ends up screwed because humans are inherently greedy and will cut corners to make more profit. The corner cutting is bad enough in IT security, I do not want to see this in any health related stuff.
The free market may be fine for most stuff in a society - but the corner stones of society must be regulated as hell: transportation infrastructure, water, electricity, telecommunication, medicine and education.
> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools, which also allows the existing schools to crank costs to astronomical levels
Your thesis is that a cabal operated by doctors is limiting more doctors from getting acceptance into med school as well as intentionally preventing more medical schools from opening, with the goal of inflating their student loans to such astronomical levels so they can have the privilege of graduating with ridiculous debt loads they'll be lucky to pay off by the time they're 50 years old? That's.... fascinating.
> One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things.
They do, are you in the USA? It's actually quite challenging to see an MD without direct pay or concierge, or without seeing a specialist (in which case be prepared to wait 2-5 months, depending on their specialty). When was the last time you went to a primary care office, urgent care, or similar clinic in the USA, and had a visit with an actual doctor (MD) and not a PA, NP, RN, or similar non-MD? Doctors are so rationed in much of the USA that many obstetric or surgical followups are handled entirely by a completely unrelated RN or PA instead of the very doctor who performed the actual procedure on that patient. And the boomers haven't even retired and reached medicare age yet, imagine what the doctor shortage will look like in another 5, 10, 15 years.
My pet theory is that the long-term reasoning for artificially limiting the number of residencies/medical school spots is to avoid an oversupply of healthcare professionals after the baby-boomers die off in 15-20 years.
Sure, there is tremendous strain (and consequently profit to be made) in the system now, at the expense of overworked doctors with limited interaction with their patients. But if the supply of doctors met market demand _right now_, in 20 years there would be an over supply. An over supply of doctors would introduce a new set of problems associated with lower salaries and eventually lower quality of care (see Soviet Union). So in a way, this artificial market manipulation of the supply of doctors is forcing innovation and timing the population market, and betting on medical advances that will eliminate many doctor visits through preventative medicine or computer asssisted diagnostics.
Essentially the AMA is lobbying to prevent a scenario that created the artificial STEM shortage myth in the 1990's that new career scientists have still not recovered from.
How did having too many doctors cause an decrease in quality of care in the Soviet Union?
And the AMA is lobbying for decreased slots because it increases their salary. American doctor's pay is way out of line with the rest of the developed world.
> They artificially limit the number of doctors available by capping the number of medical schools, which also allows the existing schools to crank costs to astronomical levels
This is such bullshit. Nobody is artificially limiting the numbers. Schools are accepting and graduating more doctors than available residency programs.
Right now the biggest bottleneck in the process is the number of residency spots. There simply isn't enough bandwidth for hospitals to teach graduating medical students to become independently licensed doctors. Medical schools will happily push as many students as possible through (and they are with new schools opening).
The problem is training a resident is extremely expensive and comes with a lot of overhead. The government pays hospitals about $110k to per residency position. While this incentivizes some hospitals, many are facing issues with finding willing and qualified staff to come teach at their hospitals. It's hard to convince an established doctor to take a pay cut and take on more work to train students.
As it stands right now, I have to disagree with letting nurses or PAs do more "doctor things". Their training isn't anywhere close to what it needs to be. Also, the term nurse is very loaded to your average patient. You could be talking about a CNA with 16 weeks of training, or a DNP with 8 years of schooling.
>ROSALSKY: The main argument against allowing NPs to practice independently is that they have less training than physicians. But there’s a mountain of empirical evidence from randomized trials, case studies, systematic reviews, and analyses of malpractice claims in states where similar legislation has already passed that all points to the same thing: when it comes to primary care, NPs are just as safe and effective as doctors.
I saw a nurse practitioner at a drug store who prescribed some antibiotics for an ear infection I had. It went well, it was a simple problem, and it didn’t require being examined by an MD. There are definitely things they can do.
It was a pretty common case of swimmer’s ear. Oral and ear anti biotics were prescribed, along with advice not to swim for awhile and later to wear ear plugs. It was all very standard.
Believe it or not, most infections will clear up with anti biotics. I get a painful infection every 3 or 4 years that require them (less often when I was younger), hardly someone you would consider abusing them.
> As it stands right now, I have to disagree with letting nurses or PAs do more "doctor things". Their training isn't anywhere close to what it needs to be.
Sort of. What people in this thread refer to when they say nurses should do more "doctor things" is a nurse practitioner:
(think of an MD as a commissioned officer in the military, whereas a nurse practitioner is a non-commissioned office who rose through the ranks but is still slightly below a commissioned office in ranking)
Source: Mother was a registered nurse
TL;DR Leveling up nurses around the country to "nurse practitioner" and having them take on more traditional doctor responsibilities is a solid path to success versus churning out more doctors overloaded with debt
That works great... until there’s a subtle reason to think that it’s not streptococcus for reasons ABC or that’s not the proper treatment for reasons XYZ and you have a mild case of death.
Physicians that you see in the office won't detect those reasons ABC and save you from death. The expert diagnosticians often work in hospitals and are only used when other PAs/Physicians tell them "I ruled out all of the common explanations for these symptoms, what could it be?"
> Physicians that you see in the office won't detect those reasons ABC and save you from death.
Any hard research showing this? Something that addresses confounding factors, overburdened doctors, etc.? Is there a study showing that spending 30 minutes with a physician is equivalent to 30 minutes with an RN or PA for all outcomes (not just death)? I have a feeling we're all acting like medical experts in this thread even though very few of us are. It's like when we see research about programming methodologies and are able to poke so many holes in the study it becomes swiss cheese.
Probably not. Or, better stated, not that I am aware of.
Let's think. Seeing a doctor instead of a PA is associated with better outcomes if, and only if, your condition can benefit from the doctor's specialized knowledge. That means it requires treatment, the treatment is time-sensitive (i.e. worse outcomes if there's a delay), and there are significant adverse effects in case of a lack of appropriate treatment.
The problem is, these conditions are either too rare to be studied in any meaningful way, or the patients' very obviously sick and taken directly to the hospital, where he is obviously seeing a doctor and not a PA.
A lot of people go to the doctor for pretty benign ailments which don't really require a treatment, or for conditions that any intelligent, motivated patient is theoretically able manage himself without a doctor. Examples : virus infections, sprains, acid reflux, chronic conditions like hypertension, diabetes, and so on. E.g. : someone has type I diabetes, understands how and when to give himself insulin, checks his feet for infection and so on. In a case like this, the doctor can barely bring any plus value apart from ordering the regular blood work.
Another frequent scenario is when the patient does have a time-sensitive, treatment-required condition, but does not follow the treatment. Again, him seeing a doctor is unlikely to result in any appreciable benefit.
No, just intuition. 70% of the primary care medicine appointments are "eh, it's a virus, come back if symptoms persist." [1] 10% is casts/sutures/I&D/debridement. 15% are "I'm telling you, these symptoms are all due to your diabetes and your diet will kill you if you don't take it seriously." Maybe 4-5% are really diagnosing serious chronic issues. And generally it's just referral to a specialist who makes the official diagnosis. A missed diagnosis here can be a serious consequence in some cases, but symptoms that can indicate those diagnoses are big red flags.
Well, as someone who has a mildly life-threatening condition that manifested "off-book", and only one of several doctors I saw was able to identify it, I'm probably a bit more skeptical than average. But, it's worth noting that my symptoms were severe enough each time I had it that a PA would've certainly referred me to a doctor (I called an "advice nurse" each time who told me to see a doctor). So maybe that's a point in favor of PAs doing initial screens.
With respect to that comic, I would've gladly paid $4k out of pocket for a diagnosis. I still think fondly of the doctor who quickly figured out the puzzle that tricked a couple other specialists, my PCP, an urgent care doctor, and an emergency medical doctor. The same doctor who quickly sent me to the hospital in an ambulance with a note on my chart that said "this is serious, don't send him home until you confirm my diagnosis."
Agreed! The whole system is in need of an overhaul. Why don't students start off medical school right away in undergrad? Who the F* wants to wait until they are 30 years old before they finish school?
So? Those extra four years of education for people who want to be doctors are mostly waste, an elaborate hazing ritual. Make undergraduate entry to medical school a five or six year programme, like in Europe. The increase in physician career years will swamp any plausible decline in incoming student quality, even if they just admit students straight from high school to the current US med school system.
That's kind of my point. How would an 18 year old know what they actually want to do without having spent some time studying it and other things? I went into school with intention of becoming a doctor and had changed my mind 2 years in. That's an expensive mistake if I hadn't been at a liberal arts school.
Importantly, the costs of our medical system relative to other systems will never be fixed until we fix this problem. But this is the hardest problem to fix, because nobody wants to talk about it. It's political suicide.
Doctors are a guild everywhere so this isn’t the big difference. They always want to limit the number of new doctors. Perhaps in the US they wield more power?
Public medical schools should just educate more doctors and make it cheaper and lower risk to become one. Add a few thousand more spots in state universities and fill them via
full scholarships.
A simple solution to the management of doctors’ time is to hire secretaries to do administrative tasks that otherwise take a lot of time. We have that here now (a recent invention) with a 2 year education.
"Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools, which also allows the existing schools to crank costs to astronomical levels (“don’t worry, you’ll make enough to pay it back”)."
- True (in principle). But even with so much filtering, I have encountered not so bright doctors practicing and it is not a pretty sight... Plus you have to consider the time investment, apart from money, there is lost time and opportunities. Take a typical cardiologist for example: 4 years undergrad + 1 year research or something else to beef up CV + 4 years medical school + 3 years of internal medicine + consider 1 year chief residency to beef up CV + 3 years cardiology fellowship. That's 14-16 years either getting in debt or being underpaid.
"One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things. Dentists, a similar profession, is going apeshit that states are trying to let specially licensed assistants (but non-DMDs) do slightly more advanced work like fill cavities.[0]"
- That's were market forces are driving us anyway, it is happening. As long as you are OK with everyone being seen by a PA or NP... Most people though that support what you said kind of feel like this is "for the other people" but for themselves they "demand" to be seen by a doctor when they are seen by a PA or an NP. Don't get me wrong PAs and NPs are fine for 95% of everything that needs to be done but they simply lack the knowledge and the training to troubleshoot complicated problems and what makes it worse is that many times they cannot even detect that it is beyond them.
"The entire health system from top to bottom would benefit immensely from free market forces."
- There is a free market for medical services in the upper bracket and doctors are making even more there.
> They artificially limit the number of doctors available by capping the number of medical schools,
Also not accepting qualifications from other countries. UK has tons of Indian doctors. Lets get them here too, I don't get why we dont already do this.
We do. In fact we make them redo their 3-4 residencies and following that, dangle the promise of a Green Card after seven years and send them to the god forsaken underpaid rural shitholes American trained doctors have fled because of the inadequacy of the cash salaries(taxed at reg brackets unlike our execs and bankers) relative to student debt and medical practice overhead. How do I know this? Because this is how I came to America.
People do not do a strict cost benefit analysis when deciding their line of work. See: English majors.
The market is being distorted by lack of residencies. This could possibly also distort the cost of medical school. It is not an undersupply problem of people wanting to be a doctor.
It's always good to remember that D.D.S. stands for Doctor of Dental Surgery. Filling cavities is a lot more advanced than taking x-rays, scraping plaque and polishing enamel.
Amen to this. Like every other government regulation, government interference in the medical field simply limits competition and protects entrenched interests, it does not keep people safe (and that is not the real intention.)
> Let psychologists prescribe common, low-risk psych drugs (instead of scarcer psychiatrists),
What the hell? No, there's no way you want a psychologist to be prescribing medication. They receive absolutely no medical training whatsoever.
If you want psychiatric drugs without going to a psychiatrist, find a GP or NP. They're at least trained to practice medicine, even if they're not specifically trained in psychiatry.
You probably should not get psychiatric drugs from a GP or NP without first being assessed by a psychologist. While GPs have meds training, they aren’t trained in how medication fits into a larger psychological treatment plan to actually address the underlying issue. This is equivalent to demanding OxyContin from your GP for a recurring knee problem, rather than seeing an orthopedist to find out what’s actually wrong.
> You probably should not get psychiatric drugs from a GP or NP without first being assessed by a psychologist. While GPs have meds training, they aren’t trained in how medication fits into a larger psychological treatment plan to actually address the underlying issue.
I'm not telling anyone to do anything, but the idea of going to a psychologist for prescription drugs is beyond ridiculous.
