How Being a Doctor Became the Most Miserable Profession
thedailybeast.com
thedailybeast.com
Making it easier to become a doctor would improve things immediately (especially given the recent research that makes it clear that nurse practitioners do just fine).
To make matters worse, Canada is suffering the effects of the American system. Doctors licensed in Canada are encouraged to go to the USA (particularly specialists), by the allure of much higher salaries. In order to prevent a vicious brain drain, the Canadian Medical Association must pay doctors as much as they can to stay and practice in the country. As such, Canadian healthcare costs have been skyrocketing due to specialist salaries soaring ever higher to compete with American rates.
Comparing physician salaries in the US and Canada with other commonwealth countries like Australia and the UK provides a clearer picture as to what is going on. The American healthcare system is completely and utterly FUBAR. It needs to be torn down and rebuilt based on a functioning healthcare system from another country.
1. http://time.com/198/bitter-pill-why-medical-bills-are-killin... (Unfortunately, it is now paywalled)
As it stands there are no published prices (or they're bogus, if your published prices are 3x what insurance companies pay it's not a real price) for anything so nobody can shop around. That means there is no competitive pressure on the non-critical, non-life-threatening things that are expensive-ish but possible to pay out of pocket. And that means that nobody can circumvent insurance. And that means that doctors have to keep spending $58 to process a form that will net them a $20 to $30 copay and maybe another $50 worth of reimbursement? So the doc nets between $30 and $40. Call it $35 and multiply by 5 (12 min per patient) and the doc is billing out at $175 per hour provided he teleports from one exam room to the next.
There are a great many people who could afford to pay $100 cash (or equivalent) for a doctors visit, for say 30 minutes with a doctor. So that's $200 per hour.
Major medical plans (for big stuff) coupled with health savings accounts will empower patients to ask "do I really need this" with a price sheet in hand and a real conversation about the benefits vs the costs. Right now that happens approximately zero.
For some ordinary, understandable things, we can get people to pay if they have the means and understanding to do so, but we need to pay for outcomes (indexed for the base sickness of the population) for more complex cases. However, paying for outcomes forces the financial risk onto the doctor, so what we really need is some mixture of "pay for performance" and "fee for service" to keep them in business, but focused on adapting their practices to evidence and modernity over the decades.
One way to reduce bureaucracy and paper work is simply "Medicare for everyone" which reduces the number of forms, data links, and creates a massive negotiating position for the payer which is needed in an inelastic market such as medicine.
To give an example, if the patients are directly on the hook and grandpa is sick, they'll just send him to the "highest quality hospital" as determined by a mixture of patient reviews ("The rooms were well lit and people smiled!") and price ("This is the most expensive and therefore best hospital in the area!"). It might even have the best metrics (the sickest and (correlated) poorest will go to the cheaper hospital and tank their metrics). They'll then pay basically anything to keep grandpa alive regardless of what the hospital asks, maybe raising money if they need to.
Hence, inelastic complex market without where transparency can actually hurt.
The other thing to note is that if people of means pay $100 cash to obtain better healthcare and jump the line, it's kind of like paying more to get gas during hurricane Sandy. You're not creating more or better resources for the people, but merely rearranging them at high cost to the benefit of the affluent. This TED talk has some interesting points about this trend:
http://www.ted.com/talks/michael_sandel_why_we_shouldn_t_tru...
Aside: I used to work in the healthcare billing industry.
I am not suggesting that the rich be able to spend $100 to see a doctor and all the cattle should be left to fend for themselves. What I am suggesting is that it's not outside the realm of possibility for people to fund their own care.
Right now the way insurance is structured they lump together "maintenance" with "serious" and "catastrophic" all in a single insurance policy. That is unfortunate because most regular human beings can self-fund "maintenance" and many can even self-fund "serious" but only very wealthy folks have the capacity to pay for "catastrophic"
The reason we want individuals to pay for "maintenance" and even some "serious" stuff out of pocket is two-fold. First we want competitive pressure on doctors to not jack their prices up. Second, it will help encourage a culture of "do I really need this?" among patients and they will ask their doctors about more than "will it help" but more like "is it worth it" and while some doctors might lie to enrich themselves most that I have met aren't the type.
