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The New York Times has been featuring a "Presciptions" section that includes short newsy items about health care reform issues. There I discovered that the American Association of Medical Colleges (AAMC) has a rather peculiar perspective on the growing need for physicians.
Kevin Sack, the guy the Times sends out to do fluff pieces on AHIP’s contributions to reform and the nice people who do rescissions for profit has an item about how Massachusetts may be facing a severe shortage of doctors, all because of the State’s effort to require everyone to purchase health insurance.
Massachusetts has lots of doctors; in fact we have more doctors per person in Massachusetts than just about any state in the country. But the A.A.M.C. says we’re short because a few years ago Massachusetts started requiring almost everyone to purchase health insurance. So now we have the lowest uninsured rate — about 2.6 percent according to the article** — of any state, but we also have all these people who want to see a doctor. What to do?
Kevin tells us of a new survey by the Massachusetts Medical Society, which finds there’s a shortage of primary care physicians as well as various specialties. As a result, the Society tells us, a lot more doctors are so booked they’re refusing to take new patients, and their existing patients are facing longer waits — weeks — to get appointments.
This, Kevin writes, is "an unintended consequence" of the state’s insurance mandate. Really? I can’t wait until this thought makes it’s way into the national discourse.
It seems rather peculiar that the Medical Society would discover it had a shortage of doctors only after people who were already there and sick started showing up with their new insurance cards. Was this a new attitude?
Fortunately, Kevin gives us a link to a previous Prescriptions article that discusses potential doctor shortages if the US adopts national insurance reforms.* The title, Who Will Care for the Newly Insured? seemed like the wrong question: who was caring for them before? And the A.A.M.C. provide us with this interesting graph:
The A.A.M.C. graph is not just telling us that we’re going to need a lot more doctors. They’re telling us they see the shortage problem getting much worse under proposals for universal insurance.
Universal insurance doesn’t create more sick people (in fact, it may create fewer) who need doctors. But it looks like the institutions responsible for training health care providers don’t recognize some people until they get insurance, and then suddenly, we need more doctors than we needed before. (Perhaps we should import them, for less?)
It’s a good thing America doesn’t ration health care.
UPDATE: See this explanation from Dr. Kirk Murphy of medical education costs, myths and the A.A.M.C.
http://www.nytimes.com/2009/09/15/world/asia/15policy.html?scp=3&sq=Obama,%20stimulus,%20&st=cse
_________
** The 2.6 percent estimate for MA uninsured is supported by this source. The Census Bureau estimate for 2007 agreed MA had the lowest percentage, but placed it at 7.9 percent in 2007. The additional year could close this gap, and the higher estimate may be including different populations, such as undocumented immigrants.
*The article goes on to interview other health experts who challenge whether the State needs more doctors, or should just deploy them more efficiently, using, for example, the Mayo Clinic as a model.
79 Comments
I would dispute the 2.6%. It’s around 6%.
As someone without insurance, I like to say I ration my care so you don’t have to. :)
That number came from one of the articles. If you have a better source, I’ll use it.
Maybe we can import doctors from Cuba since they seem to be capable of producing a few more than they need.
Let me translate:
The American Association of Medical Colleges confesses that its members have not been doing their jobs.
It’s not because there aren’t students wanting to become doctors.
Or is this a shakedown for medical education funding?
I saw on Bill Moyers’ journal a couple weeks ago a documentary where it was revealed that students of medicine were opting out of primary care in favor of specialties, apparently, to more quickly amortize their loan obligations arranged to pay for tuition, etc. Anyone else see that?
Yes.
That’s the one! Thanks for looking it up. I’m thinking this might obviate the results reported by Sacks, as well.
There truly is a shortage of primary care docs. I know that from experience.
This is how people lie with statistics–healthcare reform will mean that you (insured people) won’t be able to see doctors. See–rationing! I new it.
Healthcare reform does not directly create a doctor shortage. This is a classic post hoc ergo propter hoc fallacy. Correlation does not indicate causation. Healthcare reform does mean that more people will go to doctors. I don’t see doctors until I’m at death’s door. Yes, I am uninsured. That works now (not really) because I am healthy. In a few years, I will end up incurring big costs by not seeking healthcare when I need it.
We will need more doctors. That is easily remedied. Admissions to medical school are depressed below the point of need, I would argue. It is absurdly hard to get into medical school in the US. If students with 3.7 GPAs could get into medical school, we won’t end up with bad doctors.
So let’s create more need to doctors and more doctors. This would not raise medical costs, as people getting needed primary care is cheaper in the long run.
Actually it does. Just by adding on the 36 million million (just last week it was 48 million…reform is working and nothing has happened yet), doctors will be overloaded most of which will be the inner cities where doctors are already in short supply. Are you going to force doctors to go work in the inner cities? Funny thing is that is exactly what Obama wants to do.
