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Comment by WalterBright | Hacker News Reader

The AMA only allows a fixed number of seats in medical school.

There also can be tiers of medical doctors. Most doctoring work is routine, and can be handled by a more of a medical tech.

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False. The AMA has no regulatory or accreditation authority over medical schools. Schools can admit as many students as they want.

The bottleneck right now in producing more US physicians is lack of Medicare funding for residency slots (graduate medical education). Every year some students graduate from accredited medical schools with an MD but are unable to practice because they don't get matched to a residency program. Congress hasn't significantly increased funding in years. At one point the AMA did lobby Congress to limit the number of slots but they have since reversed that stance and are now lobbying for higher residency funding.

https://savegme.org/

There are already tiers of clinicians. Much routine care can be delivered by Physician Assistants or Nurse Practitioners working under a Physician's supervision. Specific limits on their services are set at the state level.

Why do residency programs require subsidies, are resident doctors each a large net financial loss to a hospital? I can't think of many other career paths where someone out of school is so underprepared for the job that the business could not employ them without someone else footing the bill, doesn't seem like a reasonable system that will sustain itself in the long term. I suppose pilots are a bit like this but they typically take the financial risk on themselves to some degree or get the taxpayer funded training via the military.

Hospital accounting is always messy. There's no simple way to determine whether a particular program is profitable or not; it comes down to how the accountants allocate overhead costs. But the fact that publicly owned and non-profit teaching hospitals aren't voluntarily expanding their residency training programs is strong evidence that they operate at a loss.

Very few other career paths have such an extensive body of knowledge, licensing requirements, and low tolerance for errors. Law is maybe a bit similar in that new associates in most firms are worse than useless, and training them sucks up a lot of time from senior associates and partners. But law firms aren't subject to price fixing, so they have more freedom to raise their rates in order to cover those costs.

> The bottleneck right now in producing more US physicians is lack of Medicare funding for residency slots... Congress hasn't significantly increased funding in years. Much routine care can be delivered by Physician Assistants or Nurse Practitioners working under a Physician's supervision

We should all accept a lower standard of care because hospitals can't find more funding to train doctors? What are all the $20 aspirin paying for? How does every other profession manage to train new members without needing a literal act of Congress?

Where would you suggest that teaching hospitals find more funding? Most of them are non-profits, or operate as part of state or local government agencies. They have no ability to negotiate higher rates with Medicare/Medicaid and only limited ability to negotiate higher rates with private payers (typically set as a multiplier to the Medicare rate). Voters generally haven't been willing to raise taxes. There is probably some waste that could be trimmed but it's tough to figure out where to cut without impacting patient care quality. Much of the administrative overhead is forced upon them by unfunded government mandates around reporting, quality, security, credentialing, and interoperability.

Private donors are always welcome. If you have a few million to spare then you can personally fund a residency program expansion at your favorite teaching hospital.

I won't attempt to defend ridiculous charges for certain basic medical services. Hospital accounting is a funny business, and almost entirely artificial. The teaching hospitals tend to deliver a lot of charity care (including writing off a lot of bad medical debt) and some Medicare/Medicaid reimbursements don't even cover their costs. So, they attempt to close the gaps by jacking up other prices as high as they can.

You should accept a lower standard of care because as a society we have limited resources and can't afford to waste them. If you have a boo boo then a NP can clean the wound and apply a bandage. That's what happened to me when I crashed my bike last year and it was fine. Physician time should be reserved for more complex cases.

Are you talking about the same hospitals that tripled the administrators to doctors ratio in the last 50 years (don’t remember exact numbers)? Is that why we need to accept a lower standard of care?

P.S. wait, you went to a hospital to apply a bandaid after you fell off your bike? Are you serious? Perhaps that’s the real problem…

Do residency slots mandate public funding?

Aren't they doing actual useful work same as regular doctors? (albiet with a higher error rate)

So they could be funded through via charging for services rendered.

Of course their effective pay may be close to zero, after malpractice insurance, but it will still attract some number of med school grads who can't get in otherwise.

Residency slots don't mandate public funding. The majority of funding comes through the Medicare program but private foundations also contribute some. Private payers (insurance companies) also indirectly subsidize residency slots by paying teaching hospitals higher rates.

Some services performed by residents are billable, especially the more experienced ones. But the programs as a whole run at a loss after accounting for overhead so hospitals won't add more slots without a matching funding source.

Presumably it will only happen in hospitals that charge high enough rates to fully cover the cost of overhead, I.e at one of those luxury hospitals

What "luxury" hospitals? I've never seen the word "luxury" used to describe the teaching hospitals which train most residents. Most of them have high proportions of Medicare/Medicaid patients where rates are set by the government and hospitals have zero ability to charge more. I don't think you understand the reality of healthcare economics; this isn't a free market where sellers can change prices and supply to meet customer demand.

Colloquially, from the folks I've spoken to, luxury refer to those hospitals that offer high-end rooms, fancy furniture, concierge service, and so on, for a higher fee. I.e. Places where the differences are immediately obvious to the layman

If it's indeed the case that most hospitals can't cover their overhead then by default it must be limited to the high end, if it ever does happen.

The AMA doesn't have direct control over it, I was wrong about that. But they heavily influence it:

https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...

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