Why do we want competitive pressure on doctors not to jack their prices up? Because right now the way things work is that the insurance companies have a pretty good idea of what things cost and they negotiate doctors down very aggressively on that. They will of course let the docs make a little money, but nothing crazy. Let's say 10% as an example. If you can only make 10% on your costs then the easiest thing to do is to work on increasing your costs, which then makes a bigger pie for you to earn 10% of. Furthermore there is no incentive for doctors to come up with cost-savings because if they do, it simply reduces the size of their pie to earn 10% of. The unfortunate side effect is that even though medicine has more and more technology and that technology is getting cheaper and cheaper, the cost of medicine is rising.
I realize that I don't have the answers to everything but competitive pressure and rewarding innovation are sorely lacking in medicine today. Other forces are also necessary, like publishing outcome statistics in addition to prices. But I find it very difficult to believe that for the mundane stuff that makes up a lot of a person's exposure to medicine until something serious or catastrophic happens (or late in life) would go a long way towards reshaping people's expectations as well.
Medicare is a monopsony. They represent such a large share of patients for many practices that they set their own prices. And when people expect medicare both to pay for their triple bypass and not to go broke at the same time, what we get bankrupt hospitals and over-worked doctors.
Being more responsible about the way we apportion healthcare is the only reasonable option.
The real problem is government regulation of our profession, of the whole clinical process, and of devices and medications.
Those of you who go up in arms when government sticks its nose in your internet business, should imagine how it is to deal with the government that is there all the time for us. For example, how about trying to bill Medicare for a surgery, when one phrase--one phrase-- is missing from the documentation, and I don't get a penny for a 4 hour surgery?
However, in about 2-3 years, there will be more American medical students than there will be residency spots. Still have the same problem: the bottleneck in training is the residency.
So, blaming the AMA or AAMC for keeping medical student numbers down is pointless. They are not the final gatekeeper for the creation of doctors. Residency training is that gatekeeper.
I agree that there are better examples of government regulation directly impacting medical practice, but this example illustrates the power of a monopsony[0].
To overgeneralize, the same way that monopolists (single suppliers) can exercise power over purchasers in ways that we might deem unfair, monopsonists (single consumers) can exercise power over suppliers in ways that we may also deem unfair or harmful.
These effects are not limited to Medicare patients or providers, by the way. It's not hard to make the case that customers who can choose between Comcast and Verizon FiOS are harmed by the fact that cable companies are regional monopolies in most other markets.
Similarly, even if you have a private insurance plan, there are a number of ways that you are affected by Medicare's policies indirectly, in ways that you would not if they weren't such a big player.
I am a physician too and you are repeating a lot of the falsehoods that are perpetuated among those that don't understand the billing process or aren't actually physicians.
AMA is an insurance and loan agency? I... I... don't know what to say to this. How about start by reading this (poorly written, but summary nonetheless):
http://en.wikipedia.org/wiki/American_Medical_Association
and one of their most influential functions:
http://en.wikipedia.org/wiki/Specialty_Society_Relative_Valu...
It's true that insurers set up arbitrary requirements (for sentinel effect, mostly) to try and refuse reimbursement, but often a simple change and resubmission will result in payment. These are issues that are dealt with in your contract with the insurer--have you read this contract? If not, then you can't complain! Even the CMS has a contract with its physicians.. and contrary to popular belief, they pay pretty well for most anything. It's Medicaid that is atrocious... especially since it covers children/poor and will often limit their access to healthcare.
The question is why medicine is becoming the most miserable profession (with polling data to back it up) while the gov't interference in it is at all time's high and going higher and higher all the time.
Wuh? I'm not a physician. But I do work for an ambulance service. And my day job has involved working with insurance reimbursement algorithms for Hospital and Insurance Administrators.
