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Comment by nemonemo | Hacker News Reader

I doubt US would be able to see a level of medical accessibility on par with many European countries. The medical education system has a perverse incentive to reduce the yearly graduates -- the less graduates there are, the more profits and prestiges each of the current members can garner (with arguably better trained graduates) -- and as shown in the article, they seem to have monopolistic capability for the throttling. And the incentive is only larger when people spend more disposable income for their healthcare, which has been the case. Maybe political powers may shift the direction a bit, but I do not see any evidence of a major course correction.

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There already has been. The solution was to pump out physician assistants (PAs) and nurse practitioners (NPs) that require a fraction of the training of a doctor to get licensed, and then have them practice medicine under the “supervision” of a doctor.

Some states even went as far as giving people with no medical training the right to prescribe, such as naturopaths, whatever that means.

So it is up to each person now to figure out how qualified the person giving them healthcare is.

Also, doctors now have to contend with a handful of large payers. Their customers are mostly the federal/state government, or a handful of managed care organizations like UHC/Elevance/CVS/Cigna/Humana/etc.

I would say doctors’ golden years of having a favorable negotiating position are behind them.

Hospitals have regional monopolies are are being consolidated by private equity companies. The doctors have way more leverage with the hospitals.

That is not what I have read. Doctors are having to join as employees of larger doctor groups, that are owned and operated by older doctors or private equity. Or they can join the local hospital system as a W-2 employee. Either way, they are up against big payers, so they have to also join big employer groups themselves.

Or work in undesirable locations.

My experience with PAs and NPs have been mixed. I would still prefer MD doctors if I have a choice.

Now that there are many reasonably good medical education systems outside US, why doesn't US just open more to those international MDs? I would prefer those MDs to NPs or PAs. Maybe doctors' golden years have been passed, but I don't think that necessarily means more accessibility to quality cares.

Your are extremely optimistic to think the US will make immigration easier anytime soon.

We won't but we should.

We should take everyone that can get here - everytime. It's like tryouts - want to be an American? Get here.

A person that chooses to leave their country for the idea of another knowing full well the arduous journey ahead and the struggles all immigrants face everywhere - all so they can maybe have a life they like, deserves to be an American... if they can get here.

That's the test - or so it should be.

We are the descendants of those that said "f*ck this" - we should want everyone with that mentality to come here, always.

That mentality is what being an American is.

...plus China and India have a billion people MORE than us - 100 million immigrants wouldn't catch us up. Most people do have kids tho - even if your a Trumper you should understand that not all of the immigrant children will continue to require government assistance - most will go get jobs, go to school, start families and all of that creates wealth and prosperity.

Even if it takes 2 generations for the US to recoup the expenses incurred providing for the 1st generation of immigrants or refugees - the country still wins exponentially.

Nothing is more valuable than people.

Well: https://www.statnews.com/2023/05/18/doctors-trained-outside-...

I hate that this shift is being driven almost entirely by profit motives, but I also wonder if this is such a bad thing. I love my doctor; she's been my doctor for 25 years. However, I sometimes wonder what real value she provides. All she ever does is send me to a specialist. Couldn't a PA or NP do the same thing?

Your doctor has significantly more education and training than a PA or NP.

The additional cost of seeing a doctor would quickly be recouped by the reduction in unnecessary / inaccurate referrals that would come from a lesser-trained medical professional.

Yes. But PAs and NPs lack the training and will more likely give referral for the wrong things or provide worse clinical care.

Management did the same thing with offshoring engineering. It's akin to saying, "competent engineers who understand business requirements and good software engineering principles are expensive. Can't engineers from another country (who often cost less) do the same thing if all they do is write the same code?"

You're being disingenuous. PAs are required to have 2000 hours of clinical experience before they can sit for their licensing exam. NPs however only require 500 hours. MDs require 4000 hours.

Where are you getting this 4000 hrs number from?

I’m a MD and this isn’t even remotely correct and the number seems to be pulled out of thin air. Comparing a 2 year PA program with a 4 year MD program plus mandatory 2-7 year additional training is extremely disingenuous.

Where are you getting these numbers? 4000 hours for what specialty? Let’s take Pediatric Emergency Medicine as an example. 4 years of med school, 3 years of residency, then 3 years of fellowship.

That’s many times 4k hours. The difference in training time between a newly minted PA and MD working in a children’s ER is not 2x, it’s many times that.

Your numbers are way off, but even assuming they weren't, 1 hour of PA training is not the same as 1 hour of MD/DO training.

The solution was to pump out physician assistants (PAs) and nurse practitioners (NPs) that require a fraction of the training of a doctor to get licensed, and then have them practice medicine under the “supervision” of a doctor.

This is my biggest concern about primary care. NP training significantly lacks rigor in clinical sciences and standardization. I would also say days of seeing competent primary care (even in urban settings) is behind for patients.

In Germany I can only see a specialist doctor if I 1) wait half a year, 2) am at the brink of dying or 3) give some cash. Most people have the illusion that the system works because 99% don’t have to deal with it and it’s a nice thing to believe if the yearly insurance fees are about $10k for public insurance (employee+employer). Whilst I agree that in Europe we do not have these outrageous costs for medication and intransparent and greedy billing - quality of healthcare is literally NIL. I have zero confidence this system would be able to help me beyond an ear infection or maybe removing an appendix.

You'll have a similar wait in the US for most specialties.

Most specialists in the US can see you in well under two months.

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