Next, go talk to you local MD and ask if they are going to stick around in a industry where their reimbursements from the government are already problematic. Most doctors already have to ration care to Medicare patients based off a ratio of Medicare:Private insurance. If they didn’t, their practices would be out of business in a short period of time. With Universal Coverage, they won’t have a choice keeping their businesses open, much less paying off any debt incurred when becoming a doctor based off reimbursement limits. The only way this will work is if the government start subsidizing doctors which obviously will kill the arbitrary $900 billion number Obama pulled out of the air.
Also in regards to your paragraph on the “need more doctors, it would be nice if we could just lower the standards and fix the issue. Unfortunately, as the tech industry found out, you can’t just start spitting out high tech people, they are hard to come by and takes years of training after formal education. It will be the same with doctors. We will probably end up raping other countries of their doctors, just like we did with the tech sector. This all stems to a reduction of quality of health care for everyone (except the politicians).
We already are raping other countries of their doctors because salaries are so much higher here compared to their home country.
There are qualified people who don’t go to medical school because they don’t want to risk $100,000-$200,000 in student loans for the rest of their lives. And the primary care physicians who do make it through wind up in large medical systems that pay off their student loans in exchange for a multi-year contract; they jokingly refer to the arrangement as golden handcuffs.
And too much of the cost of a medical practice is not because of the physicians’ salaries but the administrative staff they have to have to deal with insurance companies policies on pre-certification and to ensure that insurance companies deliver on payments.
I would say something about medical care in inner cities, but I won’t.
Why not?
OK, here it is:
1. That is a stereotype of who lacks insurance and where the doctor shortages are the greatest.
2. There are lots of doctors working in inner city hospital outpatient and emergency room facilities.
3. The greatest need for doctors to relocate is in rural areas far from the cultural amenities of even small cities. Applachia is underserved. South Texas outside of a few cities is underserved.
4. No one is forcing doctors to do anything.
5. Persons with health insurance, should the a public plan pass, and who live in inner cities find transportation much easier to negotiate than folks in rural areas. Doctors won’t have to practice in the “awful” inner cities after all; they can practice where they have a diverse clientele.
The reference to “inner cities” in this argument is nothing more than a racist frame. Most doctors are not racists.
Thanks. I thought that was worthwhile information for you to contribute.
It is well documented that the admin cost related to medicare/medicaid reimburement exceeds that of priviate insurance carriers.
Link to documentation?
Source?
Even if you add in activities not often counted in Medicare admin costs, and exclude private insurance profits in Medicare Advantage, the Medicare admin cost total still comes out less than Medicare Advantage total, according to this:
http://healthcare-economist.co…..ive-costs/
“It is well documented that the admin cost related to medicare/medicaid reimburement exceeds that of priviate insurance carriers.”
Just plain false. You or someone else made that up.
I am not saying that insurance companies are not a pain and don’t require resources, but think about who is loading up the insurance companies with regulation after regulation which is causing all the red tape in the first place. And then there is Medicare, you think the insurance companies are bad, take a look at how much staff needs to be on hand just to do Medicare alone. Hell I am not even concerned with the money that Medicare doesn’t pay for services rendered, just the paperwork alone is a nightmare. Get’s back to the BIG point that the government can’t run Medicare effectively, why would anyone in their right mind give the government more to manage? That’s insanity.
Um, in the real world Medicare payment requires submission of a single electronic claim form. On the form I need to state the diagnosis and the procedure code. The system is absurdly easy, because it is designed to be: that’s why Medicare’s overhead costs* are only 2-3%
(*exceptions being both Medicare Part D and the Medicare Advantage programs: designed by “free-market” ideologues to allow the private sector to loot the public sector. In the case of Medicare Part D, designed by the “free-market” ideologues to preclude price competition.)
Ok, I see where you are coming from. Which overhead cost does the 2-3% cover? It certainly isn’t all of Medicare, if it did, Medicare would not be in the shambles it is today. Your basically saying that 97% of Medicare funds goes directly to patient care. Is this true?
It is an near impossible figure to ascertain.
Yep, that’s correct 97% goes to providers–doctors, hospitals, pharmacies, and other medical care. And a bunch goes to temporary nursing care.
Medicare today is not in a shambles, despite the way the press talks about it. It will be in a shambles as more boomers start getting covered by Medicare. And it has to do with the way Medicare is funded. It is cross-generational. My parents’ taxes paid for the care my grandmother received between the date Medicare was enacted and when she died. My taxes paid for the care my parents had at the end of life, and both of them had additional insurance under their retirement plans. My children’s taxes will pay for my Medicare coverage. The concern is that the total number of workers in the next generation cannot cover the baby boomers. That concern is unwarranted except to the extent that provider costs (that 97%) increase at the rate they have in the past decade and a half.
