If we were to get to a single-payer healthcare system, it seems like we would have to tackle the issue of medical school debt.
$360K of debt would be a massive burden if the system had fixed costs.
$360K of debt would be a massive burden if the system had fixed costs.
My wife is an OB and has to pay $140,000/yr per year for tail insurance in my state. So she literally needs to make, after all other costs of the practice, $140k just to break an even $0/yr.
And people wonder why it costs so much to have a baby.
I can't imagine (but do not know) that it is more efficient to pay claims-made AND tail, versus claims-made with prior acts (unless of course your employer is paying the claims-made).
For those not in the medical field, tail or ERP (extended reporting period) coverage is liability coverage for when the original policy has ended - i.e. you were insured for 2024, but in 2025 a malpractice suit comes to you for an incident in 2024. In the auto/general world, this is fairly well accommodated, but in the medical liability world, insurers say it is because of the preponderance of claims that may arrive significantly later than coverage.
However, many insurers absolutely ream providers on it. Tail insurance is typically double the actual claim premium, i.e. insurers are saying that your insurance premium is only covering 1/3 of the claims they expect to pay on your behalf. I ... have doubts ... on that number. And I also suspect that there is a bell curve happening where certainly, complex malpractice claims may take time to be built out and filed, and that may extend beyond coverage, but then at a certain point, you can relatively confidently assume that the incoming claims are asymptotically approaching zero.
Additionally, I cannot exactly remember if malpractice insurers are required to abide by MLR - profit restrictions - like the 80/20 rule, but in your wife's case, the insurers as a whole (claims-made and tail) are implying that they expect to pay out $168,000 a year for her liability.
(Sure, charging precisely for risk would just result in some patients/scenarios being avoided, but per case or a percentage of billing would make much more sense).
Someone who does one vaginal delivery a month is not going to be as good at doing them as someone who does two or three a day. And they certainly won't be as good at cesarean sections. Delivering just one baby costs a hell of a lot of money in insurance, which is a major part of why family doctors in rural areas don't do that anymore.
By contrast, people who drive more miles - even if they are excellent drivers - are at higher risk of being in a collision because they have to deal with other people on the road, who may be terrible drivers.
Mid career, she should only expect to pay about $120k/yr…
There are patients that make a living going around doctor offices and suing them. I know 1 patient in particular that went around suing doctor offices because they would not cater to his blindness. He would threaten a lawsuit without setting a foot in the doctor's office.
He would browse the doctor's website and complain it was not blind-compliant. And start from there.
Why assume the problem is the legal system and not the doctors? Maybe their performance is the problem.
For example, last I saw, hospital error was a leading cause of death in the US. Until recently it was hard to get doctors to wash their hands between patients, or follow checklists to ensure quality. There are stories of an omerta-like rule of silence about surgical errors.
Try shopping around insurance or go with a mutual, or perhaps go with a IPA ?
NOTE: This rate is CERTAINLY valid if the OB has a long track record of attracting litigation. All insurers will ask for your "run rate" of claims. So, you can't escape a bad record. If you have a history, insurers will charge accordingly. You can't escape a poor record.
This is OB in the state of Illinois, it’s roughly the same cost ans all of the other OBs we’ve talked to here. She doesn’t have a litigation history at all yet.
I've seen many Northeast, more expensive states quotes, and West coast. I do not know about IL. So if theres some kind of special racket there, i could be ignorant of that.
No surgery. No facility /ASC . Straight up MD offices with FT coverage for malpractice.
I feel like you're conflating 2 separate issues:
1. You are correct, one of the biggest concerns for physicians is malpractice risk, and thus a big draw for physicians (especially in high risk specialties) is states that have low caps on max malpractice damage awards. I'd say there is a tendency of red states to have lower caps, but it's really a mix. E.g. Texas has some of the lowest malpractice caps, while Wyoming has a constitutional provision prohibiting caps.
2. When it comes to the risk of obgyns, the main fear is not really the cost of malpractice, but it's simply that extremely restrictive abortion laws make it impossible to give proper care. Lots of people, and politicians especially, like to see the world in absolute black and white, but obgyns know more than anyone else that there are a whole host of issues that can cause a fetus to be nonviable, or dangerous to the mother, and laws that protect the fetus above all else are not rationale. Obgyns can fall anywhere on the political spectrum just like the populace at large, and there are plenty of conservative obgyns who are against abortion for moral or religious reasons, but they also know the realities of pregnancy and that many of these laws are simply unworkable.
