Healthcare USA #1

Politics & News
421

Setting aside whether cutting doctor’s salaries is useful or desirable, it not that hard to do it on a global scale for one simple reason: doctors don’t have other options.

A doctor’s education and training is highly specialized and takes a very long time. But it’s not useful for much else besides doctoring. It would be very tough for a doc to find a job that pays even half of what they make as a doc. So if their salaries all went down, their best option would still be to practice medicine.

It would be one thing for a single employer to cut physician salaries. That wouldn’t work because the docs could just go across town and get paid competitively. However, if there was something universal that reduced all doctor’s salaries by 50%, the effect would not nearly be as much as you might expect.

If your were in a different line of work (business, law, IT) you could maybe think of some sort of career shift or using the skills you’ve developed in a different arena. If things really got bad, you could maybe think of moving to a different country. But for most docs, if salary went down 50% across the board, their best option would be to pound sand and take it.

Above is a bit of an overgeneralization and there are certainly exceptions, but it’s more or less true.

422

Some of them become asshole senators like Bill Frist and Rand Paul.

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423

True enough. But in the longer run, people will migrate away from medicine.

You get four years of undergrad, four years of med school, four to seven+ years of additional training. During med school you’re making nothing (actually less than nothing because you’re putting out a pile of $$ - I looked at Northwestern where I trained, and it’s 70K or so a year, not counting living expenses.) During residency (the additonal 4-7 years) you get paid - I was comfortably making less than minimum wage during my residency the first two years, mainly because I was working 100+ hours a week. We could moonlight in our third and fourth years (most places don’t allow it) so I did a bit better.

It’s interesting work, and I enjoy what I do for the most part, but if I was going to be 400K or so in the hole and making maybe half that when I got out? Yeah, no thanks. Which isn’t going to help with the doctor shortage.

Where you’re wrong is in saying they don’t have other options - the obvious one is to do something else other than go to med school - so you’d crush the current cohort of 40-55 year old doctors - the younger ones would never go, and the older guys (like me) would just quit working - because I haven’t had to work for the last five years or so EXCEPT for the fact that I’m not eligible for medicare, which I why I’m pulling the pin in the next few months - I wont need the health insurance any more.

But IN THEORY, you’re right.

MM MD

424

Let’s be really clear… Nobody actually wants to cut doctor pay 50%. And I’m sympathetic to the fact that they took out huge loans. I’m for bailing them out on that to some extent actually. We want being a doctor to be an attractive career that smart people want to do.

Doctors would also not have to spend very much time (if any) worrying about how they were going to get paid or getting sued. The hours would also fall a good bit making quality of life quite a bit better.

I want to bail out pretty much everyone who took massive school loans to do anything tbh. We fucked a whole generation.

425

You were doing fine until you talked about less hours.

We’re in a huge shortage for MD’s with the minor exception of some of the more esoteric specialties, and it’s going to get a lot worse. From the probably biased point of view of the AAMC (association of medical schools) - The United States will see a shortage of up to nearly 122,000 physicians by 2032 as demand for physicians continues to grow faster than supply, according to new data published today by the AAMC (Association of American Medical Colleges).

The main driver for this is the aging of the population, and I can’t believe the current anti-immigration hysteria is helping - we get a lot of Indian docs, or at least used to - but Canada is at present a lot more welcoming.

On a more personal level, I’m an ER doc. For idle reasons I got put on a locums list for one of the bigger companies a few years ago. I get stuff like this pretty much every other day A Facility in Michigan Is Seeking a Locum Tenens EM Physician

A Michigan facility has an opening for temporary emergency medicine coverage. The work schedule is 1…
A Locums EM Physician Is Needed in New York

Weatherby is looking to fill a new position available in New York with a qualified emergency medicin…

A Georgia Facility Is Looking for a Locums EM Physician

A new locum tenens emergency medicine opportunity is now available in Georgia. The facility needs a …

A Facility in West Virginia Needs a Temporary EM Physician

An exciting locum tenens emergency medicine opportunity is now available in West Virginia. The provi…