> This is equivalent to demanding OxyContin from your GP for a recurring knee problem
It's worse - it's like demanding Oxycontin from your personal trainer at the gym. At least your GP went to medical school and did residency training.
I think you missed my point. I’m not saying psychologists should prescribe meds. I’m saying that medicating psychological problems should not be done in the absence of an appropriate diagnosis of those problems. This can be done only by a psychiatrist or psychologist (edit: and most psychiatrists aren’t trained in testing either, and will generally refer you to a testing psychologist if they think your problems are complex in nature). GPs and NPs do not have appropriate training in diagnosis.
My wife is a psychiatrist. She doesn't prescribe drugs to people with psychological problems. She prescribes drugs to people with psychiatric problems. She's been trained to know the difference. The PA that works under her has been similarly trained. But he doesn't understand the non-psychiatric medicine part that patients often times have.
What is the difference between a psychological and psychiatric problem? I've never seen these terms used in the same context you used them anywhere in medicine.
Hallucinations are generally a pyschiatric problem. Being manic/depressive is a pyschiatric problem. Being a jerk isn't. Having a hard time saying saying no isn't. There are gray areas. As a rough approximation, where drugs can help it's psychiatric, where they can't it's psychological.
5-HT1A stimulation results in decreased aggression, increased sociability, and decreased impulsivity. Sounds like a lack of 5-ht1a activity might make you a jerk, and it's stimulation might cure it.
I’m not a psychiatrist, my wife is. I don’t know hat 5-HT1A is or what your point is. The brain is an organ. It’s the only organ that can be harmed by non-physical means. My understanding is that behavior problems resulting from lack of certain “chemicals” or over abundance of them are psychiatric problems. Problems that don’t arise from such brain defects aren’t. When other organs are defective and don’t produce the right stuff to function properly people take drugs in order to function properly. The brain is no different except there are times the damage is not medical. There are gray areas.
5HT1A is a serotonin receptor generally thought to be responsible for the majority of SSRI effects.
Sorry I guess I wasn't very clear. My point is that there are some conditions that are just "medical". Things like parkinsons or ms. You usually see a neurologist for these conditions.
I'm arguing that any behavior a psychiatrist treats, has some neurological component. And many can be treated with therapy or drugs. So seems weird to use two categories where almost everything is falls into both categories
Think "bottom-up/biological" (psychiatric) vs. "top-down/behavioral" (psychological). Many behavioral disorders have components of both, which means that you either need a psychiatrist doing both med management and behavioral work (e.g. therapy) OR a psychiatrist + psychologist working together to address the problem. The second option can be quite a bit cheaper, since the behavioral treatment is usually far more time-intensive, and psychologists' time is generally less expensive.
>"What is the difference between a psychological and psychiatric problem? I've never seen these terms used in the same context you used them anywhere in medicine"
You really ought to stop pushing your uneducated opinions and do more research.
One this is a completely unhelpful comment. Similar to name calling. A much more helpful one would be showing that medical researches clearly divide problems into psychological and psychiatric.
And no one I know in research, or the psychiatrists I know would say there are many problems that fall into one category or the other. The vast majority of problems you'd see a psychiatrist for fall into both camps.
Mood disorders, and anxiety. The two most common categories of disorders are at least partially treatable by both therapy, and medication.
There are Mental Health Nurse Practitioners, who can and do prescribe psych meds.
I agree that letting psychologists prescribe meds is problematic due to lack of medical training, even though clinical psychologists have a PhDs or PsyD.
You need a prescription to buy contacts? Weird. In 3 European countries I’m familiar with they are a supermarket item (literally) or anyway simply an over the counter item from pharmacies and opticians’ shops
You can get the same brands of contacts from UK websites shipped to the US very easily (and cheaply). I know a few people who do this and they haven't had any problems yet.
People who have no idea about an industry saying how that industry should be regulated.
The reason we have different professions withing the medical industry is because of the years of training it takes to specialise in that area and get to a level of competency in that field.
Optometrists in the UK already prescribe glasses and contact lenses, I'm not familiar with the US system for glasses prescriptions but having to see more than one person seems... Illogical and expensive.
Nurses already push meds. After a suitably qualified and experienced doctor has assessed the patients records, seen or read a history and decided on a course of treatment. A nurse is not capable and should not be expected to know that level of detail about drug interactions and treatment pathways, that is literally what the doctor is for. Not everyone has the capacity / interest to know all this stuff, but we still need staff to tend to and care for our patients. Hence we have nurses.
Not to be disrespectful to nurses because they do incredible work and are essential to the medical industry and patient care but I happen to know quite a few nurses and doctors through friends and what I've come to realise is that anyone who can follow an instruction can become a nurse. And there are a lot of bad nurses. Thankfully not just anyone can become a doctor in the western world, because we have stringent regulations and laws.
The major contributing factor that adds cost to medicine are patents. Companies artificially inflating the prices of drugs and medical devices, not wages on the front line.
The thing that goes through my mind when I hear people talk about delegating more procedures to less qualified staff is... What happens when the dental nurse slips up and causes bleeding or hits a nerve and causes loss of feeling / facial paralysis. Does she run and grab a suitably qualified dentist and pull him away from the procedure they are currently performing?
People don't seem to realise that the reason we entrust certain people with certain jobs is not because that highly qualified person has done x procedure x numbers of times, it's because they have a very deep and thorough understanding of any complications and what to do when things go wrong.
Not just in medicine but in engineering and many other critical professions where decisions cost lives.
What you're talking about when you say deregulating is vastly increasing risk. There's a reason why current regulations exist and were created in the first place, because at one time they didn't exist and people died or became seriously ill.
I'd be genuinely interested to know what medical procedures people here would be happy to have a nurse perform rather than a doctor.
All of my close friends are doctors and the toll that school and residency does on the body and mind is honestly shocking. I'd want to open up the residency and med school programs for nothing else but to not force our young doctors into 24 hour shifts. They're treating these young doctors like it's Hell Week in a fraternity, and the main excuse you'll get from the AMA is because that's what they (the older doctors) did so all of this fanfare is a right of passage towards full membership (attending physician) which unlocks all of these riches to justify sacrificing your youth for.
To me, that's a much better narrative to support increasing the number of doctors than "they get paid too much." Instead, this article reads like a con artist who is using slight-of-hand to distract you from the watch he's taking from your pocket. The trick is the doctor's salaries, but the real stealing is happening from the health insurance companies.
The article mentions how many billions of dollars this "problem" impacts the Federal budget. "Billions" - it's a large number in absolute terms, but relative to the problems with our inflated military budget ($850B), it's a pittance.
What I'm trying to get at is this feels like the kind of thing a propaganda outlet would do to give you a false enemy to hate. Even if the premise is grounded in truth (that US doctors are paid twice as much as everywhere else), it just feels like the wrong villain.
> They're treating these young doctors like it's Hell Week in a fraternity, and the main excuse you'll get from the AMA is because that's what they (the older doctors) did so all of this fanfare is a right of passage towards full membership (attending physician) which unlocks all of these riches to justify sacrificing your youth for.
For the sake of nipping generational warfare in the bud...
My father runs a oncology fellowship. There are laws that prevent them from doing to our generation what was done to them. In addition, they don't want was done to them to be done to us. It doesn't benefit patients, increases drop out rates, and (especially in my father's field) drastically increases suicide risk and physician counseling costs. My father is currently 67, working 80 hours per week. He's not protected by those laws so he ends up covering for those hours that no longer fit the old formula, which means he did it both as a youth and in his 50s and 60s. There is a ton to crucify their generation for, but I really don't think this one is it.
> What I'm trying to get at is this feels like the kind of thing a propaganda outlet would do to give you a false enemy to hate
Once you account for hours worked, time spent in the workforce, and debt accumulated to achieve their income, a doctor will only have a 10-20% boost in lifetime earnings compared to a UPS driver. People seem to conflate income and wealth, which is a TERRIBLE fallacy to fall into. For some personal numbers, my father's income is double mine. Once you've adjusted for the those aspects I mentioned above, I'll have earned 80% more than him in my career.
Rules in place by the ACGME are laughable, no one respects duty hours and a certain residency program I may or may not have participated in told us to lie about our duty hours so not to get the program in trouble. From my experience the worst offenders tend to be older attendings who do not respect duty hours and will round on your post-call day at noon meaning you have been at the hospital for 30+ hours before you can give sign out.
> Once you account for hours worked, time spent in the workforce, and debt accumulated to achieve their income, a doctor will only have a 10-20% boost in lifetime earnings compared to a UPS driver.
Do you have any reference to back that up? Not doubting it. Just curious.
I did this math when I was 27 and wanted to leave programming to enter medicine. When I realized I wouldn’t come ahead financially until near retirement (and that was assuming I’d make a lot less in programming than I actually have) I decided to pass. It didn’t matter what specialty I picked except a few like plastic surgery or dermatology and there’s no guarantee of getting a residency in those. That’s also not considering that extreme hours worked in medicine and the loss of your youth. My spreadsheet also didn’t account for the fact I’m making mid-six figures in programming already at my mid thirties (!!)
Medicine is not a place to go to become rich. If you already have the brains and aptitude to overachieve in medicine you can succeed elsewhere even more greatly AND retire younger.
Base salary is low-six figures. I work at [insert deca-unicorn here] and a lot of that comp is locked inside non-public stock (I've been here a long time), so it could go to $0... or it could be enough to retire on. That's just the nominal risk-adjusted value of my compensation. Even assuming my stock is worth $0, just my base salary puts me ahead of going into medicine. The only way going into medicine makes financial sense over programming is if you fast track your way into it from high school and end up in a lucrative specialty, and even then it doesn't come that far ahead. Given the loss of your entire youth, I'd say it comes out even at best, unless medicine is a natural passion of yours.
I think that factoid comes from that shitty graph where the suppose that the UPS driver starts working straight at the moment they turn 18 and they will have maximum pay rate that is available for the UPS driver position.
While in reality, the average wait time to become a driver from loading is 11 years. During that time you make about $13/hr part time where the schedule can be horrible and you could work less than 15 hours a week.
When you do become a driver it takes another ~2 years (on avg) to get your own route until then you are a part time worker and your hours worked will fluctuate a lot over the year. The first year is paid at 17.50-18.50/hr (~$36,000/yr @ 40 hours a week) and then goes up.
> they turn 18 and they will have maximum pay rate that is available for the UPS driver position.
That's not the assumption. It's that they receive median pay their entire career, which would be reasonable if they never left their job. Getting paid 60, 70, and 80 over a 3 year period is the same as working three years at 70 ignoring inflation and investments. That's the assumption
> While in reality, the average wait time to become a driver from loading is 11 years.
Then compare it to the countless other blue collar trade skills that don't require any educational debt. The point continues to stand unless you want to focus on the example rather than the concept.
I ran the numbers recently and the numbers were even more grim, but I'd need to track down all my sources again.
I just think the main point is that income is not the number to focus on. Wealth is the end result of the equation, and income is only one part of that.
He doesn't have a reference because it's nonsensical.
Say it takes you 15 extra years to get into the workforce over a UPS driver, that you're saddled with $400k of debt and that UPS driver is the highest compensated driver in history at $100k.
$350k over 30 years is $10,500,000 - $400k = $10.1MM
Why talk about reality in terms of stories and angles? Why not talk in terms of facts and truths? You speak as if it is better to blame an insurance company rather then your doctor buddies because of a narrative. Are we so weak that we can't take the truth at face value?
These are the facts:
1. Doctors the US are paid more than doctors in other countries.
2. Medical care in the US is lowest in quality among most 1st world countries.
There is a logical outcome from these two facts: The high bar required to enter medical school or residency does not produce better doctors.
The other thing that gets me is why are we attacking insurance? Obama did it. It didn't work. You know logically if health insurance companies are all so evil, a good business startup idea would be to form a company that isn't so evil and cheap. This company will of course out compete all other insurance companies, by being the first cheap and moral insurance company! What a genius idea. Sounds really similar to obamas plan of simply using the federal government to enforce some moral principles onto the whole industry.
Maybe none of this works because insurance companies are already operating on edge. To stay competitive and offer customers competitive premiums they have to screw over people asking for claims. Maybe this occurs because medical costs in the US are too high? Why are all these costs so high? Probably to payoff someones' super high salary...
Look. Every medical cost in the us from insurance to hospital bills is higher than other countries. In terms of regulation the only difference between us and other 1st world countries is the supply of doctors and the supply of medicine.