It doesn't matter that some states have caps on malpractice payouts. That's only half the matter. It's the number of times that a doctor has to be sued FOR malpractice, because a lot of those costs are going to be attorney fees. If I were a lawyer in Texas, I'd be posting billboards about specializing in suing doctors for not providing care. When women realize they can win a windfall in court for being denied care with life threatening conditions, they're going to start suing. And winning. Juries love giving away insurance company money.
More suits, higher premiums. Since that risk is spread across the state, so is the insurance rate. Most conservative OBs still understand, know, and respect the science. If Texas or Idaho or Alabama gets too expensive, especially given how absolutely garbage the standard of living is in those states, they're gonna haul ass political affiliation be damned.
This is a fantasy, it has never happened, and it's fundamentally not how the law works. Show a single instance where a doctor has been sued for refusing to give care due to risk of running afoul of restrictive abortion laws.
Where's all this noise about a regulatory stance causing malpractice lawsuits to skyrocket ?
We’ve had to change our terminology from “international medical graduates” to “foreign medical graduates” because a lot of those trying to get foreign credentials recognized are locals.
Probably a tough slog upon return to pay back the debts but net-positive in the long-run (unless interest rates go up, uh oh).
It's not just the physician/surgeon aspect of US healthcare that's expensive, it's all of it.
I'm on the Canadian side, and drugs have never been single-payer outside of a hospital, but that leg of the system is still much cheaper (on average) in Canada.
- We cap the number of residency students per year, creating an artificial limited supply.
- We don't allow immigrant doctors to transfer their credentials, creating an artificial limited supply.
- Med school is expensive, limiting the pool of applicants.
- Nurses and nurse practitioners are extremely close to the action on a daily basis. There should be a path for them to graduate into doctors, perhaps by attending night school and then some form of on-the-job residency.
NP vs MD education is not even close to being similar - that is why their is no easy path from one to the other - a typical NP will graduate having done ~600 to 700 hours of patient care hours. A typical MD will have had 12,000 to 16,000 hours of patient care experience before they start practicing - there are plenty of things were seeing an NP is more than enough - but you can't just give a few months of extra training to bump an NP to an MD - their education and knowledge is not even close to comparable.
There is a place for both in our health care system - but they are not the same job.
I think foreign doctors could fill a niche there too. I don't know why we have people going bankrupt due to medical bills when we have foreign doctors that could drive prices down significantly so that the poorest or underinsured could benefit.
The NP has seen more and been around the block. The doctor still is a baby in medicine.
They don't have a medical education. They have a nursing education. They are different things. A good doctor relies on experienced nurses for what they are good at - which is recognizing someone who's in trouble, because they have spent a lot more hours at the bedside than we have and have superb spidey senses. If a nurse asks me to look at a patient, I will. If it's an experienced nurse, I'll come running.
That said, especially in primary care, give me an NP over a PA anytime. Primary care is a numbers game and NPs roll the dice better. Specialty PAs are great; I learned some of my best ortho from ortho PAs. But generalist PAs scare me and have been the source of some horrific consults in the past.
The best friend to have is an OR nurse. She knows which doctor is on cocaine, who cannot stop shaking when handling the scalpel, who cannot bother with a prep checklist before a surgery.
If you are doing surgery for a loved one, consult an OR nurse. They will tell you what's up.
Best of all, nurses all talk to each other, so chances are someone in their group will know that Dr. Charming over at hospital X is nicknamed The Undertaker by in-the-know staff...
I've also seen doctors where their social skills honestly impaired them from getting through to people and thus getting the needed outcomes.
Also... Your "roadkill" doc may do well with me. Smooth talkers always seem to come up short for me.
One (not all) aspects of the NP program was similar to your comment, building off career and professional experience, and using that as one basis for knowledge.
These programs are not even giving you the RN -student- nursing experience (let alone post graduation), they're skipping that entirely.
Looking online:
"Become an NP in 20 months". "NP in 27 months".
From HIGH SCHOOL.
In EMS, there is a push to make paramedicine at least an associates, if not a bachelors degree (there are programs with all three, certificate, associate, bachelors).
