Providers are the core problem. Various doctor associations (AMA et al) have strangled supply side of healthcare through State licensure and scope of practice laws.
Just read medical forums to get an idea of what an average doctor thinks about competition in the form of midlevels:
It's not politically talked about because it's much easier to blame corporations than your neighborhood doctors. There's enough leeches downstream too (insurance, pharma, PBMs, administrators, etc) but gatekeeping at the supply side is what's making it possible.
> Various doctor associations (AMA et al) have strangled supply side of healthcare
To add more details to this here's something I recently read about the supply constraint and its origins.
> Then as now, Medicare reimbursed hospitals for a significant share of residents’ salaries. The Balanced Budget Act established limits on those reimbursements, effectively fixing the number of funded residents at 1996 levels. (In 1999 Congress amended the limit for rural hospitals only, increasing the numbers of funded residents at those hospitals to 130 percent of 1996 levels.) Essentially, the law stipulated that if a hospital wanted to expand its pool of residents, Medicare would not pay for it.
How could such a provision make it through Congress? Lawmakers received cover from the American Medical Association (AMA), the Association of American Medical Colleges, and other major stakeholders in American medicine who endorsed caps on funding for residents and other graduate medical education programs. In March 1997, months before the Balanced Budget Act was enacted, the AMA even suggested reducing the number of U.S. residency positions by approximately 25 percent — from 25,000 to fewer than 19,000. “The United States is on the verge of a serious oversupply of physicians,” said the AMA and other physicians’ groups in a joint statement. Since most states require at least some residency training for medical licensure, reducing the number of residency positions would curtail the supply of doctors in the U.S.
Fast forward two decades, and what once seemed like a glut now looks like a shortage. The growth in the number of residency positions — and thus the number of doctors — slowed after the passage of the Balanced Budget Act. From 1997 to 2002, the number of residents in the U.S. increased by just 0.1 percent. Although the number of positions has increased since then, each year thousands of residency applicants fail to secure a position. Factor in an aging population and a projected increase in demand for health care services, and the U.S. is now forecasted to experience a shortage of 46,900 to 121,900 physicians by 2032. Absent a meaningful response from Congress, it will be doctors — particularly residents — and their patients who pay the price.
This a hundred times! The shortage is real and urgent. My gf, who is in her second year of a low-tier residency program, received many offers from various hospitals promising her $300K/year to work for them. This is well known among residents that once you survive residency (which is not a high bar to begin with), you will make at least $250K/year.
From the the people I know and know about, getting into medical school is a very high bar. Getting through is hard though doable if you could get in and devote your entire life to it. You probably won't get the specialty you want if it's one of the more generally desired ones, but you might.
Is $250K or 300K really that much compared to the amount of work / time these people need to spend going through formal education? With the additional stress that any decisions they make could adversely impact someone's life?
I mean software developers doing significantly less work can easily make this money while working half as much right?
SW Dev working 8hrs a day can make this, whereas a doctor working probable 60-80 hours a week makes the same?
I don´t know in which world you live where SW devs make that... some FAANG developers maybe - 5.000 to 10.000 people total? Compare to over a million doctors in the U.S. only.
Well said. I get a lot of flak from, well, pretty much everyone for pointing out that your neighborhood doctor is likely a scam artist. Clearly I’m generalizing but just suggesting it may be the case is usually met with undue skepticism.
Not to mention, having an inside look at med school gives you a different perspective on the motivations of most rising doctors. It’s rarely about anything but lifestyle and money. I mean, they are people too, but most med students I’ve met are looking out for number one first, and anything else is a distant second.
Not sure where you went to med school, but couldn't be different for me for med school and residency. Very little of being a doctor has to do with money. If I wanted money, I would have stayed in software and not gone another half a million in debt.
> your neighborhood doctor is likely a scam artist.
I don't blame a Dr for trying to charge 7x the actual value of their time if 6/7 people don't pay them at all (the case in ERs). They're employing the same practice as insurance companies. But when a Dr does it he's a scam artist?
That forum is amazing! Thanks for the primary source! That said, two quibbles/questions:
Those same threads have logins like "indebt4life" and "kids2feed", which matches what I've heard from doctor friends: the length and cost of medical training and insurance are so brutal that the folks gatekeeping are themselves in an unhealthy lifestyle and don't want it to get worse. In other words, and benefits of gatekeeping accrue to the school and hospital complex more than the individual practirioners.
Separately, what's the breakdown of specialist labor costs vs drugs and equipment? My experience has been that the crazy bills are for stuff , not people.