The united states places the most restrictive cartel policies on these two areas. All other problems in the medical world stem from these policies.
The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. It’s a fairly well studied phenomenon. My SO is in med school right now and they just changed the regs from 16 hour shifts back to 24 hour shifts.
> The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes.
This isn't an argument that longer shifts result in better outcomes, this is an argument that the hospital's current handoff processes are insufficient, and that better handoff process would improve outcomes.
the hospital's current handoff processes are insufficient
Humans have 24h circadian rhythms that likely affect patient care due to timing of cortisol release and other cyclical bodily events... It makes sense for an attending nurse/physician to be present for that full 24h cycle to gain a holistic understanding of patient recovery during various phases of the day.
If you're handing off a patient every 12 hrs, you're going to have fewer experiential data-points to judge if their condition is improving or worsening, no matter how detailed a hand-off can be. It'd be even worse with 8h shifts. Further, if a Dr has a patient come in with a unique condition, they're not going to leave just because their 12-hr timer dings.
> to gain a holistic understanding of patient recovery during various phases of the day.
Define "holistic understanding."
Is the doctor actually sitting bedside with the patient for the entire shift? Of course not. More realistically, the doctor is coming in, making some observations, and then moves on to the next patient.
So here's an idea - couldn't you shoot video of the observation, and shoot a time-lapse video of the otherwise-lacking-direct-observation periods, and show those to the physician in the next shift? All that the attending physician has to do is vocalize his observations (of course a camera by itself can't sufficiently observe), and the hand-off physician can watch the clips just like he could read the chart. Such clips may also be accompanied by speech-to-text to produce quick summaries.
There's simply no doctor in the world who isn't privately treating a single patient who can compete with the number of experiential data-points which a computer can provide.
And those "data-points" are worthless. You're basically suggesting cooking thru a camera and expecting better outcomes because the broth is constantly monitored by a cam.
Is based on the premiss of a smaller incision and more precise tissue manipulations leading to better outcomes. Nothing to do with a camera ;)
> presence of cameras automatically makes medical care low-quality.
Of course not. My point is that it does adds ~ nothing to the quality of care, just like cooking thru a webcam should not be expected to result in tastier meals.
Doctor’s observations are a complex synthesis of information obtained through the five senses (and not only by seeing) and “gut feeling”. They can help narrow down the diagnosis, and predict forthcoming complications. This cannot be captured by a camera.
I’ll give you an example of the “holistic understating” kirse was probably alluding to.
A 80-yo guy is admitted at 9pm for COPD exacerbation, is treated with the usual drugs, gets better. Was very anxious and well awake on arrival. You come to check back on him at 2h AM, and he seems a bit slower, and uncharacteristically relaxed. You suspect he’s getting hypercapnic, order a blood gas, and discover that he is indeed. You proceed to treat him with a BiPAP, and save the day.
If you did not see the patient before, it is very easy to interpret his sleepiness and relaxed breathing as a totally normal state for a 80-yo guy. It is indeed very easy to think he’s got better. See, he’s finally sleeping, breathing calmly, everything’s fine.
Even a family member sitting by the guy side since his admission is likely to miss the subtle signs, precisely because his observation is continuous, and the change is slight and slow. Discrete episodes of reassessment by the same qualified person is key !
And other countries got rid of long shifts for exactly the same headline reason. Standard of care suffers if your doctor has been running hot for 24 hours and does something stupid.
I think it's possible that both things are true. The problem comes when traditionalism is in charge (as it usually is, being senior). "I had to work 48h shifts and I never killed anyone who didn't have it coming, why shouldn't they?!"
It also ignores —in the way only a doctor can— that being away from your family has both a cost on them and you. This isn't something you can just throw money at. You need numbers.
But yes, good handover procedure is essential to. However long the shift.
It's pretty widely discussed but I don't think it's as well studied as it should be. The shift from 24 to ~16 was made without much evidence, and analyses subsequently didn't support the change.
An awareness that we need to study these decisions before making them has finally taken hold. To that end, trials are now ongoing that have randomized residency programs to the (shorter+more handoffs) vs (longer) shifts.
Patient outcomes are obviously the most important, but measures of physician wellness would be a valuable secondary outcome.
So I take it there is data that the reduction from 24 hours to 16 hours that occurred a while ago resulted in a lower standard of care? Can you show it to me?
As an engineer, I used to think I didn't have what it takes to work long hours. After about 5-6pm, I'd start making mistakes, and my productivity would be roughly halved. I'd occasionally come in the next day and realize I had screwed up and would spend the morning redoing the work I did after 5pm the previous day.
Then I once stayed at work late not for my project, but to help other coworkers who I thought "had what it takes". It was insightful to see they made the same number of errors that I did, and had I not been there, they would have had to redo the work the following morning as well.
This is especially true for simple, tedious work, which a lot of medicine is about (at least at the nursing level). Things like administering medications.
I'd like to know what magic they use when training doctors in their residency to avoid such errors that other industries have not been able to master.
Yes, handoffs are risky for patients. As is being tired.
But there would still be a loss of information after 24 hours. Improving quality means upping the shift to 96 hours. We should encourage doctors to not sleep as sleeping means loss of information.
So it's not reasonable for a person to work 96 hours. But apparently it is reasonable for 24 hours. The goal is to minimize information loss while maximizing performance. There's a tradeoff. Apparently 24 hours is a local max in this tradeoff.
Absolutely does. And that's precisely the reason why inpatients are treated by the same doctor for as long periods as is humanely possible, i.e. usually one-week stretches on call.
"If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. It’s a fairly well studied phenomenon."
Doctors have a hard time, but you can't lower US healthcare costs without lowering the salaries of those involved (which is why it is so hard). The fact of the matter is that they are high for reasons both justifiable and other less so.
Insurance companies profit margin is actually not very large on average (~11% I believe -- even worse for those in states with cost-spiraling providers post Obamacare), and while they are nobody's favorite they take a disproportionate amount of heat for what is driving up costs in healthcare.
Healthcare salaries are the bulk of the costs of the healthcare industry, just like administrative & teacher salaries are the bulk in bloated education budgets (well, outside of things like waste on things like sports programs). That's just the breaks, and its important to acknowledge they are a lobbying interest group as strong as any other (actually, one of the strongest/highest spending)
So, shortage of doctor supply (like with housing) really really has an impact. It also does not help that hospitals frequently have veto rights over other health institutions opening up on their turf. Really. Another problem is regulations that encourage consolidation of providers (see BCBS & Partners here in MA) further diminishing pricing ability (and this is additionally really bad for insurance companies, who have less leverage to fight back against high charges from fewer hospital networks)
The fact of the matter is that the US over-spends on just about every sector of the economy because the US is richer. Richer countries also disproportionately spend on healthcare of frequently marginal benefit at best.
Not sure what the military budget has to do with this. It's a lot, but that it is bloated doesn't mean more health spending is justified or that we do not over-spend on doctors -- they aren't comparable things.
Whatever sacrifice doctors make in school is what justifies the salaries, but you also have other forces at play (largely regulatory burden, or bad regulations generally) that are causing them to drop out of being a GP in the first place as they chase higher paying spots as specialists.
I work in healthcare and know, and went to school with many doctors. I hear this "long hours" compliant all the time. The problem is, they all seem to assume it's someone else's problem to fix. If physicians and med students want to get rid of the 24 hour shifts during residency, well they have to make that happen internally. They drive that decision, not the patients.
The whole 24hr thing seemed ridiculous to me, until I learned about the concept of continuity of care and a loved one spent a few stays in inpatient care. Now I don't really know what the answer is anymore. It sucks to be regularly handed off when you've just established some rapport with your provider and reached treatment plans, and the evidence shows it impairs outcomes.
I speculate whether we could have duos who rotate with each other, rapidly trading naps and duty & working closely together, over say a 48, 72, or 96 hour period. Barring emergencies, each gets 12 hours rest a day, and from the patient perspective they function as a tag team. But, not a healthcare professional.
In most services, the treating physician is rotating on a weekly basis. That's pretty much the most convenient/tolerable/safe period of continuous work, as long as you do not receive more than 2-3 calls per night.
Call number is dependent on the acuity of patients' condition, and the ability of the house staff (i.e. residents on site) to manage minors problems without immediately consulting the attending by phone.
Good comment. One disagreement I have is the implicit dichotomy that it's either the doctors or the insurance companies who are soaking the patients/consumers, and not both.
Both the MDs and the insurance companies are rife with a number of rotten incentives and bad actors that contribute to expensive medical care without quality commensurate with costs.
In fact, the entire policy debate over risk-based vs fee-for-service payment models is essentially the payers and providers arguing over who gets to rip you off.
You are 100% right. You can't identify a single factor that's causing high cost because all players are rotten. Insurances, doctors, hospitals, pharmaceuticals are all bad players in a system that benefits them at the expense of patients.
The US spent 3.2 trillion on health care in 2015. 100 billion is 3.12%. It doesn't seem like that big of a problem. This article is just capital scapegoating labour as the source of the inefficiency and insane costs that is particular to the American Healthcare system. If you want an honest discussion, look to the heart of the issue, which is the fundamental incompatibility with effective healthcare and America's fetishism of libertarian market dynamics. I mean even in the Swiss healthcare system which maintains private insurance participation, family doctors on average earn CHF 198,000/USD 201,732.
This is just a hit piece by big Pharma trying to squeeze dollars out of labour and we in tech who went through 4 years of schooling to collect comfy salaries for a few hours a day of productive work, we in tech who love to bash H1B's and foreign grads for increasing our competition, and we in tech who seldom reckon with real human suffering, fear, and death in our line of work, are absolutely eating it up. I absolutely look forward to the time when the squeeze comes and companies pivot to blaming us as the reason for the high costs of goods or as the limiting factor stopping execs from achieving the revenue gains they promised investors.
If we spend $3.2TR on medicine and roughly 50% of that is 'overspending', as the article suggests. Then we have roughly $1.6TR in systematic inefficiencies. If the misapplication of occupational licensing for doctors are $100BN of that or 1/16th. What, specifically, is the other 15/16?
I think that author makes a good effort to itemize at least one of the components, now we should be asking what the rest are.
Could be wrong but I have a feeling that most of the other costs are related to either mitigating or fighting malpractice lawsuits. Do any other countries have a lot of medical malpractice lawsuits besides the US?
You would be wrong. We have a natural experiment in that some US states have imposed caps on malpractice damages, yet they have experienced only slight decreases in overall medical costs.
Among economists, Dean Baker is literally Big Pharma's worst enemy. If somebody didn't like this article about doctors, just wait until they read his proposals for the pharmaceutical industry.
You're correct that doctors' salaries are not the biggest source of excessive health expenditure compared to other countries. But the article is right that medicine (i.e. physicians) behaves like a cartel in that it places rules to limit supply and force salaries upward, even though there's no legitimate reason for this based on safety or otherwise.
Your local family doc has nothing to do with this, but there must be some powerful interest groups involved (at least historically) to make this the case. So it's actually that NON-libertarian forces (i.e. illegitimate regulations) are increasing physician salaries. If we had more of a free labor market for physicians, salaries would fall.
One of the force driving salaries up is strict control of immigrant doctors. Its is million times harder to qualify to work in US as a doctor compared to immigrant software engineer.
It's a huge issue in my opinion. Doctors who learn in Europe simply can't work here unless they get qualified in the state they want to work in, which is a waste. You see doctors from India and various other Asian countries because it's worth their effort to do so. But the USA should open it up to doctors from other countries to more easily work here. Simply passing a "Certification" or something should suffice.
I very much wanted to believe this, but the study you linked to lists "Percent of national health expenditures for physician and clinical services: 19.8% (2015)".
What do you think accounts for the discrepancy between 3.12% and 19.8%?
Covers all services provided by hospitals to patients. These include room and board, ancillary
charges, services of resident physicians, inpatient pharmacy, hospital-based nursing home and
home health care, and any other services billed by hospitals in the United States. The value of
hospital services is measured by total net revenue, which equals gross patient revenues (charges)
less contractual adjustments, bad debts, and charity care. It also includes government tax
appropriations as well as non-patient and non-operating revenues. Hospitals fall into NAICS 622 –
Hospitals.
Physician and Clinical Services:
Covers services provided in establishments operated by Doctors of Medicine (M.D.) and Doctors of
Osteopathic Medicine (D.O.), outpatient care centers, plus the portion of medical laboratories
services that are billed independently by the laboratories. This category also includes services
rendered by a doctor of medicine (M.D.) or doctor of osteopathic medicine (D.O.) in hospitals, if
the physician bills independently for those services. Clinical services provided in freestanding
outpatient clinics operated by the U.S. Department of Veterans’ Affairs, the U.S. Coast Guard
Academy, the U.S. Department of Defense, and the U.S. Indian Health Service are also included.