Paramedics are the advanced version of when you call 911. The invasive side (versus EMT which is - largely - non-invasive). Cardiac arrest and dysrhythmia management (ECG interpretation, manual defib and pacing, approximately a dozen cardiac drugs), airway management and intubation (including sedatives, paralytics and analgesia), childbirth, trauma, burns. In my area we can give approximately 60 different meds IM, IV, IN, IO from fairly benign to quite acute (adenosine, atropine, etomidate, rocuronium, etc.)
The push for this is for at least two years of school, if not four.
But yet you have schools pumping out NPs in as little as a year and eight months? With zero field supervision (for better or worse, and with varying degrees of intensity, PAs ostensibly operate under physician supervision/direction).
This is going to cause a huge problem, I expect. Not the concept as a whole, but our YOLO attitude to these things, and schools seeing dollar signs.
I specifically pointed at older NPs for a reason.
Heck even old RNs will know what they are doing.
For us programmers it is a bit like why you don't let the new kid push straight to prod. But an older engineer may have a key to do it. ;) There is some wisdom that comes with the grey hair.
Do you really believe this when a loved one’s life is on the line?
The hurdles I see are: There’s a reason doctors have really intense study time before residency, and you’d have to replicate that. There’s also a reason residency is so intense, you’re not going to get anything like resident experience doing ordinary mid level work.
You’d need to hybrid model, but who is going to agree to something like: instead of working as a nurse 40 hours per week, you’re going to work 40hrs/wk and study 40hrs/wk, for 8 years, and if you pass the tests you’ll move on to the next level. This could work but basically sounds like part-time med school.
Part time residency would be even less appealing, it would take you like 10+ years to get the amount of cases a resident has if you were only doing it part time
Compare that to an NP that went from their 18 month NP class, to work in primary medicine/family practice office - and lets say they work there for 10 years, so great, now they are an experienced NP in family medicine (and someone I for one would be perfectly happy to see as a patient for most routine things) - but what they don't have is the experience in all those other areas that matter - even if they are not practicing it.
There is just no shortcut without putting in the time - thousands and thousands of hours of study and patient facing experience under the supervision of an experienced MD.
There is nothing wrong with being an experienced NP seeing patients (and that is mostly who I end up seeing) - but there is simply no reason to somehow 'promote' those people to doctors - they don't have the same skills or the same experience, and doing so doesn't solve any problem.
What do you think is 10+ years of experience as NP in a busy office setting, exactly ?
>>> thousands and thousands of hours of study and patient facing experience under the supervision of an experienced MD.
You mean, the hours that you were cognitively impaired and mostly a blur due to sleep deprivation ? Or the hours of time you will not get any feedback whatsoever because the patient went home and you will never ever see him/her again? (as opposed to a NP, who's always 1 one call away and has a direct feedback loop to the consequences to her/his actions?)
Primary care NPs are good at what they do, but what they do is very limited - most of them will admit it. Anything they haven't seen before comes along, first thing they want to do is call an ambulance and send them to the hospital or a specialist - or they will pull in an actual MD to ask them what they should do.
So if an NP has 10 years of experience working in a primary care facility - what problem does it solve to somehow 'promote' them to an MD based on that experience? Will they magically now be able to see more patients per hour? How does that solve any systemic health care system issues? It doesn't - it simply allows them to get paid like a real MD, when they aren't - so if anything, drives up costs.
Getting motivated people moving up in the pipeline opens more avenue for care of patients, relieving the stress on the existing system. The fact that you think it drives up costs actually goes against the rules of reality. If you have more supply of something, it simply lowers the cost of that supplied.
The problems we have in healthcare in USA is not one of quality. People from all over the world go to USA, seekign help.
The problems in healthcare are related to access and cost. Both of which, this is a magic bullet for.
Why would you keep someone hostage at an underpaid role where they have no way of advancing unless they bend the knee and pay tribute to the powers that be, even though they are perfectly qualified to the role and have more experience than virtually all applicants? If you are concerned because you had to pay your way thru med school, think of it this way:
1) MD paid in dollars and sweat equity to afford that BMW at age 32.
2) NPs will pay in opportunity cost to afford to promote into an MD at age 32. No BMW yet either.
Even if doctors and nurses worked for $0, we'd still have the most expensive healthcare system due to admin, drug, etc costs.