But "$36 for epidural and not a penny for the next 18 hours?"
You might want to look into that. Medicaid allows a Maximum Fee of $1.16/minute for an anesthesiologist's time.
"Essentially, hospitals will be reimbursed at $669.90 for the epidural procedure performed in the hospital setting; whereas, in office setting, after removing the portion designated for the physician professional fee, office practice expense will be reimbursed at $30.28 to $34.36 a whopping 2,315% to 2,668% with SGR cut and 1931% to 2312% without SGR cut more in the hospital setting."
Yes, epidurals are cut - but under what circumstances are you monitoring a patient bedside for 18 hours in a non-hospital setting?
And for every one of these examples, there's a flip-side:
Wisdom teeth under general anesthesia.
"Hi, I'm Mr X and I'll be your anesthesiologist today. How you doing? Now, to confirm, no allergies, right? And it says you weigh 180lb? Great, see you in theater!"
Bill:
"Pre-operative anesthesiologist consultation: $662"
For about 90 seconds. Now, I know the principles of anesthesia, though I'd never claim my knowledge was within orders of magnitude of that of a specialist, but I routinely perform RSI for ET intubation, and I know all about "the charge isn't for the time, it's the knowledge", but nonetheless.
The supply of doctors is not restricted by the AMA. The supply of doctors is determined by the number of residency spots available to new graduates; that number is entirely determined by the Centers for Medicare and Medicaid (CMS). Thanks to the Balanced Budget Act of 1997, Graduate Medical Education (GME) was dramatically slowed due to decreases in Medicare funding of residency positions. [1]
As long as we require physicians to be US trained and to have completed a US residency, the bottleneck will be GME funding. To fix that, the AMA or any other concerned citizen can lobby Congress for an increase.
[1]: http://jama.jamanetwork.com/article.aspx?articleid=182532
Also, if you could go to med school without an undergraduate degree you can increase the number of years a doctor could work thus lowering costs and increasing supply at the same time.
Since the establishment of Medicare/Medicaid, CMS pays hospitals a set amount per year per resident. I suppose you could mandate that teaching hospitals be forced to foot the bill themselves, but most teaching hospitals have disproportionately high Medicaid and uninsured patient populations, so they aren't exactly swimming in cash.
Note: I'm editing my post, as you have edited yours.
Well, if you make students pay additional tuition / take loans for living expenses during residency training, then you can kiss goodbye the thought of ever fixing the doctor shortage. Think about what you're advocating here: Someone who just took out a $160k unsubsidized loan at 5.4% (variable) interest now has to increase his/her loan burden just. to. eat. for another 3-7 years while interest is accruing on that initial medical school balance. Does this seem like a sustainable system to you?
Man, I thought HN/Silicon Valley/Tech Industry was all up in arms at the unjustness of the unpaid internship...
Edit: As to fixing the shortage IMO remove the need for undergraduate education and you add 3+ years to a doctors career and lower costs. However, my point is you can have a sliding scale where they might make nothing for 3 months, minimum wage for 3 months, on up to full pay at year 7. Or however the cost/benefit equation works out such that there is no need for a subsidy.
Current billing rules do not allow for additional reimbursement just because a trainee took care of a patient. You're basically saying the hospital should foot the bill. Fine. That's a valid argument, but then you've got the problem of convincing hospitals to open up residency slots to train more doctors (and pay for them) instead of just hiring a PA/NP or two.
As to reducing costs, undergrad is not free so if you reduce/remove that cost students can afford to spend more on other things. Start med school with less debt and being unpaid for the ~first year of Residency is more reasonable which means you could have more slots open for the same subsidy.
Still, I would also suggest modifying the billing rules. This may create some perverse incentives but it balances the costs between Medicare and private insurance while paving the way for increasing the number of available slots.
Our options are: government, students, and hospitals. Government has demonstrated an inability to manage the market. Hospitals don't have a good reason to pay students. Therefore, it has to be the students.