The establishments included in Physician and Clinical Services are classified in NAICS 6211-Offices
of Physicians, NAICS 6214-Outpatient Care Centers, and a portion of NAICS 6215-Medical and
Diagnostic Laboratories.
So as a quick summary, physician pay isn't the same as physician and clinical services. Both categories includes salaries of doctors. The statistic people are looking for isn't readily available in the numbers they are quoting. 3.12 and 19.8 are unrelated numbers.
EDIT: You can calculate expenditure relatively easily. Some assumptions: The link lists median pay at 295k, but Bureau of Labor statistics actually has it at 208k, and google's auto-suggest puts it at 187k in 2015. I'm just going to run with 250k.
250k median salary^ * 950k active physicians / 3.2 trillion US healthcare costs = 7.4%. 100b is a commonly cited number, but I can't find the source. My calculations put compensation at around 237b. Here's a corroborating source as well:
Disclaimer: My father is a doctor, my mother is a nurse. I get really annoyed when this crap comes up on HN. Tomorrow we'll have an article that leads to a discussion about how the engineers on this site are making 150k-200k and complaining about being underpaid, all while criticizing other careers that necessitate higher educational attainment and greater career risk.
"hit piece by big Pharma" seems a bit overstated. It has the same lack of nuance that an accusation by drug companies often make against AMA as a cartel in defending drug pricing. There are examples of gross abuses and genuine value on both sides of this--and also in hospital administrators and insurance ( did I leave anyone out?) Side note: My personal experience leads me to think that many specialist physicians are more than fairly compensated, and good nurses are less so for their value.
I'm not sure what you intend on accomplishing by noting that doctor's salaries here are still more expensive than one of the most generally expensive western countries in the world.
Conspiracy theories about 'big pharma' on something from CEPR helps no one.
No, no, no, you don't understand. Although our doctor's salaries are much higher than other countries, it's okay because our drug costs, medical supply costs, ambulance costs, hospital administration costs, and insurance company overhead costs are also much higher. Therefore, doctor's salaries just a small percentage of health care costs in the United States.
1. It's actually an EXTRA $100 billion per year - "Because our doctors are paid, on average, more than $250,000 a year (even after malpractice insurance and other expenses), and more than 900,000 doctors in the country" - the TOTAL we spend is about ~$240 billion dollars
2. That is SALARY ONLY. You aren't including the fully loaded cost of doctors: many get large Christmas bonuses, company stock, health care - that could easily be an average of 75k more per doctor
1. That’s the point: how much extra we seem to be paying vs other places (which have good healthcare).
2. You are wrong here. Click through to the source and you’ll find the number is for overall compensation, not just salary. E.g.:
For employed physicians,
patient-care compensation
includes salary, bonus, and
profit-sharing contributions.
For partners, this includes
earnings after taxes and
deductible business expenses
but before income tax.
I think you should be carful about making strong claims like that without checking the facts first.
Indeed, I've read that many if not most doctors are self employed. They also own the clinics and have access to "insider" investments such as purchasing and operating diagnostic equipment. In addition, I've also read that doctors make up a large proportion of the investors in medical provider businesses, and even the malpractice insurance industry.
I'd expect salaries to be an incomplete measure of where the money is going, and to whom.
I think the only way to get a true cost accounting of the health care system is to operate the whole thing. This may be why other countries have lower costs.
That hasn't been true for a while now. More and more physicians are employees of large provider groups rather than owners or partners in small practices. The provider organizations have to merge and consolidate in order to get negotiating power for dealing with payers.
This a thousand times. In our current world, if you are still reliant on a salary as your primary source of income, you're not especially part of the problem - you might very well earn 10x what other people are earning, but you're still hustling as we all are.
The people who pull the strings through their wealth, are able to lobby politicians, and or even other companies are the real problem.
Software practitioners could learn a lot career-wise from our counterparts over in medicine. Here's a profession with salaries more consistently high and more commensurate with the value they provide, where they're not as worried about global competition, and where ageism is not a factor. They have strong professional organizations who not only set competence standards and control labor supply. They lobby the government to mitigate competition and legislate who-can-do-what, with results very friendly to M.Ds. This is in stark contrast to the free-for-all race-to-the-bottom that characterizes tech labor.
I'm not sure what an "AMA for software developers" would look like or do, but I'm pretty convinced a strong organization would be overall beneficial.
You are missing a big item in your analysis. Doctors are basically given a territorial monopoly. Just because someone in India does the same procedure for 10% of the price (they do right now), doesn't mean when you have a heart attack you can go fly to India and get it treated.
If you are just a COG in a wheel writing J2EE JavaBeans, it takes almost no work to send it over to a body shop in India.
That is why it would not work well to stamp your foot down and try to get a software union in the US. (Let's not even get into the popular view of unions right now, and assume it would be reasonable to form some kind of software dev guild).
Kinda sorta. I mean yes I hire american devs because it is easier to communicate with them. But if say you told me all american devs cost $1 million dollars (or even 500k) due to a union.. I would make Russan devs work :)
Even things that are not 1:1 replacements still influence the max value of something...
> where they're not as worried about global competition
Because, in general, it's difficult for 99% of customers to drive to another part of the world for care. It does happen, of course, for those with such resources.
> have strong professional organizations who not only set competence standards and control labor supply
That decide who can and can't create simple REST apps and games? That charge huge amounts for certificates that they've lobbied be required even though they'll be universally panned as useless?
> lobby the government to mitigate competition and legislate who-can-do-what, with results very friendly to M.Ds
So, yes. Ban out everyone that was self taught. Or went to the wrong schools. Or in the wrong country. Build huge walls around who is allowed to learn the mysteries of the machines sitting on most desks and in most pockets so that a chosen few can become rich at the expense of all those locked out
> stark contrast to the free-for-all race-to-the-bottom that characterizes tech labor
Goodness forbid you be required to be more useful than other people in order to make a living. It would be a better world, surely, if you could just get your stamp of approval and be set for life, knowing people had no choice but to choose you
I see constant need for developers everywhere. We cannot hope to create all of the programs that need writing right now, and you want to cut out a huge segment of developers for being distasteful in order to pad your pockets.
Don't forget to make users get licensed to use Access and Excel et al while you're at it. Those are pretty program-y applications.
This will never happen as long as we continue to have a broad distrust of academics and fetishize the hacker with no formal training. We don't value ourselves as a profession and so we reflexively reject the idea of forming a professional organization. There's also the fact that a significant portion of software developers have no or sub-par formal training and are insecure about their ability to pass any rigorous standardized testing, and so there's some measure of self-preservation involved in rejecting a formal licensing body.
I’ve been repeatedly denied by gatekeepers disinclined to let me inside
They say stay at the perimeter. Keep to the outer limits. They’re the ultimate limiters. Competitors can’t get in it.
If we can’t even begin, they keep taking the win. We stay thin like we’ve been. They keep raking it in.
Good luck plucking a chicken or an egg from nothing. Success flows to success, and so far I hear no clucking.
I’ve jumped through enough hoops in my lifetime. More exclusion? No thank you. If we take cues from anyone, let it be tradespeople, e.g. apprenticeships.
Main issue is enforcement. Engineering is a good example. Engineers become licensed have guilds etc. Thing is they tend to work on things that are in the physical world and if they break they will cause death and destruction. So the government will force a company to have an engineer stamp that this design doesn't suck and hold them liable when it does. More importantly, most infrastructure projects engineers work on tend to have government involvement to begin with meaning that someone with power to enforce the law will decide that it is appropriate to work with a licensed engineering firm. This becomes much more challenging at a typical software shop that is working on some run of the mill web app that won't really impact anyone's life adversely if things go wrong and generally have an opt in mechanism to begin with (i.e. Facebook or Google). I'd say where it would be very very useful is making it so that license software engineers are the one's who sign off on something like Equifax to prevent security breaches, or basically any software that impacts someone's life directly and can't be reasonably avoided (think banking software, medical software etc.)
* You can't outsource your doctoring from another country easily.
* People can get hurt or die from a bad doctor, but that doesn't apply to the vast majority of software development.
This puts doctors (and many healthcare professionals / companies) in an excellent negotiation position that we don't have.
I also think that doctors aren't the only stakeholders. I think doctor's offices hardly compete with each other and can still have terrible hours, fewer working days, and still make you wait after showing up for an appointment because the supply is so constrained. I wouldn't want "software developed in the US" to be similarly non-competitive.
On the other hand when a doctor has a degree, chances he/she is very competent.
On the software side of things, everyone claims to be the best and disasters happen every day. If there was an "AMA for software developers" Equifax probably wouldn't have happened.
Hiring software people is very hard, recruitment business around hiring software developers is booming. I'm building Cruitie: https://cruitie.com
I think Cruitie would be irrelevant for doctors, the software world is wild.
This guilding is done at the cost of other doctors and at the cost of patients.
Sure, if you ban immigration and dont allow americans to use software from other countries software salaries in the US will surge, at great cost to americans in general.
I'd rather not be in the side that oppresses people.
Sure, but when the salaries are too low like they are in Southeastern Europe doctors don't want to schedule surgeries($500+), do a proper look-up ($50-100) or even bother to check on you or when an inadequate doctor/nurse/practitioner checks on you or does a procedure and screws up what happens? Nothing. Tough luck pal. Healthcare is public, you're required to pay for it and it's deducted from your salary. What do you get in return?
Two nights ago I brought my girlfriend's sister to the ER, her appendix was inflamed, she couldn't walk, talk or move due to pain and was left waiting for an hour. They did blood work and gave her an IV and sent her home, told her "we cured you" after another blood work was completed and her leukocytes dropped a bit. No ultrasound, ct or anything advanced, they haven't even properly checked her stomach. Her leukocytes were >19000.
I was later told by a friend that I need to give a 50 to the nurse to push her through the line and another 100 to the doctor. Great world we live in.
Don't get me wrong, but I think you should not fix something that is not completely broken. Your doctors still do their work and don't expect money, expensive gifts, bottles of whiskey and roasted pigs like they do in my home country.
In my country number of doctors you're allowed to have in a Clinic/ER/Urgent Care is proportional to the number of people living in the region. There is 1.3 gynecologist on a region of 10,000 people. Is that normal? My grandmother has to schedule a month and a half in advance to get her prescription medication and check ups are every two-three months. Not sure how it is in the States now, but in my 10 year tenure there and 10 times I was in the hospital, I never waited for more than 10-15 minutes after my scheduled time.
> Sure, but when the salaries are too low like they are in Southeastern Europe doctors don't want to schedule surgeries
Nobody is saying to pay doctors according to undeveloped country standards. We're talking about developed countries with similar if not better health outcomes.
Salaries for doctors are too low for the Southeastern Europe standard. The whole point I was making is that you should not lower it as per your standards. It's good as it is.
The point the article is making is that the US is getting significantly lower value out of their doctors than other comparable countries. They pay doctors more and get worse outcomes, which points to the conclusion that the doctors are overpaid for the value they provide.
Jacob - I'm living in Serbia. This has happened to us in Novi Sad couple of nights ago. I should have maybe added Southeastern Europe. I'll fix that. Estonia is light years ahead of my home country! :)
It's too bad this is the case. My experience with the medical professionals in my area isn't particularly positive. Many of them just look up symptoms on some kind of medical Google and regurgitate what the screen says.
I had RSI in my wrists for years. I had several different diagnoses, and none of the treatments worked. Finally I found Dr. Sarno's book and my RSI has been gone since then.
I guess my point is - we pay these people a lot, and they aren't even particularly competent at what they do. I'm sure the Mayo Clinic specialists are, but those folks are making more like 500k a year. To be competent.
I understand that feeling of incompetence when you watch them look up symptoms in front of you. But think of it like a programmer digging into a language’s documentation or a structural engineer looking up calcs in a load table. You can’t be expected to remember every single detail. And it requires tons of experience to trust the result you’ve chosen. In other words, would you rather have a practitioner that works purely from memory, or one that checks their assumptions against the corpus before making a diagnosis?
If I hire a web application developer who says they are proficient in JavaScript, I expect them to be able to get moving without checking documentation constantly. Certainly they should check it to confirm a hypothesis or to jog their memory on individual API calls, but any decent senior programmer need not check the docs for simple things, or at least they will start with an idea of what they are looking for "I know there's an API that does this..."