So why did provider costs increase? The incentives to create huge medical systems also created private, university, and nonprofit medical system bureaucracies in which administrators are compensated with high salaries for managing very large organizations. A university medical system administrator salary of $1 million is not that uncommon. The companies that sell medical supplies are essentially a cartel that bargains for changes in Medicare rates nationwide in order to increase their profit margins. The medical equipment industry is concentrated with lots of players dominating a field because of the long length of their patents and the capability of their lawyers to prevent entry of competitors into the market. Hospitals themselves have become more concentrated, with smaller hospitals closing. And with concentrated specialty facilities providing equipment services (x-ray and lab work) that once were normal procedures at a GP’s office.
And like I said, the whole idea of cost accounting by mini-procedure has placed information technology costs on hospitals and discourages smaller practices from implementing electronic medical records technology at all.
Finally a major cost factor in Medicare as in all other insurance is the fact that providers shift the cost of treating those who cannot make payments to those who do make payments through their indirect costs. Healthcare reform will reduce eliminate that cost shifting, allowing more people to be treated at less cost overall. A public plan that competes with private plans in an exchange creates incentives for insurance companies not to put those savings in costs to their bottom line but to lower premiums. It also indirectly makes Medicare cost less likely to spiral out of control.
Without commenting on all your points, I am sure smarter people than us have tried to implement changes to Medicare since its inception and yet Medicare has still “spiraled out of control”. I highly doubt that moving to another ‘Single Payer System’ like Medicare will resolve anything.
Somehow I bet Medicare does not have to pay overhead for facilities it uses as a government entity, nor does it have to pay for the facility itself. I am also betting it doesn’t have to pay corporate taxes like a private insurer does. I am not going any further with Cujo359 and TarheeDem analysis because you are not comparing apples to apples. There is no way that it’s overall costs are 2-3%. I can rationalize the DoD as being a efficient entity using that logic.
The only one saying Medicare is spiraling out of control is you. There are long term problems financing it, but at the moment it’s doing it’s job well.
The US spends almost as much GOVERNMENT money on medical care as nearly-socialist European countries do, and when you consider private insurance the US pays a far higher percentage of bureaucratic overhead, and yet a considerable number of Americans (and a considerably higher proportion of sick Americans) do not have medical coverage.
I’m lucky in terms of health, so during my 23 years with good coverage I hardly used it. If my medical plan had been a total fraud I wouldn’t have found out. But a lot of people who think that they have coverage only find out that they really don’t after they get seriously sick.
That’s why the “percentage who have coverage” statistic is bogus. It should be “the percent who think that they have coverage”.
And to repeat, in #17 Kurt admitted that in America we’re rationing care by ability to pay.
That’s not what I said John. I said
Most doctors already have to ration care to Medicare patients based off a ratio of Medicare:Private insurance
. One thing I could have said clearer was private practices have to ration care based off this ratio. Anyone can go to a hospital ER and get medical care.
Maybe you didn’t say it in so many words. What you said is that we don’t have enough doctors to give medical care to all the people who need it, and that if everyone who needed care got it, we’d have a shortage.
It’s true and I thank you for saying it, and I won’t listen to you trying to take it back.
The ER is designed for a specific purpose: accidents, fired, and sudden-onset diseases. They’re not designed routine care, or for people who get sicker and sicker until they are very seriously sick and just can’t stand it any more. The claim that ERs substitute for medical insurance is one of the most destructive misrepresentations conservatives use, since it is effectively false because the ERs are overloaded, and it also reduces the quality and availablity of response to actual emergencies.
OK John!
I see I wrote theis before I got your correction, but that is OK, I feel like venting some more.
I will not take it back. I think the physician induced demand theory is crazy, but it is still all over the place. Many influential docors and non-doctors who deludedly advertise themselves as economic experts in heath care believe it. So many that you have to be very careful in criticizing it, policy office politics being what it is.
If you look at international evidence in high income countries, there is no evidence that an increased supply of physicians in itself increases health care inflation or expenditure.
I think that that the process of determining health professional supply, which includes nurse practitioners and physicians assistants, and others, was well as docs, needs to be rebuilt. I have no fear in meddling witht the current system, since I can see no evidence that any rational process at all, market based, planning based, bureaucracy based or anything else based went into it. It just grew out of series of short term fixes for lots of problems, few of them directly, or even remotely, related to the questions of how many health care professionals we need to maintain population health in the US.
I have taught medical, pharmacy, nursing students, residents and actual doctors the economics and statistics they need simply to perform their clinical duties competently, as well as for formal research. My opinion is that there are plenty of people with the intellectual skills needed to be excellent clinicians, and I fear no shortage or intellectually qualified people. I cannot speak to issues of personality needed for a good clinician, which a doc could talk about.
There is a huge resevoir of talent in the country qualified to be doctors. These kind of people flow towards medicine, finance, law, engineering, depending on their guesses and impressions about the relative long run career prospects. I know several residents who considered jumping ship for finance before the bust. I tried to persuade them not to. I find it hard to believe that anyone who has experience working with college grads at entry level to the job market or any kind of post grad education would doubt what I say.