We see a lot of people trying to justify medical salaries due to the cost of education and malpractice insurance, but an integrated program could work around that.
We should treat it like the infantry. If you want to drive a tank and blow up people, you don't apply to a college and get a Doctorate in Blowing People Up. You don't buy insurance to cover if you blow up the wrong people. You join the army.
I'd like to see health care reform inspired by military structure. A high-schooler eager to get into medicine joins the Health Corps, and gets their education covered in exchange for n years of working in state-run facilities. There's strongly restricted legal recourse if the Health Corps hospital cuts off the wrong foot-- here's $500 and a really nice wooden peg.
As a self-contained system, I could also imagine it working around some of the structure that's restricting the industry. I'm picturing programmes to advance in both through direct study and training, and where appropriate "field promotions" (think of the 20-year term nurse who knows more than most of the doctors from experience, but will never be able to escape their position without expensive and onerous formal training/certification)
There would need to be other changes. Right now many doctors work insane hours. My dad is a doctor who we rarely saw growing up. Now in in his 70s he has retired to live near a native american reservation where he works at the clinic. He puts in 60+ hours a week and claims that that is retirement for a doctor. I imagine that young doctors not making the big bucks would not be willing to work themselves to death like the current ones do.
I have experience of single player (UK) and private insurance based but properly managed by the government (NL) and can tell you that single player is much cheaper to run. When I moved to NL about 15 years ago the UK was spending the same per capita on the NHS as The Netherlands spent from the central government to cover the shortfall to the insurers.
In 2019 there isn't as much difference: a significant amount of providers in the UK have been privatised which increased costs whilst at the same time the NHS budgets have been systemically strangled in real terms - something like annual 2% budget increases against annual 15% cost increases thanks to demographics and lifestyle choices.
So in short: single payer is great but the second the Republicans (or whatever the "don't tax the rich" party is at the time) get to touch it they'll ruin it.
> Those same threads have logins like "indebt4life" and "kids2feed", which matches what I've heard from doctor friends: the length and cost of medical training and insurance are so brutal that the folks gatekeeping are themselves in an unhealthy lifestyle and don't want it to get worse.
It's gatekeeping that causes that.
There are complex procedures that require a decade of medical training and simpler ones that don't. If you take the doctor with the extensive training and have them do only the complex procedures, it's easy to justify paying them mid six figure salaries that cover their costs.
But if you have regulations that require that same doctor to spend three quarters of their time doing simple procedures that could reasonably be done by a PA or a nurse, the average value of their services drops and they have a harder time commanding a salary that can pay for their schooling and insurance.
It's not just the cost of training. In the US there's implicit expectation that becoming a doctor is a way to become wealthy, similar in earning potential to becoming a lawyer. There's no such expectation in most other countries which are often used in arguments for how socialized medicine "costs less". Their doctors make a fraction of what US doctors do, so of course it "costs less".
Right now in the US you'd be "socializing" the expectation that a doctor should make $300K+ a year, with a very weak upper bound. Which I'm not going to say real good ones shouldn't, but good ones, in my personal experience, are few and far between.
This is something we'd need to deal with before forcing taxpayers to pay for these inflated expectations at gunpoint, _if_ we decide to go the "single payer" route. ACA, ironically, did nothing at all to address the _affordability_ side of things. If I'm forced to give up a good chunk of my income for "free" healthcare, I'd be categorically not interested in paying for yet another beach house some surgeon wants to buy.
Just like all problems involving human motivations, this is a tough one to solve. It's so tough, in fact, that I think the most realistic path forward is gradual automation of everything that can be automated, though technological means, such that we only use doctors where a robot or a computer can't do the job. Someone needs to start another Theranos, but do it for real this time.
There better be a $300k+ payday at the end of a doctor’s training, otherwise I don’t see how the gauntlet they get put through is worth sacrificing their best years (20s and early 30s).
Maybe the gauntlet would be less severe if there wasn't such a massive pot of gold at the end of this particular rainbow. Much of it is just hazing and weeding out of the "unworthy".
But that's sort of orthogonal to the problem I'm discussing. The cost structure that enables "low cost" socialized medicine in other countries is just not there, and it's not going to be there in this country in the foreseeable future. Given this, all this talk about "medicare for all" etc, is just electoral pandering and nothing else. It's not doable without turning the whole system into a money black hole that's even worse than what we have now.
If you are trying to make free market arguments for doctors salaries come on. The doctors guild restricts supply through the state. No free market here.