The doctors I encounter are the equivalent of a junior developer right out of code school, checking the docs for everything. That might be OK, if we were paying them commensurately with their value add.
Using the same analogy, when you hire a JavaScript developer they are going to know a ton about JS itself, but nothing about your internal libraries and system, and that's something they are going to catch up on when they can, and for a large enough system, they are going to probably gain domain knowledge in a specific portion of your code base. However, they will know how to make an array, class, subroutine, etc. (I'm not proficient in JS right now, and would probably have to look all this up - in perl I can do it without thought).
Similarly, my doctor _should_ know how human anatomy and microbiology work by default, but the person that they are speaking to is essentially a black box. When that black box is diseased, then it's as if the body has imported a library. They cannot easily check the source code to determine which library they have imported or what calls it is making, so they hunt through a bug database to determine which library they have imported and what the code is doing, and then they have to find a way to get that code out of the system, still without access to the source. Of course, they will probably know some things (sinus infection, flu) by default, but medical science is constantly updated. Still, that knowledge of anatomy, microbiology, etc., is tantamount in being able to accurately use that data for assessment.
> they are proficient in JavaScript, I expect them to be able to get moving without checking documentation constantly
You might need to adjust your expectations.
I check documentation all the time because I can't remember what language uses 'size', 'size()', 'length', 'length()', 'count', or 'count()'. I have no value in memorizing those facts because I can simply look them up.
Yeah, if my bugfix was scheduled three months out and had to be figured out, implemented and merged during a half hour appointment without making things worse-- I would read the docs for literally everything, and probably copy-paste from them to avoid typos
I guess the point is that they're largely technicians drawing from "the literature" (doctoring books, research, as well as user manuals for drugs and instruments). With a ~first year grad school level of understanding bio/chem pretty much anyone can be a competent technician in 90 percent of cases, and literally anyone can implement a cure so long as they can read the instruction manual (and it isn't tricky surgery).
I dealt with an RSI issue and had a similar experience where traditional hospitals and MDs did not help. I needed to go outside that system to get help. The hospital system is simply not setup to deal with those things; it is setup to deal with people who are possibly going to die. Imagine this is your job: the city you live in collects all the people who are so seriously sick or injured that their families/friends are worried they might die and brings them to you. You have to deal with all of them. Any of the people you can't assist don't get treatment and their illness takes its natural course. Now imagine how much of your training is focused on RSI.
If you think of a modern hospital as a direct organizational descendant of a war triage hospital, albeit one that is dealing with the health issues that kill the American public (generally cancer, heart disease and other manifestations of our unhealthy lifestyles), then you will have a better idea of when to go there. i.e. your problem must be acute.
Yes - but they start accumulating wealth in their early 20s. That gives them at 10+ year head start on the average physician who finishes paying off their debts at ~35.
Software engineers aren't $200k+ in debt at 32 either.
If you are an average salaried software engineer, you can accumulate more wealth than a doctor if you invest at recommended rates. The break even point is somewhere around 60-65 years of age.
It's more difficult to gain admission to veterinarian school than medical school (in America).
Veterinarians pay about the same for their schooling (but they don't really have residencies) and vets make ~70k-80k/yr.
If we think of a job's salary as a function of the talents used by the job and the cost of admission to the job, it's unclear why doctors and vets should earn substantially different amounts of money.
But I agree that it's easier to accumulate wealth as a non-doctor than a doctor. Just treat the first couple years of your career like medical school and it shouldn't be too hard to crack 6 figures - if you live modestly outside a megaopolis, you can save 40k/yr and get a six figure headstart over a doctor.
Many Univ. alumni associations will provide access to UpToDate along with their regular academic journal access library. My Univ. was an upfront $200 lifetime fee or a $10/year fee. Compared to NetFlix, the benefits are insane and obvious.
I'd have to agree that they aren't very good at solving certain issues that aren't just acute and short-term. I had been developing worse and worse shoulder, neck, and back issues from sitting at desks and working on computers.
The doctor wanted to prescribe muscle relaxers and pain relievers, and suggested I try massage therapy. While those things helped some of the symptoms, what completely transformed my situation was hiking and doing yoga (especially yoga). I never have pain like I used to in my back, neck, and shoulders and any that does arise never lingers like it used to.
My doctor did not suggest yoga or hiking (or exercise in general) to solve the issues I was having. I know it's an anecdote, but in general in my life doctors seem to try to be experts on matters of health yet can't seem to help with basic beneficial suggestions for certain issues.
Funny that you mention Mayo. Their doctors are paid mostly on a tenure basis and their income is not based on how many patients they see or what kind of procedures they decide to perform on them, unlike in most other places. It's still not cheap, but there's less of an incentive to milk the patient or the insurance company.
The article failed to mention the high cost of medical school, high interest rates for loans, and being phased out of interest deductions from earnings (which are capped quite low IMO to being with). My wife attended a Big 10 university medical school, costing around 50K/year, graduating with around 200K of debt, added to her 50K of undergrad debt, deferred through most of training, making 50-60K as a resident and fellow, looking at a 2000+/month expense for P&I on those loans. We've re-financed it, but the rates are still quite high relative to car loans, home mortgage etc., so of course this reality of essentially carrying a second mortgage of debt, was a factor in her choosing to go into a specialty, with additional training (fellowship), and moving to a lower cost, higher demand (higher wage) area. We pay 15K+ INTEREST annually on those loans and we are phased out from deducting any of that. If undergrad was less expensive, or free as it is in other countries, if med school was less expensive, doctors could enjoy the same quality of life with less salary.
A common argument to justify high salaries is that the education is expensive. But its the other way around: education is expensive because salaries are high.
I also dont feel sympathy for how the medical education gets to have people hostage, as a reason to "not lower physician salaries". Its like saying that a slaver paid for his slaves, how can you take them away from him! It cost so much!
In any case, if salaries went down, less doctors would go to college, and colleges will either lower students or lower prices. Easily make-upable if you allow reasonable residencies for foreign doctors. The US could absorb an infinite amount from abroad where the cost of education is not irrational.
In argentina, a cardiologist might make 4000 U$S a month. If he could, he would jump ship to practice in the US immediately.
Isn't the important statistic when break even with someone who makes less but started saving earlier with less debt (say only college debt). I haven't run the numbers but 250k in debt doesn't seem so bad if you make 300k after you finish at 32, compared to making $100-150k with 50k debt starting at 22.
You could also compare the opposite, if you have 250k at 19 is it a good investment to go to medical school or take a less lucrative job and just invest the 250k in index funds, I'm guessing medical school still comes out on top, maybe after 20 years.
I agree with your point. I never understood why making >150K starting at the age of 32 with a debt of about ~300K is an insurmountable burden. I have a close friend who fits the above profile. She actually makes about ~200K/year (after tax and everything, she nets about 100K); her work hours are nothing unusual--~9-10hours. With this rate, she can comfortably pay off her debt in ~10 years top.
Changing careers is definitely an issue when you end up with 200k+ in debt. Although, even without the debt 10 years has a large opportunity cost. However, not saving because you make money is up to you, if you want to live lavishly to make up for the 2 decades living like a student who is to say thats wrong. You'll obviously end up with less savings but if your a doctor I think you can figure that you.
"The number of slots supported by Medicare has been frozen for two decades after Congress lowered it in 1997 at the request of the American Medical Association and other doctors’ organizations."
Fact check: False. That figure is comparing the total number of applicants to the match with (first year) residency spots. But the total number of applicants to the match is not the same things as students accepted to (U.S.) medical schools. Foreign medical grads are dying to get trained in the States.
If you read on in your link, you'll see that "[t]he PGY-1 match rate for U.S. seniors was 94.3 percent", while the match rate for non-U.S. medical school graduates is slightly above 50%.
Again from your link:
"This year, 35,969 active applicants vied for 28,849 first-year and
2,908 second-year (including physician (R)) residency positions.
U.S. allopathic medical school senior students comprised 18,539 of
the active applicants, 352 more than in 2016. "
US medical school graduates have no problems matching, the ~5% who don't usually do so because of their match application strategy, and have the opportunity to scramble at unfilled positions (of which there are ~1300).
The drop out rate for med school is under 5%. Infectious disease is a 3 year fellowship that's done after completing a 3 year internal medicine residency. Oddly, the average salary for infectious disease specialists is lower than that of internal medicine physicians. Economically, it doesn't make sense for internal medicine physicians to spend 3 years doing a fellowship only to make less money on the other end. On top of that, these physicians are missing out on an attending's salary during those 3 years of fellowship.
1) Physician salaries have been decreasing relative to inflation for the last 30 years. Decrease it further, and opportunity cost will drive smart talented people away from healthcare.
2) Physician education and training are fundamentally different from nursing education. Not just in duration, but also in mindset. Doctors think through medical problems through a physician mindset, and nurses think through nursing problems through a nursing mindset. Simply letting nurses make medical decisions without the proper frame of thinking has been proven to have higher rates of complications and misdiagnosis and physician consultations.
3) The main driver of healthcare costs is not physician salary. More attention needs to be paid to equipment, capital infrastructure, nursing staff, administrators.
One problem not covered by this story: it takes too many years to acquire a medical degree. In India, you can go to medical college right after graduating from high school. It only takes 5 years in the medical school to become a doctor. By age 22 you are a doctor. Compare that to the US: you have to get degree from a 4-year college before going to medical school. This is wasteful, unnecessary, and increases the cost of medical education, which in turn increases cost of medical care.
You don't always have to have an undergrad. A good friend's Dad earned an MD/PhD from the University of Chicago without an undergrad. This was in the 1960s though and he entered after doing a stint in the Peace Corps.
This is less likely now since competition is so high so undergrad courses/GPA is a filter, but it does speak about how an undergrad degree is strictly orthogonal to the job. You could probably get away with it today based on the MCAT as proof of pre-qualification maybe...
Same in my country (somewhere in SE Asia) too. I went to med school there for 2 years. It takes a total of 5 years there and doctors who are trained there eventually leave the country to practice in UK, US, etc. I have a few friends who graduated in my country and are making big bucks; all of them came to the US as IMGs (international medical graduates) and did well in USMLE exams to get into residency programs and hospitals eventually. That's why I don't think the 4 additional years of undergrad education (implicitly) required in the US is necessary. It only adds more debt to the would-be doctors.
I'm aware that that many of doctors' high salaries are due to the government creating artficial shortages and I support less government regulation in order to make helathcare better and more affordable.
That having said, I don't think high doctors' salaries are the most important societal problem in healthcare. Years and years of studying, long working hours, great responsibilities, saving lives and healing patients: doctors are welcome to their high salaries.
Thanks! Had that wrong, or remembered it incorrectly. NYT says 10% in another article.
Its still considerable. Have to take into account that a 5% reduction in price can lead to a much higher increase of consumption than 5%, particularly on things like healthcare in the us that have clear excess demand.
My wife is in medical school and we often talk about these types of issues.
I think this article is a bit misleading in suggesting that the limitation of spots in residency programs are intentionally and disingenuously imposed.
The reality is training doctors is very, very hard and there simply enough resources to do it properly. This is not an issue with medicine alone.
We're seeing similar trends in the tech industry where developer salaries are sky-rocketing because there is a lack of highly qualified talent. Even with a slew of "bootcamps", "code universities", and a general influx to the industry the tech industry still doesn't have enough highly qualified individuals.
The medical industry is facing a similar issue, but everything has even higher standards because medicine involves human life. The medical industry is trying to keep up (my state has opened 3 new medical schools in the past 5 or so years), but it takes a very, very long time for organizations to find the proper resources and build a proper program. I believe my wife's school was in works for 10 to 15 years before opening its doors 4 years ago.
Opening more spots requires finding qualified doctors who not only understand the subject well, but can actually teach it. This severely limits the sample size. On top of that, these programs also require doctors who are willing to put up with medical students and residents on a daily basis.
Could you imagine if you were paired with the new development intern every day of your working life? You'd go crazy.
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I do think something needs to be changed, but I don't think medical schools and residencies are really the place to make an impactful change. I see a lot of value in doctors becoming "supervisors" and managing a team of nurse practitioners or physician assistants. Then again, we're seeing similar training issues in both of those fields.
Programmers are making a fortune because they are critical to generating massively superlinear business profits, and the market is winner-take-all competitive
My doctorcan't generate superlinear profits for curing me better than your doctor cures you.