What you describe makes perfect sense to me – I hope you’ll consider making it into a post on its own for the Seminal!
How exactly is Medicare out of control? Documentation, please.
http://en.wikipedia.org/wiki/M….._States%29
Fraud and waste
The Government Accountability Office lists Medicare as a “high-risk” government program in need of reform, in part because of its vulnerability to fraud and partly because of its long-term financial problems.[46][47][48] Fewer than 5% of Medicare claims are audited.[49]
http://www.whitehouse.gov/omb/…..8/hhs.html
Need more, let me know
That’s from the Bush Administration, Kurt. No one with any sense will take it seriously.
Well insurance premiums have spiraled out of control faster than Medicare costs have.
Medicare uses few government facilities. An office staff whose primary function is to audit the providers and the IT providers and to determine any issues with the program. It’s a simple program. It does indeed not pay corporate taxes, nor do its administrators make multi-million-dollar salaries. But insurance companies pay taxes only on their profits; if they have high taxes it’s because they have high profits. Insurance companies also have large marketing, sales, and advertising costs that Medicare doesn’t have.
Essentially all you need to run Medicare is a claims and payment department, customer service department, and auditors. And some of those functions are outsourced to private contractors.
DoD audits, finds fraud, and never punishes the fraudsters. In some cases there have been hundreds of millions that military contractor have defrauded the taxpayers. Where DoD does control costs in in the uniformed military and in the DoD civil service employees; left up to those two, we would have a more cost-effective military.
Post hoc, ergo propter hoc reasoning, and as usual it leads to an incorrect result. Medicare is in a “shambles” to use your term, because it’s been underfunded, and because the Congress has managed to make things worse nearly every time it’s taken a crack at “fixing” things. It is also a victim of the same cost inflation that’s hitting all parts of the health care provider industry. Medicare is roughly seven times more efficient at paying for health care than private insurance. We could eliminate roughly 20 percent of the cost of health care by paying for it through Medicare, rather than using private insurers on that basis alone. Plus, as Kirk Murphy explained earlier, administrative costs for providers would also be lowered.
I will agree that the paperwork that Medicare recipients receive is a nightmare. My mom’s end-of-life ICU paperwork was an EOB that ran 250 pages and failed to cover a $50 x-ray because the insurance company (Medicare uses private insurers as contractors for their IT) had applied a rule that did not exist about what constituted a duplicate payment.
But this paperwork is not the result of government failing to operate healthcare, it is the result of the Reagan administration trying to control cost through a micromanaged fee-for-service cost-accounting system of payments. A system that was rapidly picked up by private insurers and which results in the 1500 systems of payment with which providers must contend.
But you don’t understand the legislation. It gives government much less to manage than a single-payer bill would. The key thing is that it would provide a plan to compete with private plans; if the plan could compete it would draw limited addition policyholders; if it couldn’t compete, those policyholder would go to private plans.
The opposition to a public option is primarily driven by insurance companies who don’t want to compete against a benchmarked plan.
Seventy per cent of physicians support a public option (New England Journal of Medicine poll). There is a reason for that.
“Regulation after regulation” does not cause the insurance company red tape. What causes the insurance company red tape is the insurance company desire to find some excuse to not pay a claim. It takes a lot of extra documentation to make it complicated enough that the insured will make a mistake they can pounce on. And if the insurance companies were not so corrupt, they wouldn’t need as much regulation as they do. The problem is that there is not enough regulation as it is.
Kurt, I’m resisting calling you names. Look, according to WHO the US Health Care System currently ranks 37th in the world. The countries that have higher-ranked systems all have some form of Government-funded health insurance, or have Government provided health care, or have very highly regulated private systems that could not be easily copied here in the United States because our private companies won’t accept regulation.
In short, the facts are that our system works far less well than systems in other nations. We need to have the wisdom to look at what they’re doing and to design some variant of it that will fit us and implement that. If that involves Government-funding, so what? We’re Americans. We do what works.
Kurt, that’s all bullshit. More doctors can be trained.
You may be right that we don’t have enough doctors to give medical care to everyone who needs. it. But don’t you see that that proves the reformers point? [No, Kurt does not see that, he’s a liar or an idiot].
There are a lot of Americans who aren’t getting the medical care they need because they can’t afford it. That’s called market rationing. Obama (and the House Democrats even more so) is trying to change that, but he’s being met by a barrage of stupidity and lies.
American medical schools ration the number of physicians they produce to keep demand and salaries high. A lot of American graduates of medical schools go into specialties both because the salaries are higher and the workloads are lower. Shortfalls in areas like primary care are often made up with imports from places like India.
I would say too that the quality of American medical schools is not especially good. The schools select for good test takers and this continues on into selection for residencies. The development of good clinical skills is almost an afterthought of an afterthought.