> [paraphrasing] But then students will have to borrow even more! Costs will spin out of control!
You're assuming the inflated education costs that are a direct consequence of the government paying for graduate medical education will persist indefinitely when the government stops paying for graduate medical education. Medical schools currently sell an artificially scarce commodity. Prices will decrease if we allow supply to increase. New schools will be built to handle the influx of students if necessary.
If college grads find the cost of medical school + graduate medical education unappealing, medical schools will have to look for customers earlier in the pipeline (college + med + grad might be too much, but med + grad won't be).
> [anticipating an argument] But it's still an awful deal for current college grads.
Easy: pass a bill saying the government will stop paying for GME in 10 years. If GME funding was an actual roadblock and not just an excuse, AAMC will announce lifting the supply controls in 10 years (I personally suspect they would have to be strong-armed into this, but that's another argument). Medical schools will anticipate the ability to increase supply of seats in 10 years and will build out as necessary so that when the deadline hits, the new pipeline will be ready to go.
New grads of 2024 wouldn't be screwed because they would have already had a chance to price the new policy into their decisions. For instance, if they wanted to be a doctor they might have worked (perhaps in a medical-related job) for 4 years in anticipation of accelerated direct-to-med-school programs opening 4 years after their high-school graduation.
Yes, there would be a market shakeup with winners and losers, but nobody would get the rug yanked out from under them in a way they could not have anticipated and planned for. Realistically, that's the best we can ask for.
> [another anticipated argument] But then our doctors won't be as good.
Give certificate-granting entities partial liability in malpractice cases. Then they'll be forced to price their actual opinion on the matter into their admissions policies.
I'm not qualified to determine where the lard should be cut, but I find it difficult to believe that there isn't a lot of it in the lucrative monopoly we see today.
See: http://www.quinnipiac.edu/academics/colleges-schools-and-dep...
2. Inflated education costs are the result of easy access to loan money that is not dischargeable. Most university education cost increases follow from this. I'd argue we should make schools hold the loans for their graduates at the bare minimum, and then allow them to be discharged in bankruptcy again.
Or, even more radically, I'd argue we should make medical education free, but require tuition for residency. That way, if you want to specialize, you owe more years of tuition, but supposedly will make more money later and can pay it off. This way, you actually have a strong incentive for people to consider primary care specialties, as it will lead to a much lower total-loan-burden.
Or even more radically, let's lop off a year of residency for the primary care specialties. Canada seems to do fine with GPs only completing a 2 year residency. That's gaining a whole year of attending earning power. That could be huge.
I do not see medical education costs responding to general market forces so long as educational debt is easy to obtain.
3. Again, American medical school operates typically as a 2 + 2 system, where the first two years are spent heavily in class learning the basic science of medicine and the last two years are spent clinically learning the fundamentals of history taking, physical exam, differential diagnosis, and medical decision making.
The premedical requirements actually are useful for establishing a common foundation of knowledge which allow for us to only need 2 years to cover all the pre-clinical coursework. If you lop that off, you will simply transition to the non-US systems of medical training, which are only 1-2 years shorter in total duration. Mexico has a 6 year system. Chile is 7 years. UK grad entry is 4 years + 2 foundational years + residency, so at minimum 6 years before residency begins. Fine, there's some cost-savings in 2 years of undergrad removed, but most undergrad tuition is cheaper than medical school tuition. I think there will be no net savings.
4. Again, you are fundamentally misunderstanding things. The AAMC has no supply controls. They can only control how many students a medical school has. They have zero say in the amount of residency spots. Those are created by hospitals and accredited by the ACGME. Most hospitals only create as many spots as they receive CMS funding for. They could create spots and fund them themselves, provided they meet the minimum standards set by the ACGME for each trainee (sufficient case volume and teaching). If the government were to stop paying for GME funding in 10 years, either the hospitals would start paying or they would begin charging tuition, but in EITHER CASE, you've got to create quality residencies to train people. You can't just open a residency at random hospital because you want to.