A Facility in Ohio Needs a Locum Tenens EM Physician

An emergency medicine physician is needed to provide coverage at an Ohio medical facility. The provi…
A Locum Tenens EM Physician Is Needed in New York

Weatherby is looking to fill a new position available in New York with a qualified emergency medicin…

Locums Position in PA for EM Physician

A Pennsylvania facility has an opening for temporary emergency medicine coverage. The work schedule …

Locums Position in Virginia for EM Physician

Weatherby is assisting a facility in Virginia with filling an emergency medicine opening. Your work …
Temporary Job in Alaska for EM Physician

Weatherby is looking to fill a new position available in Alaska with a qualified emergency medicine …
A New Mexico Facility Needs a Locums EM Physician

Weatherby is assisting a facility in New Mexico with filling an emergency medicine opening. Your wor…

And on and on and on - every one of these positions pays $200+ an hour on the low side, they’d fly me there and house me and cover my med mal and licensing. There are half a dozen similar companies. I could work 24 7 365 if I wanted to, because there aren’t enough docs in my specialty - and my specialty isn’t considered one of the “tough” ones in terms of supply.

So, yeah…

MM MD

426

And you don’t think the solution is free med school and a lot of seats?

427

Nope, but not for the reasons you probably think. I’m fine with free/low cost med school because I think pretty much ALL higher education should be that way as a societal good.

But it would be FAR more efficient to markedly increase PA/NP programs to staff the majority of primary care positions. They take half or less the time.

The major bottleneck is residency slots. You can churn out as many med school grads as you want, but you can’t work without completing a residency (you can work is some states, in a half-assed sort of way - but you can’t get hospital privileges without that ticket, so any sort of specialty career is impossible - and I’m trying to fill the primary care positions for the most part with the NP/PA types) And residency slots are as I noted a while ago, frozen. Even if we started opening up a bunch of residency slots tomorrow, it’s YEARS until people go thru the pipeline and get out practicing. You’re actively dangerous until you’re at least two years into your residency - I was, and I work at a teaching hospital where training occurs, and it’s no different now. Residency programs are EXPENSIVE to run - you’re paying docs to train docs, and again, we’re the most expensive piece of equipment in the hospital.

FMG’s don’t get you any help, because for the most part, they need to complete a residency just like everyone else (Canadian, ANZAC and some European programs are exempt - but they’re all short docs too). I can go work in New Zealand tomorrow if I want to and am willing to sign on for 6 mos. - a lot of guys I know have, and enjoyed it.

It’s complicated.

MM MD

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428

So more NP’s and PA’s and way more residency slots… It seems like drastically expanding the number of residency slots would cost a lot in the short run but would decrease the cost as the supply of doctors came up right?

To be clear when I said doctors would make less money and work less hours I definitely didn’t automatically mean soon. We can’t have a situation where docs here make the same amount of money as they do overseas for doing 150-200% of the work or whatever it actually is. That’ll make the doctor shortage worse… much worse.

The supply of doctors is just one front in the war on medical costs… but it’s not an unimportant one.

Obviously the war on pharma costs, medical device costs, and administrative costs are separate very important fronts.

429

Which specialties are short right now?

430

I’m with Hobbes here. I think there are a lot of things that need to be addressed before doctor compensation. It will need to be addressed but on a micro level. Some doctors are currently underpaid.

Plus if you truly shift the system to a PA/NP front line that will reduce average costs a great deal.

Drug pricing, medical devices, hospitals insane billing practices and more need to be addressed first, imo. You can’t really get into doctors until you resolve hospital billing. In a M4A environment that will likely be addressed head on as hospitals won’t derive prices via magic dice. That in turn will impact some aspects of physician compensation.

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431

This is probably a good point. Also doctor supply can be addressed on the demand side by making them do fewer unnecessary things to avoid getting sued, or because the hospital wants to charge the patients insurance for something.

We for sure need to start paying healthcare providers for outcomes rather than procedures. But that’s been obvious for a long long time.