When every single mainstream(corporate) media outlet promotes provable lies as accepted fact, and when 50% of the population accepts those provable lies, even though they are shown to be lies, it’s time to get the hell out of this country. Remember, the brutal Sunnis who ruled Iraq accounted for only about 30% of the population. It can happen here. It is happening here. And with a president who believes in nothing and is willing to fight for less, it will continue. They’re not buying all those guns just to hang on their walls.
Dave, I am not following your rant here. Are you comparing the Sunnis against the majority of Americans who do not support the current plan(s) in the congress?
well, in fact we ration care even for those who have insurance, for instance, I can’t get doctor prescribed conventional treatment even though I have health care, the treatment is recognized and not extra-ordinary nor expensive, that treatment will prevent an operation
yet they insist I pay for this treatment out of pocket, they also insist on paying my chiropractor less then he charges and that is out of pocket as well
my care is being rationed even though I have health care
America rations care to people who have insurance!
My wife has a hole in her abdomen from when our baby was born. The muscles never came back together after the pregnancy. She can feel her intestines through her skin. The muscles separate even further when she does something that requires straining in what fitness trainers call the “core”, such as picking our son up to put him in his high chair. Her doctor wants to operate to put her abdominal muscles back together so she can avoid health problems later including, but not limited to, back trouble.
Our insurance company, UnitedHealth, denied the claim. These worthless bastards consider the surgery to be “cosmetic” because it would have the secondary benefit of improving the appearance of her stomach.
That is health-care rationing motivated by profit. This is what the teabaggers are defending.
I don’t have documentation, but attempts have been made to lower the number of MDs graduated in order to keep MD incomes high.
Medical education nowadays is also financed primarily be heavy debt. A doctor coming out of med school with $100,000+ debt will be more money-hungry and also will be more at the mercy of the HMOs, since starting or buying into a private practice is more expense on top of that.
There’s a doctor here who has set herself up to do low income uninsured patients on a mostly-cash basis, but she’s only able to do it because she came out of school without debt (her father was wealthy). She makes an OK living but isn’t getting rich. She just happens to be more oriented toward service than toward the business end of medicine.
OT president speaking to GM workers (just now): no mention of PO at all
Well with things just so swell and getting more swell in this ‘The Jetsons’ future we were told would be waiting for us here in early 21st century back there in the 1950’s and 1960’s what is there to complain about again?
Just had a Hep B shot at the local nicely decorated health clinic and being I do not have health insurance not because I am a American slacker or risk management scofflaw but because currently not employed by employer and not able to afford requisite for profit health insurance going rates.
One Hep B shot was originally discounted down to about $100.00 but now I have gotten the final billing for it and the discount somehow was incorrect and I owe about another $45.00.
I truly am one American who sincerely believes Single Payer/Medicare For All was where this so called Obama WH healthcare reform proposal needed to start and end at.
I supported Barack Obama last year. I feel and believe he has forgotten about me now as the Blue Dogs,Democrat Corporatists and so called Democratic Party leadership in Congress and the WH are selling out to Big Pharma,Big For Profit Health Insurers and the K Street vendors.Why are they selling out? Afraid to do the right thing. Want to retain political and personal power.
Where does this come out in another 10 or 20 years?
Same place we are now when measured back to the Clinton WH first term and the failed healthcare reform from that time. If this reform gets shanked so the entrenched powers that be can pocket some more profits and the politicians can retain some more power it deserves to crash and burn.
Meet George Jetson indeed.
You got ripped off. I paid cash and got the whole series of Heb B shots for just under a $100. Those shots are considered ‘Generic’ now as far as drugs go, so you should have shopped around.
Actually did inquire with the local Public Health Dept. at county level as they conduct open clinics but was informed by the nice person at the front desk that they were not able help me out with this Hep B shot.
I will be visiting the nicely decorated clinic again as it is and will take these newly mailed upcharges up with the front desk. Hopefully there will be some relief given.
Getting this shot took about five minutes tops and as you point out is at generic level as it is and being there were no complications how they arrived at this fee schedule must entail some fancy ciphering.
In theory this is where Single Payer Plan when multiplied by how many Americans walked into clinics across the United States just last month for this same shot could have some real access,delivery and cost control impact.
I am lucky to not be in situation where I need to secure care for a family or am not able to stay out of American healthcare clinics and hospitals thus far as well as I do. Being in poor health in the United States,not employed and not with wealth in place or steady income is a precarious position.
Especially when compassion and mercy or a American Single Payer Plan are not seen as profitable. Witness Americans bankruptcy rates due to medical calamity or misfortune. President Obama claims going with Single Payer was too hard. Too difficult to do. I think he took the easy way out for the ease of the attendant politics.
I won’t comment on the last paragraph, but if you do this again (with any procedure), start out the conversation with the med office “I’m paying cash, what will it cost for x”. Chances are they will not even know and will need to get back to you, but it will be a heck of a lot less than what insurance/Medicare gets billed.