The reality is both programmers and doctors have a highly technical skill. A high school can build an "app", but they likely don't have the depth of knowledge to build it properly and reliably.
The same goes with medicine. A nurse, WebMD, or other resource might get you the correct answer, but that's not really the name of the game. Medicine is about both getting things right and not getting things wrong. It's easy to teach the first, it's very hard to get the second.
A big point people often forget when comparing doctors' s salaries to other fields: physicians are expected to cover a large number of their own work-related costs, like continuing education, insurance, or even medical equipment and (sometimes) overhead like office space. Because physicians almost always pay AMT, these work-related expenses are not tax-deductible.
$250,000 sounds like a lot, but it's really not once you take into account how much of that goes towards insurance, licensing fees, equipment, supplies, and all your normal business expenses. (The article linked says that this is "even after malpractice insurance and other expenses", but that's clearly not what the underlying source data represents.)
Their gross pay is way higher then $250,000. Actually $250,000 is the net salary after all expenses, and that's about right for not particularly enterprising doctors (ie. internal medicine, no surgery).
> Actually $250,000 is the net salary after all expenses
It's not. The article says that, but it's flat out wrong - even the source that the article links contradicts this claim.
> For employed physicians, patient-care compensation includes salary, bonus, and profit-sharing contributions. For partners, this includes earnings after taxes and deductible business expenses but before income tax.
The author of the article clearly doesn't know that "deductible business expenses" covers only a tiny fraction of the business expenses that physicians are expected to pay - most are not deductible.
> Are these cost categories true even for non private practice folks who are employed under a larger organization?
Yes - depending on the employing org, they may not have to pay for some things office space (though many employers won't even cover that). But the bulk of their expenses - insurance, continuing education, and licensing - are not covered, and are paid for out-of-pocket by post-tax money.
I don't think it is fair to compare physician salaries from countries where education is heavily subsidized by the government. Are new doctors in the UK or the rest of the EU starting their careers $200k+ in debt?
Part of this is because medical professors make a salary that is at least twice (and usually higher) what the next highest paid professor at a university makes. You fix the salary program across the board, and medical school will become cheaper as well.
Either that or you will have even fewer doctors with much higher salaries. How would a doctor be able to afford any sort of life working 80hours a week to barely pay back loans accumulated over a decade of education. Supply/Demand
I have doctors in my family. They would be sad to know the truth, just like you. There's nothing special about American doctors... the education, the quality. It's just another classic example of the fat needing to get cut. And there's a juicy chunk of fat to cut here
Not too mention the personal sacrifices they have to make to maintain a career (long hours, odd schedules, being on call, the stress of having someones life in your hands, etc).
Not to mention one mistake could cost you your entire career and all that training/money invested into education would be thrown away. And someones life is in the balance.
Pay them more by taking the money out of the hands of big pharma and insurance.
Honestly, while cost is a real factor, I don't think the number of doctors that pass the bar would increase by as much as you think. The amount of knowledge, skills, experience in that practicing physicians possess dwarves what people in many other specialized professions have. I doubt most people would have the grit and patience that it takes to cross that bar. (Disclosure/source: my partner is a physician, I am a software engineer).
That said, (only) one of the reasons for compensating physicians more is the time and money they put into their education. At least 2x - 3x more than other professions. Reduce this time / money commitment, you will be able to reduce the salaries.
most of the health care cost is NOT due to doctors salaries. the reason health care costs are so high in America is due to the way Providers (Hospitals, small clinics, and large Systems) charge insurance companies. Several decades ago when insurance really started getting big, they realized they had huge groups of people they could send to "in network" hospitals. they choose which Providers are in their network. therefore they have leverage over the Providers, and use it to negotiate the price they pay for all claims (the bill the provider sends the insurance company). They negotiate huge discounts on the "listed" price for a claim. Therefore, every year for decades, hospitals have been jacking up their prices in order to actually be able to stay in business (given that the large majority of costs are paid for by insurance companies, who are getting a huge discount). So 2 tylenol go from $3 to $10 to $100 to $500 over time, as the insurance companies negotiate bigger and bigger discounts. This is why the "cost of healthcare" is so high, even those it's not really the true cost. Unless you're not insured, in which case you have to pay the "actual" rate (ie $500 for 2 tylenol).
> most of the health care cost is NOT due to doctors salaries.
It bothers me that people continue to oversimplify problems and spin yarns about how "these people did this" and "those people did that" and that it's all due to one or two groups of bad or greedy actors.
The problem is so huge and so complex that it's worth considering that all of the proposed causes are contributing factors. There is now a systemic dysfunction that is broad, multi-faceted, and tough to dissect and study. Ultimately, many incentive systems are misaligned. The fact that the problem does have so many facets seems to always give rise to these distracting conversations where well-meaning commenters drive the discussion away from the actual findings to their favorite hobby horses instead.
RTFA. Doctor pay is an actual issue. They did not claim it is the whole problem. But it is a problem, and there are things we can do to tackle it.
And no, for the record, I am not disagreeing with you. But please, don't distract. Solve problems instead.
I feel a simple solution would be a law hospitals/clinic etc have to publish prices and all people/companies have to pay those prices.
It would stop this dual pricing and encourage healthy competition. And private insurance companies would negotiate better rates for the market as a whole.
Make an objectively true statement, watch it get voted to the bottom. You are now my Punxsutawney Phil for US healthcare: Six more years of overpriced healthcare.
Do you mean to suggest that physicians' incomes should be several orders of magnitude less than what they are currently? If not, I'll continue to be "distracted" by the Tylenol.
No, it means to suggest that the number of people who have actually paid anywhere near $500 for a couple Tylenol pills is so small as to be an irrelevant rounding error in the grand scheme of things.
20% is still a problem. Putting a cap on the the 20% contributes to the solution. If it was 1% of the problem then hosepipe bans would be inn-effective.
...While refusing to even entertain regulations on or reduction in the 80%? When the problem is truly massive, far exceeding what home use can hope to change?
I never said that. If political walls make it impossible to reduce the 80% then do what is possible. All I'm saying is that 20% contributes to the solution.
I would imagine that farmers will start revolutions if you cut off their water supplies, while city folks won't care too much if the lawn isn't watered. 20% is an easy target... hit it first and slowly work on the other problem.
The Centers for Medicare & Medicaid Services (aka the government) is the largest payor in the country and it sets floor prices for care per region. This is what primarily drives reimbursement rates.
It blows my mind that people can’t see this is as one of the glaring issues with out healthcare system. In addition to the outrageous costs of higher education and the litageous nature of our judicial system, it’s pretty obvious why healthcare costs so much. We can talk about insurance and Medicare until we are blue in the face, but those are just symptoms of a system that was broken from the start.
There should definitely be more med school slots and more residency slots in the US. The idea of nurses prescribing pills is very bad though.
The shortage of doctors is a problem, but we should not kid ourselves -- the biggest problem in America's health care is out of control drug costs. Even with the shortage there has not been a massive inflation of doctors' salaries. In fact all of my doctor friends are constantly complaining about how they are paid less than the previous generation.
But there has been a massive inflation of drug costs.
Prescription drugs represent about 10% of healthcare spending in the US, so while their prices are very high in the US, it's hard for them to explain very much of our high cost system. See https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
The second sentence is "We tend to blame the high prices on things like drugs and medical equipment, in part because the price tag for many life-saving drugs is less than half the U.S. price in Canada or Europe."
Its point is that drug prices are only part of the issue.
* for hospital care: 32.3% (2015)
* for nursing care facilities and continuing care retirement communities: 4.9% (2015)
* for physician and clinical services: 19.8% (2015)
* for prescription drugs: 10.1% (2015)
If drugs were free, expenditures would go down only 10%.
If "health expenditures for physician and clinical services" were cut in half, it would also go down 10%.
In any case, neither alone are enough to explain why we pay "more than twice as much per person for health care as other wealthy countries".
Why are nurses unable to prescribe? Nurse practitioners (mid-senior nurses) have been able to prescribe a limited set of drugs in the UK for quite some time now, quite successfully.
This right. In fact CVS MinuteClinics are usually manned by nurse practitioners. They can do many things typically associated with internal/family medicine.
And it takes years of education and training to become a nurse. Why do people think that nurses shouldn't be able to prescribe medications? Is it because of the gender they're traditionally associated with?
I feel like doctors should at least be paid as well as programmers. My wife is a physician with $500k in debt and she completes residency next summer. That took 4 years of undergrad, 1 year to burnish her credentials, 4 years of medical school, and 6 years of residency. Her job offers are all under $200k for pediatric neurology. With that enormous amount of training, debt, and responsibility, I feel like she should be making a lot more than your average AI programmer.
In other countries the education process is much shorter. For example, in Columbia, I'm told, you skip undergrad altogether to be a physician. Some other nations make training free, which encourages more general practitioners.
Can anyone explain why Medicare subsidizes residency slots? Moreover, why do they need to be subsidized? Residents earn about $40-60k per year and work 80 hour weeks.... If you think PhD students are slave labor, talk to residents.
I don't understand the reasoning that because one opts for expensive training that incurs debt then a high salary is necessary. What other forms of debt behave that way, where the more you take on the more compensated you should be?
I did a physics PhD, which took roughly 8 years of graduate training. My stipend was ~$12k per year for 80 hour weeks, and from that I still had to pay student fees. It's possible to graduate debt free in that situation (I did not), but does that imply that my working salary should be less? Or, because I did take on debt, I should get paid more?
In Sweden, there's no undergrad degree required for med school, but med school is 5.5 years (followed by 18 months of the Swedish equivalent of residency). Like in the US, most physicians are specialists which requires around 5 more years of training. Their student debt will generally be around 350k SEK once they finish med school which is around 40k USD, but they're paid peanuts compared to physicians in the US (~50k-80k USD per year). That is, unless they work as independent contractor physicians in which case they will make (almost) equivalent amounts before taxes.
I sorta figure if you spend around about a DECADE of your life training in a profession then that profession should give you that sort of salary.
The amount of education doctors have to do compared to the other routes to getting $200k p.a. makes me much more sympathetic to this outcome than say investment banking.
Thankfully, it is not up to the individuals to gauge what the value of other peoples labor is.
Any decision that strays from what people want to pay is going to be either more expensive than it should, or lead to supply shortage. In this case, both are happening.
> Much of what we choose to spend money on is stuff that we as Americans seem to value. Much of that value, unfortunately, isn’t all it’s cracked up to be.
This speaks volumes, far beyond just the healthcare system too.
Most other wealthy countries subsidize the cost of medical education to some extent. This article didn't touch on the possibility that the extra $100 billion the US spends on doctor salaries is just being spent on education subsidies in other countries.
Many professions in the US are paid more than their counterparts elsewhere. Software development is a good example, where the salaries I see in the US are often twice as high as what I see in Europe. But Americans have basically no rights as employees, very little time off, no access to universal healthcare, no access to high quality public transportation, etc.
So lets just say the savings as described in the article by not paying doctors as much would be $100billion (cut doctors salaries by half). Spending on US Healthcare was in 2015-16 was $3.2 trillion. Assuming there are no side effects in the market (such as number of students entering medical school would decrease etc) the $100 billion in savings is 3.1% which is a very small figure.
Medical education in Europe is free. In the US, it costs hundreds of thousands of dollars, on top of 4+(1-9) additional years of training with grueling hours during the prime of your life. 80% of doctors are burned out. The emotional toll of watching innocent people die, telling their families, and doing your best with variable levels of success is indescribable. Doctors in the US are not overpaid - the pay is the only thing keeping them in the profession. The real money is going to hospital administration (non-profit hospitals with executives paid more than 6 million per year), malpractice insurance which can go up to 30% of a doctor's salary (a single malpractice case can cost $1M to defend, whether you are guilty or not), and most importantly, tests that have to be done, not out of necessity, but because there is a 0,1 chance of a rare condition that can get caught by it, and the doctor can be sued if they miss it.
And now let's look at the size of US drug market and it's 4.6x the size of estimated salaries from the article. Almost looks like article was sponsored by Big Pharma
Before making a judgement on whether doctors are overpaid or not, I’d kinda like to see an analysis on the value doctors provide. For instance, how much does an average doctor’s treatment affect the economic productivity of all her patients in aggregate? If patients would produce substantially less without treatment, and she sees many patients, a high salary is much more justifiable. If you’re not keen on analyzing things strictly in terms of GDP, how much does an individual doctor influence quality of life, happiness, lifespan, etc? Again, an outsized effect warrants an outsized compensation. Of course, value is quite difficult to assess - especially added value versus alternatives (I.e. online self-diagnosis) - but it’d be interesting to see.