I’m saying with the current requirements of becoming a doctor, a very high pay is needed to incentivize smart people who have options to choose to become a doctor.
> Those same threads have logins like "indebt4life" and "kids2feed", which matches what I've heard from doctor friends: the length and cost of medical training and insurance are so brutal that the folks gatekeeping are themselves in an unhealthy lifestyle and don't want it to get worse. In other words, and benefits of gatekeeping accrue to the school and hospital complex more than the individual practirioners.
This really depends on the forums you read. If you hang out on the whitecoatinvestor forums you'll see that there are plenty of folks who are getting by just fine on their $600k annual salaries and may even be retiring early.
Reading those forums it's clear that there are challenges (not buying a doctor house, avoiding loan debt, budgeting like a resident even once you're in your real earning years) but there are plenty of opportunities, in some disciplines, to be happy with an eight-figure lifetime earnings and a balanced lifestyle.
Disclaimer: I'm still a medical student, take my biases into account when you read this.
It seems like mid level providers are being granted more and more autonomy each year. In fact, they have full practice authority in 20 states (no need to work under a physician). Knowing that, are the AMA et al truly strangling the supply side of healthcare? From the politico article you linked, it seems that the number of specialists we have is unnecessary, so that can't be it.
I'd like to think that most doctors aren't trying to out-compete mid-level providers, and that most doctors are trying to do right by their patients. Maybe that's naïve.
I also agree that the wages for physicians are too high, and that reform from the ground up (education costs, healthcare costs, and reimbursements) is desperately needed. However, to state that providers are the core problem is tremendously naive. The average salary of physicians, even at $250,000/yr, with 1 million physicians in the US is $250 billion/yr. In comparison, the revenue from the health insurance industry was around $1 trillion in 2017. The hospital industry made $970 billion in 2016. The pharmaceutical industry made $450 billion in 2016, I can only imagine that number went up. I can see how the insurance industry and hospital revenue would be tied in physician reimbursements somewhat, and obviously pharmaceutical payments, but the pharmaceutical industry shouldn't be impacted by physician salaries.
As a side note, very few doctors I've had the pleasure of knowing have any idea what their services cost patients. Proceduralists generally have a better idea.
For those of you interested, I'll try to explain what is needed in a residency program. Your program needs to provide you with the training necessary to be proficient at all aspects of that specialty by the end of your training. That means you need the patient volume, mentorship, and variety to meet that standard. It just so happens that it's very difficult to meet that standard unless you're at a larger institution. Community programs do exist, but today the vast majority of programs except for family medicine are at academic centers.
What that also means is that you can't train too many doctors in one place at one time. Especially in the case of surgical specialties - You need as many procedures as you can get in your residency, extra residents take those procedures away from you.
That isn't to say that more family medicine and primary-care track residencies aren't needed, they absolutely are. At the same time, without more Medicare funding for these residencies (per the politico article it takes around $150,000/yr to train a resident physician) hospitals aren't willing to take on the extra cost. A bill is hopefully making its way through the House to increase the funding for more residencies (15,000 new spots over 5 years).
Ultimately, I think the trend is going to be that more and more doctors will specialize, and mid level providers will be mostly nurse practitioner or physician assistants. Hopefully the data will continue to be positive in terms of outcomes, and prove that we just don't need the amount of training we thought we did for those providers.
P.S. While I'm not going into primary care, I loved my family medicine rotation in school. I felt like I had genuine impact on my patients, met some of the most down to earth doctors, and it was an active day with lots of variety.
Very few people would happily train someone to take their job. And, some of those people will be vocal about it. The midlevels do the same thing in reverse. It's a stretch to extrapolate this to all "providers" and call that the "core problem" of health expense. How much of your bill do you think goes to the "provider" anyway?.
Providers are the core problem. Various doctor associations (AMA et al) have strangled supply side of healthcare through State licensure and scope of practice laws.
Just read medical forums to get an idea of what an average doctor thinks about competition in the form of midlevels:
https://www.auntminnie.com/Forum/tm.aspx?m=581583
"Don’t teach your mid levels procedures... Ultimately, a mid level that can do procedures, even easy ones, are your competitors."
https://www.auntminnie.com/forum/tm.aspx?m=581130
It's not politically talked about because it's much easier to blame corporations than your neighborhood doctors. There's enough leeches downstream too (insurance, pharma, PBMs, administrators, etc) but gatekeeping at the supply side is what's making it possible.