Good luck!
I thuink so too. How’d that work out for him so far?
On the percentage of uninsured in Massachusetts, the 2.6 % number is supported by this source for 2008:
http://www.ama-assn.org/amedne…..sd0629.htm
The Census Bureau for 2007 placed it still at 7.9 percent, higher than the number the Times used, but still the lowest in the country given how the Bureau calculates the percentate. I suspect there are differences in how undocumented folks are counted.
http://www.necn.com/Boston/Hea…..74411.html
I am reading these comments in Britain,(you know the place with a broken National Health Service)and am just soooo glad to be here!
Yeah, but it rains there a lot.
Wouldn’t this be a good thing – doesn’t this mean that there are growing opportunities for bright young people to go to school and become doctors? Or are they saying that they are only going to make x number of doctors no matter what the demand or need?
These guys are not only intellectually dishonest, they are idiots.
The insured have rationed healthcare too. If you go over your “cap” you will learn that you have already gotten your ration of healthcare, and you will not be getting more from your health insurance company.
What do fascist pro?lifers and anti-health people expect us to do for health care? Buy a $4 bottle of asprins and just take them all at once to end our problem? I pray my children and grandchildren aren’t left with this choice.
You take the blue pill as some president just pointed out.
It would be great if doctor’s medical school debts could be erased by working in the inner cities.
Well, we provide education tuition benefits for veterans (paid for part of my law school) and education tuition benefits for those who volunteer to Americorp, so it’s not like there’s no precedent for covering education for those who perform worthwhile public services.
In the bill is a provision to up the number of slots in the National Health Service Corps, which does just that. But not only in inner cities, which are not as underserved as other areas, but also in any underserved area. I believe it requires a 5-year commitment and the program has been around for at least 30 years. My doctor in a rural area of NC was an adjunct with a medical school and he rotated new MDs through his practice for the five years required by the program.
I’ve been saying this for months. An obvious problem is that if only two-thirds of the population is actually in the health care market, the health care market will shrink to two-thirds the size of the population. It’s an obvious conclusion that anyone familiar with the most basic economic principles knows without having to think about it, and yet our politicians continue to screw around at the edges of the problem.
The reason there’s no documentation that “attempts have been made to lower the number of MDs graduated in order to keep MD incomes high” is that this is a false statement.
Just as “American medical schools ration the number of physicians they produce to keep demand and salaries high.” is a false statement.
In real life, clinical medical education is massively expensive: at every step on the learning curve (3rd year med student, 4th year med student, intern, resident, fellow) more experienced people – almost all of them physicians – need to directly supervise the trainees “below” them.
The necessary result is that clinical medical education requires a near-duplicate staff of trainers supervising the learners. When I’m training students (or residents), I’m using time that could otherwise be used to provide direct patient care.
In real life, as part of the Office of Student Representatives, I participated in the AAMC’s governance for three years in the mid-80’s, during which I attended annual and quarterly AAMC governance meetings and sat in on the discussions. In real life, the AAMC dispatched herds of med students, deans, and faculty to go beg the Congress for more money to EXPAND medical education. In real life, Reagan had begun the process of cutting funding and reimbursements for medical education to such an extent the institutions couldn’t even keep pace with existing expenses.
In real life, we’ve now lost thirty years of potential expansion in the “through put” capacity to turn out new primary care docs. That loss of capacity is reflected in the AAMC’s statistics on physician supply in Massachusetts. For what it’s worth, British Columbia is experiencing a similar shortage for the same reason: underinvestment in medical education.
The AAMC is not perfect, and the fact their Council of Teaching Hospitals includes genuine non-profits and academic institutions (yay!) along with “fig-leaf” nonprofits (Kaiser and – IIRC – Catholic Healthcare West, for example)and overt for-profits like HCA (the most criminal hosptial chain in human history) and Tenet (now – thanks to HCA – merely the second most criminal hospital chain in human history) has undermined AAMC’s capacity to bring a clear, unified voice to the need to expand access to healthcare. Yet wrt expanding physician training, the AAMC and med school deans aren’t part of the problem: they are part of the solution.
Are there groups of docs who constrict access to training out their own economic self-interest? Yes: they are called specialists (proceduralists). The most lucrative specialties include opthamology, radiology, various surgical specialties, and medical specialties such as gastroenterology and cardiolog. These specialties are lucrative precisely because the US payment system is skewed to excessive reimburse physical actions while at the same time underpaying simply talking with patients without cutting them or sticking tubes in them.
Some studies suggest the US has an over supply of some proceduralists (cosmetic plastic surgery is the most obvious area; IIRC GI may be another, but I’m not sure of that). Tehre is certainly a maldistribution of proceduralists – in no small part because the current Medicare payment structure pays significantly less to docs and hospitals in rural areas. Of course, docs also tend to practice in areas like those they grew up in: so increased recruitment of docs from inner city areas as well as incentives for all docs to practice in underserved areas can help redress those imbalances. One tool designed to redress such imbalances – the National Health Service Corps – was effectively gutted under Reagan and the neoliberals who followed him.