2. Easy access to loan money increases demand for degrees, yes, but you're forgetting the supply side of this equation. Supply will increase to compensate unless there's a barrier to creating more supply (such as accreditation or actual economic demand for prestige, which only becomes significant when the degree itself doesn't suffice for employment).
Why would government funding of medical school not fall victim to a similar fate to GME? What if someone offered the compromise "government pays for tuition, but then government gets to set the salaries." How appealing would that be?
3. I'm familiar with what IS done, but I would be astounded if the "we can't possibly cut expenses" line continued once competition started to kick in.
4. No supply controls? Xodarap's evidence looks awfully damning: http://skeptics.stackexchange.com/questions/4561/does-the-am...
5. Yes, the point is to have students pay for their education, so that the supply of medical education can scale with the demand for it. It's not reasonable to expect the U.S. government to manage the supply of doctors at this time or in the near future.
Dentists make more money and work less than doctors. Simply forcing medical students to pay to be residents won't make things cheaper.
http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot...
I met a resident the other day, and they routinely get four hours of sleep or less and worked for shifts that are insanely long that are basically dictated by patient demand. Why not just hire more doctors, maybe lower salaries by increasing supply, and give them a healthier lifestyle? Maybe medical school prices would go down with additional scale.
So this is useful training, albeit at a cost. Although if they make a mistake that kills a patient during residency and learn they can't deal with the consequences of that, I suppose the earlier the better. They can of course move to less life and death specialties.
If your goal is to reduce medical errors, create systems that don't depend on a single person's fluctuating energy level (e.g. have two doctors responsible for each patient, keep patient loads low enough that they can deal, automate as much as possible with computer systems (e.g. billing), and delegate to e.g. PAs for mundane diagnoses). Exhausted people make mistakes, can't work or think as quickly, are less creative, and are generally less happy. All the technology in the world won't help you if the key decision makers screw up at the wrong time.
After all, coffee does exist for those times when your natural energy level won't do it for you. ;)
Nonetheless, I don't think these guys are getting 4 on 4 off... I think they just work basically straight through for 12-16 (or more) hours and get maybe a day a week off.
I can completely sympathize though that 4 on 4 off would be incredibly hard in and of itself. I'm not sure I could do it for weeks let alone months on end.
There's no justifiable reason to give a large, urban hospital an organization system fit to the battle field.
I learned this primarily from my mother, who was a RN nurse anesthetist, and a doctor who became my father's primary hunting partner about the time I was old enough to start actively hunting.
Additionally, the work hour restrictions placed on residents over the last few years appear to have done nothing to reduce the overall number of medical errors.
(I am in favor of reducing medical work hours myself, but these are some of the data-driven reasons that it will be very difficult, not to mention the structural reasons inherent to the current system of medical training.)
It seems like a bit of a chicken and egg problem. Medical school is already so expensive that the salaries are necessary in order for newly minted doctors to have the same disposable income after loan payments that, say, a programmer or chemical engineer who's 7 years younger has (4 years medical school + 3 years residency minimum). Who would make the sacrifices necessary to become a doctor, taking out massive loans, only for an income that won't sustain them comfortably?
Currently, in the United States, we believe all of the following things: (1) Human physicians, are the only qualified parties to diagnose, treat, and/or recommend courses of action related to health (not nurses, physician's assistants, computer programs, etc.), (2) everyone has a fundamental right to healthcare, (3) health professionals must undergo expensive, lengthy, difficult courses of study and training, and (4) we reimburse for procedures, not pay for outcomes.
Given these incentives, it's not hard to see why doctors are some of the most overworked, stressed-out, and generally miserable professionals out there. They're at the nexus of a crushing conflict between keeping people healthy, a management system that demands more revenue (and remember that revenue=procedures, because we reimburse for procedures, so the only way to increase "productivity" is to do more, faster, with fewer breaks and longer shifts), and a legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study.