But the main argument is that US health outcomes, with their much higher costs, are not better than the outcomes in other developed countries with much cheaper costs, and there are lots of studies to back that up.
Seems like you can skip all the analysis you are asking for, at least as long as salaries in the US are much higher than elsewhere without commensurate improvement in health outcomes.
I think comparing salaries across the world isn't really a good way to measure whether a provider is "overpaid" or not. If you're just looking at contribution to well-being and human happiness, that way of looking at things might be valid, but even if well-being/happiness outcomes in different healthcare markets are equal, productivity outcomes might be quite different. Americans work longer hours than in the countries outlined in the article, resulting in significantly higher annual productivity per capita compared to other countries. From a labor economics perspective, doctors in the US therefore might (again, depending on real metrics that I'd like to see) contribute more in absolute terms to GDP than doctors in other countries.
Additionally, it might be the case that, relative to their productivity, doctors in other countries might be significantly underpaid. This sort of distortion happens in many other industries. Software, for instance, is notorious for this. Internationally, people might look at US software engineering salaries and balk at how high they are compared to the rest of the world, and might make the judgment that US software engineers are underpaid. But if you look at the profit per employee at leading tech companies, that figure dwarfs engineer salaries (e.g. Facebook's profit per employee is north of $400,000/year, Google's is similar). So, relative to value delivered, many software engineers in the US are actually underpaid. This implies that software engineers abroad are significantly underpaid, as they often work for the same multinationals doing the same sort of work.
At the end of the day, salaries are determined by all kinds of factors, including competition, regulation, value generated, etc. I think that real value added is the only way to determine if a position is overpaid, and comparing to other systems doesn't really help us evaluate that.
I do think that there might be too much regulation in medicine. It seems strange that someone should study for 20 years to learn how to perform the same operation on a specific human organ...
Most doctors tend to specialize anyway so why should a heart surgeon spend so much time learning about other organs which they're never going to sink their scalpels into?
Doctors are extremely well rounded these days, maybe they don't need to be. There are plenty of very good software engineers who never went to university, could it be the same for doctors; if we allowed it?
I don't think "less" and "more" should ever be used when discussing rules, regulations, and laws. Only "better" and "worse".
As for "specializing" in a type of medicine, this is naive. The human body is not separated into discrete modules; every part is extremely interconnected to many others. Doctors must understand general medicine because treatment can effect all body systems.
Maybe you do need at least one person who understands everything to oversee treatment but does the person who actually does the 12 hours of precision meat-cutting need to be that person? I don't know, it's just a thought.
Master jewelers can do very fine work and handle lots of variation in the materials they work with but they don't need to know anything about the chemistry of gold in order to actually make the jewelry... They just need to know the right techniques and potential issues that can arise.
I would start with diagnosing and prescribing (possibly computer/statistics assisted) versus trying to tackle surgery first. I think you'll find that surgery is considered the hardest skill for a MD to obtain. Plus anyone getting cut up will want someone who REALLY knows what they are doing.
Most doctors tend to specialize anyway so why should a heart surgeon spend so much time learning about other organs which they're never going to sink their scalpels into?
That makes sense and it's the same as software engineering. That's why you have a product manager/generalist to coordinate the different domain experts.
Most surgeries these days require a team of doctors already so doctors are already capable of working together with divergent skillets... Maybe there is no harm if these skillets diverged just a little bit more.
Maybe if there was more focus on communication skills as part of training, it would be better.
The problem are not doctors salaries, it is everybody elses. Double the salary of everybody else, to where it would have been if they hadn't been fooled into dropping unions.
Oh my. That's not how it works. Thats not how any of it works.
There are less people getting health services than there would be if it weren't a constraint field. Also, the total amount of money paid to doctors would be much higher if more doctors would join: it just would be a lower average.
The doctor community makes less money by contraining supply the same way a bagel shop makes less money if it doesnt satisfy its demand. This is absolutely basic microeconomics.
The next great thing tech can do is to automate and streamline as many procedures that currently require a physical doctor. We will need to lobby Congress to change regulations and possibly even torte reform for automated, computer based health care.
I believe it's the best way we can scale health care. We need machines that can do the majority or tests and diagnosis to at least flag things as suspicious and then send the person onto a human doctor for further analysis.
The article fails to mention the debt-load that doctors acquire through their lengthy schooling. I agree that it seems ludicrous to pay (some) doctors the outrageous salaries that they are paid, but most professions don’t require a couple thousand dollars of post-college debt to practice. That may be fine for a specialist surgeon pulling in 600k annually, but it’s quite different for academic primary care docs making more like 120k$ in major metropolitan areas.
OK considering the time it takes for someone to start making that amount of $ in medical field to be honest we in IT should really be the last to complain.
I'm a big fan of the NHS in the UK and I live in Sweden now which also has national healthcare services that are heavily subsidised. There are some things that allow the system to be cheaper- for sure. As one hospital buying cotton balls might be more expensive per cotton ball than if you decide as a country to produce or procure millions of them at a time.
But RE salaries; Is it the USA who pays too much? or is it those other countries which pay too little?
The NHS in the UK and the Vardcentralen in Sweden are both having intense crisis' at the moment due to funding and are overstretched to say the least. In Sweden in particular Doctors are more keen to be contractors and hire themselves out to hospitals and offices, mostly due to the fact that Vardcentralen has limits for how much it will pay permanent staff Doctors. And since that's so ubiquitous the Vardcentralen cannot avoid paying these contracting rates, else it would not have Doctors for people.
So, are they greedy? or are they just getting what they should really get? Eitherway we end up paying the Doctors the full amount out of tax money-
>In Sweden in particular Doctors are more keen to be contractors and hire themselves out to hospitals and offices, mostly due to the fact that Vardcentralen has limits for how much it will pay permanent staff Doctors.
This is much the same in the UK.
Hospitals struggle to fill rota gaps, so offer locum shifts at sometimes 2-3x the normal rate to fill gaps at short notice.
However staffing is so tight now, one can sustain a workweek solely on locum shifts.
Most doctors at junior level have taken notice, and many (more then half afaik) defer entering specialty training after their first two years to spend a year (or three!) solely filling these shifts.
At the cost of job progression and workplace continuity, you're getting paid way more for the same work, but with way more shift flexibility and less CPD paperwork.
Sounds pretty good to me!
Are docs greedy? Hard to say.
If locum wages are what fills rota gaps, is that the market dictating the true price of medical labour?
The feeling among a lot of my friends is that if regular and locum wages met in the middle, it might help things.
Can't really account for that flexibility of what is essentially taskrabbit for doctors though.
If you want to reduce doctor salaries, then you need to reduce the exclusivity of their skillset. You need to reduce their working hours, their student loans, and you need to automate the detection of issues/mistakes.
Their hours need to be limited to sane levels. Medical schools need to get cheaper. Robots, IoT health and fitness devices, and nurses need to take over more functions that Doctors perform.
Yup. As unionjack22 says, this is just a hit piece. For instance, hospital bureaucrats can make way more than doctors. This from a 2014 NY Times article: "The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor." -- https://www.nytimes.com/2014/05/18/sunday-review/doctors-sal...
The first step is to actually start spending more money, specifically on grants for med students. One of the reasons we have to pay doctors so much is because they have so many loans to repay. I've been told that between med school and the low pay during residency, a doctor's break even point can be around age 40. If we paid them less, they might not get out of the hole with time left to save for retirement. But if we can keep them from going so far into debt to become a doctor, it'll be more reasonable to pay them less. Other countries have programs to help or even fully subsidize their training...we should have something similar. Because the way it is now, they get bitten by interest twice, on their loans and on their inability to save for retirement during their 20s and 30s.
Totally agree with this article. All excellent points. I think these sorts of improvements to a free market medical system need to be fully explored before we turn to socialized medicine. I'm not opposed to socialized medicine if it's necessary, but I think all else equal, market-based systems are better. If we truly can't make a market based system work, then i'm all for it. But I think there are a lot of ways to improve competition and drive down costs without making that leap.
Just to pile on a few other things:
- In order to open a new hospital in the US, you need to demonstrate 'need' for it. Who certifies that there is a need? A panel of the other hospitals in the area. https://en.wikipedia.org/wiki/Certificate_of_need
- A large percentage of the things people go to the doctor for right now could be handled by a nurse, or someone substantially less qualified. You don't need to see an MD to get diagnosed with a cold. Making it easier for people with lower tiers of qualifications to provide basic types of care, and even write prescriptions for simple issues would dramatically increase access and reduce costs. There has been some movement in this direction, but not nearly enough.
- Breaking the doctor-pharma company relationship. This is a tricky one, and i'm not sure how to go about doing it in a way that doesn't overly trample either entity's rights. However, there is an enormous problem in the US of drugs being prescribed to patients without regard for cost. Often there are many nearly equivalent pharmaceuticals to address a given problem, but doctors will prescribe the latest and greatest one, because they are incentivized to do so by the pharmaceutical companies. Since that drug is still under patent, it costs substantially more than many 'nearly as good' alternatives. Patients don't have the information or education to know this usually, and so they just follow their doctor's recommendation.
1. Someone's paying for those mansions Doctors live in.
2. Someone's paying the people selling drugs to doctors, advertising on tv etc
3. Someone's paying to run the insurance business
According to my uk taxes I'm paying £800/year for the NHS
My wife is applying for family medicine residency right now.
There are 20 slots for the entire Bay Area. 6 at UCSF, 6 at Kaiser San Jose, and 8 at Stanford.
Family medicine isn't neurosurgery or radiology but the artificial limitations on residencies still lead to hyper competition, long hours, and an insane "match day". When graduating med school it doesn't look that much harder to push a bit more for a specialty and get paid twice as much.
And now we have too many specialists in the United States. It seems like we could solve this pretty easily by simply increasing the number of residency slots for GPs.
One thing not mentioned is the cost of medical school (both in time and money) in the US vs. other countries. I’d imagine that a decrease in doctors’ salaries in the US could cause a significant drop in the number of people willing to spend the amount of time and money necessary to become a doctor. If we want to decrease the pay to match other countries, I think we’ll also need to decrease the investment required to become a doctor in order to maintain a reasonable level of supply.
This is a big reason why the NHS is a lot more affordable, average wage for a GP is still something like £90k, but it's not in the hundreds of thousands. Staff costs are just a really big part of the total cost of providing care. The rest of the benefit is making clear cost:benefit decisions on buying drugs, reducing bureaucracy from the insurance system, the ability to centralize and scale care without so much replication, etc. But doctors salaries are still a big part of it.
The issue here is we don't directly pay for the services. It is handle by 3rd parties, AKA health insurance companies. Health insurance company is not true insurer. They pay for everything. I meant, do you call your car insurer to pay for oil change?
Since health insurance companies merely handle the payment and get a cut for this services, they have the incentive for the cost to go up. High cost equals to higher profits.
Insurance company should be insure on highly unlikely illness, such as cancers.
> Insurance company should be insure on highly unlikely illness, such as cancers.
I get what you are trying to say, but I think it's worth looking a little bit deeper. It's possible that it could be more cost effective to also cover some preventative care.
As an engineer my salary is frozen in 1998, technical salaries have been effectively frozen so long that my salary thinks Biggie and Tupac are still the big thing. It doesn't matter how rare the technical skills there's a hard ceiling on income coupled with high cost of living and you work 100 hours a week but still have to go hungry on some days. Salaries are frozen in time for the benefit of the thin layer of people who own other people for a living.
I'm a surgical intern right now, it's not fun. I'll be doing radiology next year, and very much looking forward to it.
I'm biased, but I don't agree with the premise of the article; Doctors should be among the highest earners in any country, it's the price you pay to ensure the brightest students are attracted to medicine despite the long training. I do agree with the following:
A second route would be to end the requirement that foreign doctors complete a U.S. residency program in order to practice medicine in the United States. This means setting up arrangements through which qualified foreign doctors could be licensed to practice in the United States after completing an equivalent residency program in another country. The admission of many more doctors would put downward pressure on the pay of doctors in the United States, as insurers would have a new pool of physicians to add to their networks who will accept somewhat lower compensation.
I've met many foreign-graduates who have already completed residency. In makes ZERO sense to have these individuals repeat a residency in the U.S. They have already undergone 12+ years of training, actively treat patients in their home countries, and there's a need for physicians in the U.S. This is very much cartel-esque of the AMA. I know it would result in lower salaries, but this would (hopefully) translate into lower-cost medical school in the U.S.
