The Problem of Doctors’ Salaries
politico.com
politico.com
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...
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.
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.
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
You really ought to stop pushing your uneducated opinions and do more research.
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.
Counselor: Here's a medical questionnaire used to assess depression.
Yep you sound depressed.
Here's a script for Celexa.
For you example:
> Counselor: Here's a medical questionnaire used to assess depression.
> Yep you sound depressed.
How do you know it's not bipolar? (Your medication choice just caused severe harm).
I agree that letting psychologists prescribe meds is problematic due to lack of medical training, even though clinical psychologists have a PhDs or PsyD.
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.
"Okay... I guess Bob the EMT over here, he's a physician!"
Sort of. What people in this thread refer to when they say nurses should do more "doctor things" is a nurse practitioner:
https://en.wikipedia.org/wiki/Nurse_practitioner
If you needed an experience ranking, it would look like this:
CNA -> Registered Nurse -> Nurse Practitioner -> MD
(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
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.
"Oh you have a sore throat. Let's do a strep test. Oh it's positive here are some antibiotics"
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.
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."
1. https://www.hopkinsmedicine.org/news/media/releases/study_su...
from a recent freakonomics episode
http://freakonomics.com/podcast/nurses-to-the-rescue/
>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.
there are links in the transcript.
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.
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.
No, the fact that hospitals don't just hire more residents is what demonstrates that it's not profitable for hospitals to simply 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".
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Yes, because they aren't yet trained to practice medicine. Residency is where they are trained to practice medicine.
> Do they require so much supervision?
Yes, both by practicality and by law.
> If residents are just cheaper doctors
They're not "just" cheaper doctors
> then hospitals would optimize for a high resident:attending ratio.
They tried. Patients died. Now we cap both the number of hours they can work per week (80 hours/week) and the resident:attending ration.
Sources :
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2896592/ https://www.ncbi.nlm.nih.gov/pubmed/21747093
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.
But maybe the problem is that if we would have more generalists that'd just shovel more load on the specialists.
Once again, "non-profit" or "government agency" doesn't mean "no profit motive". The profit motive affects all players.
Someone has to pay for it, at the end of the day.
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?
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.
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.
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.
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.
But do they do so at lower total cost including both their direct costs and the additional cost of supervision by a more senior doctor?
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.
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.
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.
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.
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.
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.
It's pretty clear you are wrong here. Let's look at actual sources for a change: https://www.cms.gov/Outreach-and-Education/Medicare-Learning...
"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.
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.
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.
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.
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".
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?
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.
Ok, then please define what you mean by COGs.
>This is the classic "we'll lose money per customer, but make it up in volume" argument.
You misunderstand the argument. Since I wasn't clear, these two articles highlight the main points:
https://www.kff.org/report-section/a-primer-on-medicare-how-...
https://www.washingtonpost.com/business/economy/medicare-pri...
Also with respect to these and the efficiency argument, please see:
https://theincidentaleconomist.com/wordpress/hospitals-medic...
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. [0] http://www.modernhealthcare.com/article/20150719/news/307199...
...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).
Or provide alternate ways for people to demonstrate equivalent competence.
Or eliminate the residency requirement completely.
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.
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.)
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.
> 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.
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.
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.
[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.
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.
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.
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
Yea, but this is on over $12 billion in revenue. That's less than 2.5% margin.
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)
https://www.forbes.com/sites/brucelee/2016/05/08/very-profit...
https://www.beckershospitalreview.com/lists/100-top-grossing...
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
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.
That is terrible about your family member though. Its a horrible system
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.
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.
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.
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.
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).
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?
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.
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?
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?
Because they expect revenues to outpace those expenses??
My lord, that clearly means an excess of demand over supply.
Residents need lots of close attention by experienced doctors. The current attending:resident ratio is already suboptimal, from what I've seen.
The following shows the percentage of residency positions filled by speciality: http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Re...
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.
0: http://www.nrmp.org/wp-content/uploads/2017/03/2017-Match-by...
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).
Most of the residents I've been around either seem to be in denial about how terrible their debt situation is or quickly change the subject.
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"
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?
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).
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.
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.
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.
https://www.texastribune.org/2017/11/16/regents-vote-create-...
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.
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..
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.
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.
[0] https://news.ycombinator.com/item?id=15758833
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 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 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).
>> 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.
https://mises.org/library/how-government-helped-create-comin...
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.
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.
http://www.med.monash.edu.au/medicine/admissions/direct-entr... - Bachelor of Medicine, a 5 year undergraduate degree with direct entry from school, and the 5th year being clinical rotations.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
The difference is that most students make nowhere near that much money as doctors do.
The comment that they reply with is "when am I going to enjoy my life"
This results in large portion of students being highly levered and betting that salaries will steadily increase in the future.
This will not end well.
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.
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.
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.
How is this even allowed?
Schools do have a bit more flexibility in scheduling and resource management that can allow them increases in capacity if so demanded.
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.
"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.
In the end, perfect is the enemy of good...
- A CS student graduates around age 24.
- A physician finishes their formation around age 30 or more.
How is this important?
- 6+ more years of substantial pay / debt
- No real salaries for 6+ years
- Around 6+ years of fewer professional experience as your target occupation.
By the time the physician is done with all the preparation, the CS student may be already a senior engineer and may have vested stock options.