I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. I believe this outcome is inevitable, but will take a decade or more to surface, because it requires major shifts in how doctors and insurance companies think about billing, greater human trust in computers and recommendation systems, and a collective realization that the current state of healthcare is untenable.
I agree completely, but you forgot to add under what we believe: (5) "government has the solution for everything." At least that's what it feels like lately.
The cynic in me says that the healthcare industry will continue to get worse for some time before it gets better, if ever. We may see complete nationalization because the government must swoop in and "save us" from the monster it has helped to create through misguided regulation.
Americans actually display stunning recalcitrance towards this fact, and as a result we have an incredibly polarized debate which has led to a bastardized and amalgamated system comprised of several other, and often conflicting, constructs.
I think integrated systems could help, where the financial and operational sides of healthcare are combined (e.g. Group Health in Seattle, or Kaiser). The key thing is to remove the conflict between the payer and operator -- it's just madness that we have a system where one party has 100% of the incentive to control costs, and the other is completely responsible for outcomes, cost be damned.
Administrative overhead of government vs private insurance: http://healthcarereform.procon.org/view.resource.php?resourc...
http://www.commonwealthfund.org/~/media/Files/Publications/I...
Essentially, we excel in a couple very specific things, like survivorship of breast cancer. We're middle of the pack in some things, like general cancer survivorship. And we're the worst by quite a bit in others, like chronic diseases. Basically, I would say we're not getting our $'s worth.
Here's some Commonwealth Fund info if you don't want to trust some random white paper.
http://en.wikipedia.org/wiki/Commonwealth_Fund
Oh, and if you want something from an organization with a known bias: http://www.rand.org/content/dam/rand/pubs/working_papers/201...
Key abstract quote: "But one key finding emerges – the US ranks poorly on all indicators with the exception of self-reported subjective health status."
My girlfriend is a doctor here in Europe (though she has worked in Mexico). As such she has worked with private and public systems (generally in Europe, you are automatically part of the public system. You can pay private yourself and generally have to wait less).
Anyway, both her and her boss pointed out that if you have anything serious, go to the public system. Why? Because insurance companies always want to pay the least for the cheapest drugs / treatment. The doctors don't enjoy working for the private, because too much of it is trying to justify using the more expensive treatment to the insurance companies.
At the end of the day the public healthcare system exists to help people get better. The private healthcare system exists to make money.
Per the American Academy of Physician Assistants: "PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling and make rounds in hospitals and nursing homes. All 50 states and the District of Columbia allow PAs to practice medicine and prescribe medications."
http://www.aapa.org/the_pa_profession/what_is_a_pa.aspx
Disclaimer: I work for the Physician Assistant Education Association.
They are not tried and true. A friend of mine worked as a QA engineer at my city's most prominent children's hospital (a minor power on the world stage). His thankless task was to find ways to improve communications between departments and curb the errors. It was simply not possible - every doctor had their preferred provider, sometimes from merit, sometimes because they liked the shiny goodies that the sales reps brought.
All the individual systems interoperated very poorly, and none of the physicians would budge, and the hospital administration could not force their hand. Any time admin tried to regularise something, the affected physician would just state "If we make this change, children will die". It didn't matter that everyone at the table new that this was a total lie, because the official authority for that department (or speciality) was that specialist. They got their 'free market', being able to use their preferred products for each individual specialist, for personal preference at the cost of better overall treatment. The whole was very much less the sum of its parts.
Another friend became a sales rep for a pharma company. The rep she took over from was a fairly standard rep, but she was quite ethical, and would only allow her 'freebie' budget to be used on things that developed the practise. Some doctors already do this. Others were more like "ah, well, the ride is over with this rep". Some were absolutely outraged that she should dictate to them what this 'extra income' was spent on - how dare she suggest medical charts instead of football tickets?
I myself have personally seen a specialist in a field report on some clinical studies so badly that we technicians had to go to other specialists and get them redone. That specialist didn't get any more of that kind of work at our practise, but his utter incompetence was never followed up beyond "don't hire him again".