This is a situation that may benefit from tech solution. There are already certain states allowing foreign medical graduates to practice in the U.S. If you're looking for a "startup pain point", let me present you with the two sided market:
1. There were ~7,500 international medical graduates who applied to residency in the U.S. (http://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outc...) Presumably, these are individuals who want to practice in the U.S., but must undergo a U.S. residency. I don't know how many of them have already completed a residency in their home country, but let's conservatively say 25% or ~1,800.
Even if all of the foreign train medical graduates were allowed to practice in the U.S. w/o residency, it still wouldn't be enough. Maybe there's a startup opportunity that matches foreign MDs to positions in the U.S. As I mentioned, states like Missouri have already allowed some non-residency-trained physicians to practice (https://www.statnews.com/2017/05/15/missouri-doctor-dearth/). My preference would be to have a foreign doctor who has undergone residency in his or her home country rather than a U.S. grad with no residency.
This article is founded on bad research. Research that considers only what it costs to have a consult with a doctor. The same research does not consider what it costs that doctor to become and remain a doctor. Those costs are borne much more directly by the physician in the US, whilst in the other countries discussed it is far more diffused into the public tax burden.
In other words, the entire article is built on sand.
You have a similar number of doctors per capita as other comparable countries so it seems unlikely that the mere supply of doctors is the problem, Patients per doctor Norway: 320, US: 390, UK: 440. (http://bigthink.com/strange-maps/185-the-patients-per-doctor...).
I’ve been expecting this type of discussion for a long time. It’s part of the march toward socialism.
We are now starting the price fixing phase of the march. Now that enough of the nation’s healthcare bills are being paid by tax payers, it will be popular to blame overpaid doctors.
Forget all the government involvement that got us to this point and just blame the free market. Things like this make me sad for our future.
Hmmm, shouldn't you compare doctor salaries not just with doctor salaries in other countries, but also salaries relative to other professions that require similar level of IQ and schooling in the US? 250k doesn't seem that high in that context. A mid level manager in a company can make that much
I feel like the most obvious explanation here (one which the article doesn't really cover all that well) is that college tuition is disproportionately high in the US. This means doctors (and other professionals) have to be paid more just to be able to pay off student loans.
Not-yet-so-famous musicians should be able to hang out at a doctor's office or house for free. I even see room for mutually beneficial symbiosis, as music as something cheerful in and on itself can help enhance medical treatment.
Isn't politico a fairly conservative news hub now? I don't see paying physicians less as a good thing, do we really want the lost cost physician operating on us?
> Doctors and other highly paid professionals stand out in this respect. Our autoworkers and retail clerks do not in general earn more than their counterparts in other wealthy countries.
You need to compare doctor pay with pay on other skilled careers like software engineers and lawyers. A software engineer earns considerably more in the US than in Europe.
Disclaimer: I'm not a doctor nor do I work in the US. My prespective is as a software engineer who contacts daily with doctors.
In order to get into med school you must sure that your high school grades are on the top 5%.
You must ensure that the hospital(s) you work in are able to function 24/7. This means you don't really control your vacations,
you must work nightshifts and you will work on special holidays.
You don't get to clock out when your shift ends. You are medicaly responsible for your patitients until someone else takes over.
If the patient starts having problems just before the end of your shift, you have to handle it. Its frequent to only actually
leave the hospital 2h after.
Your work doesn't end when you come home either. You are supposed to study for exams, to refresh your knowledge over the diseases
you are currently working on. You need to build your curriculum by publishing research papers and attending expensive conferences.
Your hospital rarelly pays for this. You either lobby with pharmaceuticals in exchange for favours or pay out of your pocket.
In order to get a specialization you have to go through 4-6 years of training/evaluation. That is, if you can get into one in the
first place. Due to the limited amount of positions available, doctors have to compete against each other. Only the top 2%
will get to the prestigious/high paying positions such as neurology or plastic surgury.
The pressure is huge. People will die or live depending on your decisions. You'll make 10s of those every day.
People will still die everyday regardless of what you do. Its not cost/health effective to try every procedure on all patitents.
You will have to come home to your family knowing that you could have saved someone but you decided not to.
You will be the one informing their relatives.
They might sue you or the hospital over malpractice. The hospital has insurance for this but its there to cover the hospital, not its
workers. You are expetected to have your own insurance if you work in high risk zones (e.g. ER).
Being a doctor is a high risk profession. There are plenty of infectious diseases just lying arround. You never know what the next
patient might have. You have to be wary of criminals trying to steal drugs, criminals comming in to finish of someone,
patients with mental issues trying to hit you. Not to mention people that have received bad news or have simply been waiting for
too long, wanting to take some frustration out on the next person they see.
The 200k average is most likelly misleading. Where I live doctor salaries are very skewed. Most high profile doctors also have management
positions and can make 10x than regular doctors.
Sure they get more money at the end of the month, but for what its worth, I wouldn't trade my salary/responsabilities/perks over theirs.
Increasing the supply of doctors will not only lower their salaries but it will alleviate a lot of the issues you talk about which is largely caused by the fact that we don't have enough doctors because it's so hard to get into med school.
Paying doctors humane salaries to work humane hours leads to better doctors.
This article is total bollocks. Doctors are not overpaid in the US, the ones in Europe are massively underpaid and overworked because they are funded by tax payers.
In Russia most of doctors getting very low salary, less than MacDonalds employee. It doesn't work very well, talented people moving to other professions.
When you start with the premise that a price is too high (or too low) the resulting reasoning is bound to be sloppy and fraught with bias.
This article is no exception. It is embarrassing to read this article, because it is full of small, emotionally-potent morsels for those who don't like doctor salaries being high. It's as if the article were read as ASMR but the excitement is instead induced by those potent "the price is bad" morsels.
The truth is that not all doctors make even $200K and many struggle for years to pay back their med school loans once they finally are able to earn a salary after years and years of training.
But it's only by a slight of hand that we are even focusing on doctor salaries instead of the broader issue of the cost/benefit offered by the healthcare system as a whole.
Doctors combine a form of scientific authority with both social and moral authority. They have scarce knowledge, they judge whether or not we deserve workers comp, a paid sick day, a sticker to park in a coveted parking spot, permission to take a pill that takes the pain away, etc. They tell us which of our symptoms we are to blame for vs which we can blame on others, and they offer us hope when our loved ones are at death's door.
This makes doctors the closest thing modern, mainstream (secularized) culture has to priests and priestesses. The status held by doctors goes far beyond any financial rewards.
We must ask ourselves the difficult question of why we (as a society) need the absolution and authority offered by doctors. Why can't we just (as the article suggests) make pragmatic decisions that would lower the bar for entry into the profession?
To do this, we must appreciate that there is a uniquely American view of health that differs from the view held in many other places. Health is something we deserve. Health is understood as something that can be restored or improved through science. Disease is understood in a way that is analogous to "evil forces" that can be successfully eradicated from the body. The social and psychological aspect of disease is minimized, and the physicalization of mental health challenges is nearly completely denied.
Death too is treated differently. Death must always have one cause, and the implication is that were it not for that cause life would have gone on much longer.
In such a view, it is only through the perfect knowledge and/or perfect technical performance that we can overcome disease and stave off death, so doctors must be close to perfect. This is why the bar is set so high for entry into the profession. Those who are selected into the profession are typically very highly skilled. Medicine is among the most popular career plan for college freshmen, but only a small percentage manage to be admitted into medical school. The rest wash out either because they don't want to work that hard or because they can't make the grades.
This pressure on perfect outcomes (and all the fallacies the notion entails) results in expensive malpractice insurance and far too many costly interventions that have little chance of significantly benefitting the patient.
A massive amount of lifetime healthcare spending occurs in the last two months of a person's life. The author seemingly blames this on doctor salaries. This is false. The problem is that patients and their families expect the 80 year old with pneumonia to miraculously recover and live to be 100. The fact is, when an 80 year old gets very sick and ends up hospitalized, it's quite likely that a cancer or two might be discovered, as well as all sorts of other impending problems. But the family still thinks of the person as a healthy 80 year old. Most of the cost of our healthcare system comes from this adjustment process during which we flush money on useless tests and interventions, all to help a patient and family adjust to the reality of old age and impending death.
Yes, there are some docs who profit from largely elective and arguably wasteful surgeries, but many of those are also the optional "lifestyle" surgeries that the public demands most (arterial stents, plastic surgeries, many cosmetic derm treatments, etc.).
Until I met my MD wife, I would have agreed with most of the points in this article. Doctors in the US are certainly well compensated relative to Doctors in other countries. Also, the story of physician credentialing as a means of restricting labor supply appeals to my economic rationale.
However, there are some weaknesses with this argument. To start with, physician compensation makes up just 8% of total healthcare costs in the US:
So, if they were somehow cut in half, that would net a savings of just 4%. That assumes there wouldn't be a corresponding drop in quality as a result of loss of physicians from the occupation. Keep in mind that this is an occupation whose supply is so tight that one of the primary ways being discussed to increase supply is by lowering the credentialing requirements for primary care by having Nurse Practitioners and Physician Assistants provide primary care, unsupervised by a Physician.
I think that's really the rub in terms of talk of lowering physician pay. The barriers to entry in the field (in the US) are so high that if physician pay were significantly reduced without a corresponding reduction in the barriers to entry, it would disincentivize our smartest, and hardest working people from becoming physicians. Which would lead to a significant decrease in the quality of healthcare in the US.
In the case of my wife, she is both smarter and harder working than I am. She spent her 20's and early 30's working 60+ hour weeks doing work that is very taxing mentally and emotionally. She went through four years of undergrad and four years of medical school. She exited medical school at 26 with a significant amount of student debt (though less than many, and at a lower interest rate due to smart decisions on her part) that started capitalizing immediately. She then spent four years in a residency program, making $50,000 a year, and then another four years in two different fellowship programs also making $50,000. When she finally got to a point where she started making a Physician's level of compensation, she was almost 35 years old with $240k in student loan debt and a small amount of savings and retirement built up. She could have dropped or failed out at any time and, if she had, she would have taken on the full cost of the student loan debt without the ability to repay it. This level of debt represents a significant personal risk for physicians that shouldn't be discounted. If you were to compare our financial situations independently, as a software developer, I'm in a better position financially. I've had the opportunity to invest my earnings in my 20's and 30's and haven't had to forfeit so much of my later earnings to debt. As a result of this financial head start, even though she makes more than twice what I make, she doesn't have a chance to catch up with me in terms of wealth accumulation until she's in her 40's, assuming she's financially disciplined and doesn't succumb to physician lifestyle inflation.
If she had instead aimed to become Nurse Practitioner or Physician Assistant, she would have been looking at a low to mid 100k job in her mid-20's with maybe 40k in debt. This would have been a much lower risk in terms of debt, it's much less work to go into one of these fields, and I would argue it may be a better move financially because of the ability to put her money to work earlier from an investment standpoint.
So, if the carrot of higher compensation later down the road is eliminated, I think we will see less quality people entering the field. Physicians are some of the smartest and hardest working people in the US. They'll be able to weigh the cost benefits and will choose alternative fields that have better financial renumeration or lower risk. If the student loan burden were reduced for physicians, you might be able to get away with lower pay without disincentivizing becoming a physician. But I don't see the government providing more assistance to cover the cost of medical school.
If we really wanted to cut down costs for healthcare in the US, the first place to look is administrative costs. We pay more than twice what other countries pay in administrative costs as well. And administrative costs make up a greater percentage of the total money spent on healthcare. Administration costs are mostly waste in that the reason it exists is to keep the gears turning so people can receive healthcare. One of the reasons administrative costs are so much higher is b/c of the complexity of the private insurance system in the US. As others have noted, some of the administrative burden would be simplified by a universal healthcare system.
I don't see marxists here, some socialist tendencies yes.
American doctors are good but "best in the world" is a very difficult claim to substantiate. One thing is certain: they aren't provided the best price-performance ratio, but one of the worse ones. It's not just doctors of course, it's the whole system.
It looks like my country (Finland) shines in that price-performance ratio, according to the link provided above:
One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things. Dentists, a similar profession, is going apeshit that states are trying to let specially licensed assistants (but non-DMDs) do slightly more advanced work like fill cavities.[0]
The entire health system from top to bottom would benefit immensely from free market forces.
[0] http://www.mercurynews.com/2017/07/01/dental-lobby-bares-tee...