In summary – while the lucrative procedure based specialties listed above actually do restrict training of residents and fellows (folks who have already completed med school, already have their MD’s, and are seeking to enter these specialties), the net result is to shift docs back into potential lower paying areas like pediatrics, general internal medicine, family practice, and psychiatry. [Of course, I’m not in any way suggesting this result excuses the self-interest of the specialists who restrict training in their areas just to keep their own incomes high.]
I’m not seeking to criticize commenters who repeat the false statements I’ve addressed above: they are so widespread as to have taken on lives of their own. I am seeking to accurately describe the workings of a very complex system which is poorly understood.
And now I need to get back to work at the inner city clinic where I see folks with little or no income. I have less flexibility this week than in other weeks: this week I resume volunteer teaching of med students…at a medical school that increased the entering class size – and hence throughput – by approximately 5% this academic year.
Be well!
Interesting read. Thanks
Thanks much for that background, Kirk. I’ve added an update linking back to your comment.
Scarecorw, thanks for your amazing coverage of health care – glad to help!
Kurt is making things up again. The only insanity is his own.
With all due respect, Dr. Murphy, I am not willing to believe that the medical profession and the medical schools have no part in this problem, which seems to be your point. I did not say that they were the sole cause of the problem and I agree that underfunding medical education is a major port of it.
“The 1997 Consensus Statement on Physician Workforce”, by a number of important medical education groups, definitely worried about an oversupply of physicians and specifically recommended limiting MD immigration. I was working in a medical school at that time (in a non-technical capacity) and heard a bit of the debate.
The report advocated increased spending on medical education, but what would you expect? The members were all medical schools.
I can’t find a text of the statement but here’s a more recent retrospective look at the issue.
Sorry, this is the link I intended, from 1996. (Editing completely garbled my comment. The link there is relevant too.)
UNCERTAINTY about the future shape of the health care market has now translated into two reports that urge serious changes in the number of doctors American medical schools should train. The newest, from a National Academy of Sciences committee, urges that medical schools cut down sharply on the training of foreign doctors — whose numbers have risen sharply in the past five years — and recommends more general discouragement of would-be doctors as well, saying young Americans should be told to consider seriously whether a medical education will prove “a poor personal investment”
I’m not certain if the NAS committee did or not include medical school deans, and I couldn’t actually get the WaPo article in the link provided.
The link did contain the following:
“Pumping up the volume U.S. medical schools predict a need for more doctors to treat a rising and aging population” INTERNATIONAL EDUCATION from a 2009 article….
It just seems to me that the schools were taking care of themselves, and the doctors were taking care of themselves, and they were also taking care of the patients, but that there was a bit of self-servingness about what they were doing.
I remember overhearing people talking about how the doctor job was becoming less lucrative, and some of the people (med students) thought that was perfectly OK, and others wanted to do something about it, including restricting immigration. The migration into specialties was part of that dynamic, and from what you say it was accelerated by skewed reimbursement rates.
I sure agree the med schools and AAMC aren’t perfect: the 1997 report you cited made a spectacular mess of predicting demand, because the models were absurdly flawed (within 5 years the AAMC was backing off that blunder, but it shouldn’t have happened in the first place.
I don’t want to pick a fight. I was thinking of things from awhile back. Seemingly the profession has come around.
The last MD I talked to complained that his HMO was treating him like a factory worker (Three minutes for the flu, five minutes for tonsillitis, bonuses if you give less care). I’m sure that he’s on board with us. The local low-income MD doesn’t take insurance of any kind, she just does uninsured patients (Amish, Hispanic, and poor whites) on a cash basis.
Hi John, i sure don’t want to pick a fight either – rushing comments in between patients prolly makes the comments seem snippy, and that sure isn’t my intention. My bad. FWIW, I totally agree with yuo that the AAMC blew it on the ‘97 report, and at the time the whole premise seemed absurd.
IIRC the premise was basically along the lines that “patients don’t cost money – docs do”..and what followed from this was the absurd conclusion that limiting the # of docs would make more available for patient care. Though it may have validity for proceduralists, it was absurd for primary care, and the result was the idiocy behind the 97 report. I’m actually glad you brought it up!
One of the provisions proposed by Obama was that medical school debts be waved – perhaps with willingness to do primary care in underserved areas; don’t know if it ever got into either the senate or house bills.
Some of the most powerful pro-reform true propaganda ads have featured the likes of CIGNA and UnitedHealth refusing to pay for legitimate care and procedures.
I’ve just recently been told that Kaiser Permanente’s standard practice is to refuse diagnostic procedures for anyone with neuropathy because it’s so common; and if they don’t know what a problem is, they call it neuropathy and that’s it baby. They have been denying proper diagnostic services and care for years. Years ago I challenged the head of their medical services to make KP THE place for PNers to go; so much for appeals for righteous, even lucrative medical care, given that there are some 500k people with some form of neuropathy in Nor Cal.