If we add up those things, we could say that's equivalent to not having a salary for like 10 years, relative to the CS guy.
What is the incentive for going through all that? higher pay.
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.
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.
Absolutely true: http://jakeseliger.com/2012/10/20/why-you-should-become-a-nu...
This totally makes sense.
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.
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.
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.
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.
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.
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.
I mean... this is a thing:
https://en.wikipedia.org/wiki/Robot-assisted_surgery
It's not like the presence of cameras automatically makes medical care low-quality.
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 !
Do you have a citation for that?
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.
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.
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.
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.
Do you have any reference to back that up? Not doubting it. Just curious.
http://www.er-doctor.com/doctor_income.html
In case people don't bother reading it in depth, here is one of it's updated links:
https://www.linkedin.com/pulse/70000-per-year-start-now-kevi...
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.
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.
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.
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
$100k over 45 years is $4.5MM
Your net earnings is >200%
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.
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.
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.
https://www.bloomberg.com/view/articles/2017-07-20/spending-...
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.
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.
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
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'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.
What do you think accounts for the discrepancy between 3.12% and 19.8%?
Hospital Care:
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:
https://www.jacksonhealthcare.com/media-room/news/md-salarie...
I think this is a more relevant read than the politico one, given that these conversations always degrade into "my country vs your country":
http://www.healthcarefinancenews.com/news/physician-compensa...
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.
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.
If you accept the premise that doctors are overpaid by 25%, then that represents $20BN of systematic inefficiency, or 1/80th.
It absolutely is not. You should read up on the author's affiliations and background before making such inaccurate and uninformed statements.
Conspiracy theories about 'big pharma' on something from CEPR helps no one.
It's basic math, really.
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.
The people who pull the strings through their wealth, are able to lobby politicians, and or even other companies are the real problem.
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.
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.
Try to have a look in the defense or finance industry.
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).
In theory, yes, in practice, you will find out that things are not so simple when you try to actually use that code.
Even things that are not 1:1 replacements still influence the max value of something...
* 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.
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.
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.
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.
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.
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.
Irrelevant of the salary, most medium cities will only have a handful of tech roles available, at best. It's super hard to find and hold a job.
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.
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.
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.
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.
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.
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.
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.
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.
2. Because when they make $300k/yr they feel entitled to spend $250/yr or more
I also dont feel sympathy for how the medical education gets to have people hostage, as a reason to "not lower physician salaries". Its like saying that a slaver paid for his slaves, how can you take them away from him! It cost so much!
In any case, if salaries went down, less doctors would go to college, and colleges will either lower students or lower prices. Easily make-upable if you allow reasonable residencies for foreign doctors. The US could absorb an infinite amount from abroad where the cost of education is not irrational.
In argentina, a cardiologist might make 4000 U$S a month. If he could, he would jump ship to practice in the US immediately.
Wow, just wow..
See "Figure 1" http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Re...
There is also a lot of residency spots that go unfilled. I know infectious disease is struggling to get bodies into spaces.
http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Re...
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).
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.
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.
Source: https://www.jacksonhealthcare.com/media-room/news/md-salarie...
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.
If net income for a large amount of people is 100 U$S, and healthcare service costs 101U$S, the jump from 101 to 96 would surge in demand.
Medical services have low elasticity but there are millions of people in america not getting medical service.
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.
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.
$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.)
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.
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.
A 100k expenses does not translate to 100k of tax savings.
If medical school was free and had unlimited places, do you think we would have the same number of doctors that pass the bar?
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.
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.
Here's an article that explains further http://www.npr.org/sections/health-shots/2014/11/15/36406408...
Note I said paid, not billed.
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.
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.
It would stop this dual pricing and encourage healthy competition. And private insurance companies would negotiate better rates for the market as a whole.
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.
Its point is that drug prices are only part of the issue.
Quoting https://www.cdc.gov/nchs/fastats/health-expenditures.htm for "Percent of national health expenditures":
* 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 "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".
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.
For example, the average salary for a Pediatric Neurologist [1] within the US is higher than the average programmer salary [2].
[1] https://www.glassdoor.com/Salaries/pediatric-neurologist-sal...
[2] https://www.glassdoor.com/Salaries/programmer-salary-SRCH_KO...
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?
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.
https://theincidentaleconomist.com/wordpress/what-makes-the-...
Physician salaries are a part of the problem, but by his numbers they are a pretty small part (as shown in his pie chart at the bottom): https://theincidentaleconomist.com/wordpress/what-makes-the-...
This speaks volumes, far beyond just the healthcare system too.
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.
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.
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.
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.
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?
Because everything is linked?
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.
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.
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.
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.
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.
Disclosure: doctor
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-
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.
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.
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.
According to my uk taxes I'm paying £800/year for the NHS
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.
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.
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.
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.
2. The AAMC is estimating a physician shortage of 30,000 by 2030 (https://news.aamc.org/medical-education/article/new-aamc-res...).
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.
A lot of money also goes for people to process insurance claims
In other words, the entire article is built on sand.
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.
But I digress... :)
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.
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.
Paying doctors humane salaries to work humane hours leads to better doctors.
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.).
However, there are some weaknesses with this argument. To start with, physician compensation makes up just 8% of total healthcare costs in the US:
https://www.jacksonhealthcare.com/media-room/news/md-salarie...
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.
http://www.commonwealthfund.org/publications/in-the-literatu...