I guess the moral of the stories are that freedom to run practises as you see fit does not mean ethical (or even ethically neutral) behaviour, and that an environment where every physician uses their preferred products does not mean better care is delivered.
The point remains the same, though - letting physicians choose whatever they want is not a magic bullet given by 'the free market', and can make things worse in practise. And it's not like 'the free market' has shown us that comms protocols are followed with any particular veracity in the software world, for things that have no regulation on them. Do we have an open video codec yet that runs on all browsers, for example?
I am an MD and have a degree in CS. Expert systems are not remotely there yet for this purpose. On no planet would I trust care of my patients to a computer. Far too many subtleties involved in accurate diagnosis and treatment that are not encoded in a machine-readable format.
> legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study
Good reasons for this - it actually takes that lengthy course of study to safely perform many procedures, and, more importantly, to fix things when they go wrong.
NPs and PAs are helpful but based on the quality of care that I personally observe they should not function without physician oversight.
There is no escaping that medicine is an extremely complex field, and it is only getting more so. Not long ago, many of the people who today are restored to their usual state of health would simply have died. The sicker a patient is, the more complex and difficult to manage they are. By definition a doctor is the one who is able to do so.
I am still waiting to meet a patient who comes to the hospital and prefers to have their care rendered by non-physician providers over physicians, or would even settle if there were an option.
Attach a price tag to each and find out. Maybe someone who couldn't afford a $500 consultation with an MD could settle for a $250 or $100 consultation with a PA, or an expert system. You really don't know until you experiment, and find out.
It is not without ethical concern though. Unfortunately, most patients are not sufficiently informed about medicine to make a rational market choice. (Indeed, outside my specialty, I am not really either, and would seek the advice of a trusted physician friend, which is a luxury most don't have.)
For example, the PA and expert system would not reliably know when they are in over their heads and require an MD. Some subset of people would suffer serious injury or death through no fault of their own other than not having had the information necessary to allocate their funds in a manner most benefiting their interests.
US medicine has been very successful at creating a guild system that's prevented lower-cost provision of care for decades, all under the concern of "it'll lower the standards of patient care." End result has been millions of people who can't afford medical care at all.
One anecdote: for a time I was splitting living in the UK and the US and had health care experiences in both places. It was fascinating to see the differences in treating my (very ordinary) health issues. One time I came down with a mild rash that rebounded a few times before it finally went away. In the UK, the GP looked at the rash, punctured the pustules with little pokey thing so they'd drain, and they cleared up in a few days. In the US, the dermatologist wheeled in a big machine filled with liquid nitrogen and froze the pustules; they went away in a few days after that too. End result the same; cost to administer - orders of magnitude different. In the US, it seems like there's no medical treatment that we can't make more expensive by requiring more specialists with more years of training, using ever more expensive machines and medications.
I love modern medicine. My dad's a retired doctor and I almost became an MD myself. But the system we've created has costs out of control while simultaneously creating worse societal health outcomes than other countries.
The society in question has not realized it.
> US medicine has been very successful at creating a guild system that's prevented lower-cost provision of care for decades, all under the concern of "it'll lower the standards of patient care." End result has been millions of people who can't afford medical care at all.
Even the bottom rungs of the doctors in the "guild system" are not very good - lowering standards even more is very hard to agree with when push comes to shove. Especially there is no guarantee that this will actually lower costs to society.
But I guess this is what will have to happen, at least in primary care, because that is a miserable field that I am incredibly glad I didn't go into. I hope that at least some kind of care turns out to be better than none at all.
But still due to huge resistance by doctors, who like the autonomy of the job, such systems are rarely used.
I could only imagine how rapidly such systems would improve if the backbone of medicine would be dependent on them, and enough revenue would be shifted towards them.