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432

Good doctors are underpaid, bad doctors are overpaid. Seems suboptimal that we don’t really have a better way to separate the whey from the chaff. @boredsocial how are you gonna pay for outcomes? Like tell me a practical way that can happen.

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433

They’ve already done it at a few major health systems to the best of my knowledge. Hobbes probably knows more about the details. It’s already considered to be the direction we should go but it’s not super popular with the people getting rich off fee for service.

It’s not that it gets radically better results for the patients, it’s that the doctors magically end up doing less work per patient. The current system incentivizes people to do a lot of stuff (because they get paid per action) instead of just watching and waiting a lot of the time, which is often medically optimal or a push with doing something.

434

Oh I get it. Your point is that fee-for-service incentivizes procedures. Yeah that is a well-established effect. I’m talking more about objective measures for diagnostic and surgical skill of physicians. Like, I’d prefer to see someone can who diagnose a tricky disease versus being misdiagnosed for 20 years. Seems like the burden is on me for that.

435

My other point is that there will be ways to game the value-based systems as well. I’ll just make an example up. Let’s say it’s pay-for-performance with bonuses for complication and readmission rates below X% and penalties above Y% for CPT code Z procedure. So what if I just screen patients a little tougher and only clear the lowest risk ones for surgery?

436

Yeah, I was just talking about ones who were done with training or close to it. I’d widen your range to something like early 30s to late 50s as far as the ones being without options.

Also if you don’t know a ton of docs in their 60s who are still living paycheck to paycheck with a pretty mediocre retirement plan relative to lifetime earnings (and projected spending), you need to get our more. Plenty of those guys have to work. Admittedly, many who have their shit together, like you, don’t.

As far as people not going to medical school in the first place. I think you’re right, but I have heard the argument that in plenty of other countries, docs don’t really make nearly as much compared to other people and there are plenty of people who go to medical school anyway. Of course, in other countries the path is definitely chaaper and may be shorter, so I don’t know how valid that argument is.

437

Heh - I know at least a dozen.

When I was finishing up my residency one of our senior attendings had a private lecture for the departing docs, titled “The Secret to Success in the Practice of Emergency Medicine” - we all showed up with our notebook ready to take notes, 'cause this was gonna be a stream of wisdom. He puts up his first powerpoint slide - “One spouse, one house”. Last slide, too.

MM MD

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438

It’s hard, because bad outcomes are VERY episodic, and a lot of them aren’t particularly linked to bad practice, but “shit happens” You do have the occasional actively dangerous docs, but they’re pretty rare, and getting sued isn’t necessarily a marker - we had a guy in our group who we finally terminated for essentially psychiatric reasons, and when I reviewed his charts (I was chief of the group at the time) he was doing shit that made less than no sense - but he managed to dance between the raindrops.

IMO what REALLY helps is evidence based medicine - meaning that a specialty group gets together and hashes out the best way to handle a particular problem and states that THIS is the way to handle the problem. There are a number of good examples - head injury protocols that (especially in kids) reduce CT scans, protocols for STEMI (heart attack care) and things like that. But they don’t always work, for a number of reasons.

MM MD

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439

This can be a BIG problem, because especially in specialties like Cardiac Surgery/Neurosurgery, some guys have “bad” outcomes because they’re the only guys who will take on the nightmare cases. And heathcare systems get frowned at for not hitting benchmarks by CMS - a place I worked at long ago basically stopped doing any borderline CABG (heart bypass) cases for a couple of years until their numbers shaped up - they weren’t doing a whole bunch of them in the first place, and had a series of bad outcomes that after review honestly seemed like bad luck rather than technique - but losing your medicare ticket will close your hospital - so they referred a bunch of people out and only operated on “healthy” cases until the numbers got better.

MM MD

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440

You can’t really judge teachers or doctors stats without knowing what they started with. If you take the really really hard cases (and specialize in them) it could be totally reasonable (and possibly even exceptional) to only have 25% of your cases end well. I’m guessing the healthcare system doesn’t even allow for that.

Everything in life is relative. You need two data points (start, finish) to judge almost anything.