Blessings,
In most cases people who pay cash pay more than the insurance company or Medicare pays. Before people jump on the Doctors for being greedy, they should know that they have a regular price, then the insurance company agrees to pay a lower amount and the hospital agrees to take it and not go after the patient for the rest. If you pay cash you do not get the benefit of that bargain. If the hospital accepted the amount the insurance company paid as the regular cash amount, that would become the new starting point with the insurance company and then the hospital would get less from the insurance company. Don’t take my word for it. Google it. On the other hand, some places are set up for low income people and they do lots of good. Like I said, the problem is not greedy Doctors.
Good thing that guy wasn’t a physicist.
I think the issue of supply of health professionals is very important and failure to address it risks failure of health reform. I have some experience working in health education, and my experience mostly confirms Dr. Kirk Murphy’s view.
Colleges and universities have been asked, and are very willing and eager, to produce more health professionals, college associations have worked to increase enrollment, and in theory, there have been efforts to expand post-graduate medical education (internships and residencies). The problem is, from my knowledge of how decisions are made, and my own personal experience, the problem is that no one wants to pay.
I do not agree with Kirk Murphy in one respect. There is a school of economic thought among some doctors in high policy positions, and health services researchers and in health policy circles, that physician induced demand is THE big reason for increased inflation and expenditure in healthcare, and this effect will dominate, regardless of reimbursement policy or institutional setting. I think this is, with all due respect, crackpot economics that has had too much influence in medicine and health policy. I do not think it stems from a conscious effort to restrict supply, I think it is simply a mistaken view that has been adopted by too many influential people.
The concern about physician induced demand probably influenced the consensus statement 1997, but I do not think it was an intentional effort to restrict supply for selfish reasons. On the other hand, the bizarre horror of a future surplus of doctors was shared by many non-doctor health policy experts, so it is not solely a scheme cooked up by doctors. Some who called themselve economists actually signed up with the madness for awhile.
The bigger problem in my mind, is that even after professional groups reversed course on supply, efforts to increase supply did not work as intended.
The process of determining the supply of health professionals is simply out of control and no one knows exactly what is, or has been, going on. I do not believe any one agent has the power to control a training process that has such a fragmented and unaccountable financing and decision making process.
Considering post-graduate training alone, Medicare finances the majority of it, and very short term federal deficit control concerns have dominated the funding process. About ten years ago there was an effort made to expand post-graduate medical education, but I do not think anyone knows what happened. The idea was to train more primary care doctors, but most accounts I have read say that the extra training funds were used to add additional years on to the end of existing training programs (that is, they were used to add a year or two of even more advanced training for existing advanced residents) and very few net new doctors of any kind came out of it. There was some shifts in which advanced specialties got training funds, but much less than planned went to increasing the number of new slots for primary care.
It is more difficult to find slots for any kind of practical training either during professional school or for post-graduate training. Health providers and health plans want to spend as little money as possible on practical training (even when they are getting Medicare payments explicitly intended for training). There is an increasingly desperate scramble to find training slots for all sorts of health care professionals. From my experience with medical and pharmacy residents over the last ten years, the practice of using them as low paid low skill wokers has increased, and the amount of training has decreased. The problem is that the system is so poorly documented, and the conflict of interest that arise from how Medicare and other training funds are disbursed, that is difficult to know what is going on.
I cannot judge the quality of their clinical training, but training for research skills needed for everyday planning and management (setting aside academic publication) has declined.
Filling slots to expand primary care and some needed specialities is a problem because doctors and other health professionals who need post-graduate training flow towards the highest paying specialty fields. You can open slots, but if no one wants them, it does not good.
And the income of specialty fields is determined by rigid and arbitrary reimbursement formulas (used by both Medicare and the dominant insurers, health plans and benefit reimbursement consultants), and AMA committees.
Sorry, comment addressed to wrong place.
My answer would be more doctors and various other trained personnel (physician’s assistants, nurses, nurse practitioners), **fully** subsidized education, and to a degree (per supply and demand) less-well-paid doctors — we may already have reached this third goal for FP doctors. During my years as a support person I met a certain number of MDs who had gone into the business for the wrong reasons. It had to affect the quality of care, for example when doctors despised their low-rent, tacky patients.
Before the tech bubble burst and before the recent crash, I met a few doctors and residents and even medical students who spent a lot of time whining about how much better off they would be (oops) and how much more respect and recognition they would get (quadruple oops from my perspective from working in finance in the past) if they had gone ito finance.
I think there are plenty of potentially excellent clinicians out there who could be trained with no sacrifice in quality, and some people who entered health care who are not suited for it.
In my humble opinion, I see more very promising students being let down by less than good education, than I see excellent education being wasted on unpromising students.