Holy meaningless platitudes Batman. How do you have a system that is simultaneously profit driven and that allows everyone a fundamental right to healthcare? Short answer: you can't! You can either have a system that avoids treating the most expensive (free market), or you have a system that ensures a certain level of care for all (socialism), or you have some bastardized hybrid that costs ungodly amounts of money and does not serve the sick and poor well. (the system we have).
[1] http://en.wikipedia.org/wiki/Conditional_cash_transfer
See also: http://www.economist.com/news/international/21588385-giving-...
EDIT: In the essay I describe why it can become so hard to leave medicine after one has invested more than a year or two in med school because of student loans; that may help explain the suicide issue: people who feel trapped may in turn feel like death is the only way out.
A surprisingly large number of doctors hit residency and realize they don't want to become doctors. In most professions that's not a tremendous problem, but in medicine the only way to pay back $100 – $250K in graduate student loans is by becoming a doctor.
To be clear, it's a huge problem, and we shouldn't have this sort of debt loads on those who want to educate themselves. It also weakens the broader economy and drives up professional services costs. But to say people are killing themselves because of student loans is a mistake.
Further, implying that Doctors are willfully ignorant of loan financing options is...interesting. All Federal borrowers are required to complete exit loan counseling upon graduation from medical school. That counseling includes discussion of the various repayment options (Standard, Extended, ICR, IBR, PAYE, and forbearance).
OP missed a perfect headline opportunity: "9 out of 10 doctors recommend not becoming a doctor."
But seriously, we wonder what's wrong with healthcare. I seriously believe it's because of the lawsuit-happy nature of patients nowadays. Yeah, something could go wrong during your surgery, or your diagnosis for that matter. But that's an inherent risk in having something wrong with you that you need checked out.
It's a revenue optimization problem -- the goal is to collect the most revenue overall. Set prices too high and people/insurance goes elsewhere, too low and you leave money on the table the org could use to cross-subsidize non-payers.
you have to be careful with that statement since it can be a clever way of talking about what insurance agrees to pay with the chain versus the "retail" rate the doctors charge.
my father is a general practitioner and I was always amazed when he started saying about 25 years ago that he wouldn't let me become a GP if I had gone into medicine. and this article covers all of his concerns well.
malpractice is a big part of the issue and it varies state to state. for example, in pennsylvania malpractice insurance is amazingly expensive. and people sue all the time, which is sad unless it is gross incompetence, since every doctor I've met is trying their best.
I don't know how to solve this, or whether it's fair, but it's pretty universal if you talk to people in healthcare billing.
The problem is that management is filled with perverse incentives. It looks good on the books to have fewer employees - until you realize you have highly trained specialists spending hours per week working on paperwork or rushing their actual job and increasing long-term costs.
It's amazing that the billing costs in the US are a factor of magnitude higher.
I know that compared to much of first world Europe, our nurses and doctors often make two to four times as much as their counter parts there. Wonder if that's true compared to Canada as well.
http://www.health.gov.bc.ca/msp/legislation/pdf/bluebook2012...
The average for Family Doctors is around $240,000 CAD and for specialists is about $430,000.
Average registered nurse salary in BC is about $61,000 CAD.
Doctors in Europe live quite well, and don't have as ridiculous workhours as the numerous USA examples listed, or the suicide problem.
http://en.wikipedia.org/wiki/Canadian_Medical_Protective_Ass...
I'm curious how the arithmetic on that works out. The median pay for medical assistants is $14.12/hour [1], which means that assuming the assistant is handling the insurance form, that works out to just over 4 hours per patient encounter. There might be some fixed costs (filing space, for instance, is not free), and some costs associated with communicating with the insurance company, but it's really not obvious to me how any of those can add up to $58/visit.
[1] http://www.bls.gov/ooh/healthcare/medical-assistants.htm
That just sounds crazy. Can you imagine if your car insurance had to pay less if you complained about your mechanic? Not to mention that medicare is for the elderly who tend to have a lot to complain about anyway.
Can I pay my taxes based on my satisfaction with the government?
There's also this: http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-sh...