I recently wrote a comment on Outside The Beltway with eight observations on health care, specifically on the subjects of how doctors are made, why there are so few, and the relationship that has with cost-containment. I modified it a bit, added two items, and decided to make a post of it here. These are not so much coherent advocacy of any particular point of view (except “it’s more complicated than that,” perhaps) but rather thoughts and clarifications.
1. While Law Schools are profit centers, Medical Schools are expensive. Even if the LCME wanted to prevent any medical schools from forming, the American Osteopathy Association would love for their to be more DO schools because they want a larger voice in the medical establishment. The problem is getting funding.
2. Even if a bunch more medical schools were opened, it actually wouldn’t increase the number of doctors without other changes. The real bottleneck is residencies, as far as that goes. Right now extra residency slots are filled by foreign-trained doctors. The end result of more medical schools without more residency slots is replacing foreign-trained doctors with American-trained ones. This might be desirable, but it won’t alleviate the shortage.
3. The best way to alleviate the shortage is by either increasing the number of residency slots or allowing foreign doctors to practice here without going through residency. Residency slot numbers are not one of the things limited by the medical establishment. Funding goes through the federal government, and if the ACGME doesn’t want the residency programs to happen, the federal government could work with the AOA. Notably the PPACA does have provisions for increasing the number of residency slots.
4. The normal rules of supply and demand don’t apply as strongly as one might think in the medical profession. The biggest shortages that exist right now are in primary care, where the pay is the least. If limiting the number of doctors automatically reduced salaries, primary care docs would be making more and specialists would be making less. Instead, our payment system continues to favor specialists far more than in most countries.
5. An exception to #4 is various incentives in place in underserved areas. These tend to be limited in scope (usually student loan debt repayment) and often fail to compensate for salary differentials (they’ll repay $100,000 over six years, backended, but you’re taking a $20k pay cut to work there)
6. Increasing the number of primary care physicians may lead to better care, but it’s far from certain that it would actually reduce costs. Since doctors are paid for each thing they do, more doctors doing more things would rack up larger bills collectively (even if they were individually being paid less or being paid less for each thing they did). When people can’t get in to see a doctor, sometimes they will go to an ER, but often they will forego care. I know that for my part, if I am feeling sick and any appointment I make is going to be more than a couple weeks out, I will let things run their course rather than spend 5 hours in an ER.
7. Increasing the number of doctors might help with access, and therefore allow the government to pay doctors less. First, however, see #6. Second, consider the wide latitude doctors have in drumming up their own business. They get to decide what is necessary and what is paid for. For some unscrupulous doctors, this is a gold mine (see McAllen, TX). But even for scrupulous ones, there are a lot of gray areas in medicine where every problem is a nail that you have multiple hammers for. So somewhere in here, we really need to evaluate standards of care and make what may seem to be heartless decisions about what is and is not warranted and under what circumstances.
8. In a single-payer system, the government can cut back reimbursements and pay without adverse consequences. It’s harder to do in a mixed system like ours, particularly when there is a shortage. Sending Medicare/Medicaid recipients to the back of what is already a long line could save money, but it could have adverse effects on wait times and by extension, people seeing the doctor at all. Of course, it’s good for the people at the front of the line. The more doctors that rely on private insurance, the easier it is for people with private insurance to see a doctor. It’s zero-sum, as far as that goes.
9. People should be wary before concluding that doctors will have no choice but to see Medicare/Medicaid patients unless we are going to pass laws forcing them to. While many doctors cannot afford to forego Medicare patients entirely, they can limit the number of Medicare patients they see, by limiting themselves to only existing patients, for example. Doctors can also specialize in fields where they are less likely to rely on Medicare patients, or relocate to parts of the country where the bulk or entirety of their practice will be insured patients. The burgeoning field of geriatrics may either die a slow death or be staffed with doctors who find a way to make it profitable (on Uncle Sam’s dime).
10. Whether a single payer would work would depend in good part on whether or not would depend in part on whether we are able to make the heartless decisions in #7. As the “boots on the ground,” present standards of care are largely set by providers with both financial and personal (nobody wants to not do something that could help!) incentives. We have sort of let the difficult decisions be made by the dollar. If we intend to increase access (while streamlining the system and preferably reducing overall expenditures), somebody is going to have to make the difficult decisions as to what qualifies as elective, non-urgent, and unnecessary. And we have to be sure that they have the resolve to do it.
Will, I haven’t finished digesting this yet, but I thought I should acknoweldge that there’s heavy, rich stuff here and you should know that you’ve been read and folks are chewing on what you’ve offered.
Thanks. I’m hoping Russell Saunders takes the time to put his two cents in, since he is more connected with it all.
I almost never disagree with Will, so this feels somehow cheap and dirty. But…
I would argue that the main thrust behind this argument – costs will be lowered if we can get more physicians into the healthcare system – is not quite correct.
From the data that my company follows, areas that have higher per-captia levels of doctor have higher levels of utilization and therefore cost, even if there are no statistical differences in community health factors. The studies I have seen in the past on this revolve around back care, but for a better case than I have the skill to make Atul Gawande has a fascinating article on his research with the town of McAllen, Texas.
One has to assume that eventually the curve reverses, but the in most cases increased provider competition in a community leads to greater HC expense per patient, not less.
Forgot the link to the Gawande article: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
Still, getting back to my comfort zone of agreeing with Will, I think the latter part of #7 and #10 are not only strongly correct, but quite insightful.
We’re not in disagreement. See #6. I even had a reference to McAllen in #7!
That being said, there are reasons to believe that it’s possible with a differently structured system, more doctors could lead to reduced costs. If, for instance, the government started setting up its own clinics with stricter guidelines of care. One of the main obstacles with the VA writ-large is being able to staff it with doctors.
But yeah, under the current system, I am skeptical that it would lower costs. I just didn’t really expand on that point.
“mixed system like hours”
like hours?
You caught me. Fixed.
For some reason I am really, really prone to mistypes that involve words that sound even vaguely similar or the same.
Most of the political controversy about medical care seems to focus on its cost rather than its availability. We assume that more supply will lead to lower costs, although as you point out this is not necessarily what the outcome of that sort of tweak to the system might produce.
From a public policy perspective, one change that could be made in short order would be more H1-B visas for doctors and easing of the immigration process for appropriately-credentialed professionals and thier families. (This does not mean relaxing the standards of the medical boards; it means making the rest of the bureaucratic package simpler and less expensive to navigate.) Dovetailing in with point number 4, of course, we’d need to make more residencies available for those doctors.
Query if residencies need to be as long as they are. If residencies were shorter, more doctors could make their way through this chokepoint in the pipeline.
Could these be combined? Could residencies be restructured to include, or at least encourage, substantial amounts of time in a primary-care setting, as a proving ground of sorts?
Aloha!
OK, so let’s go through your points:
1) You’re absolutely right that medical schools are expensive. (In addition, it takes a lot more time to see patients and teach medical students than to simply see patients at a steady clip.) It’s very important that cuts to health care costs don’t end up making teaching hospitals financially unviable.
2) I don’t have the numbers, but I believe that residency slots are also expensive. From what I understand, regulations over the past few years have required much more documentation and time spent per patient by attendings in order to bill for patients seen by residents. It makes an already burdensome system more onerous.
3) I would imagine there would be vociferous objection to foreign medical graduates being allowed to practice in the US without going through American residencies. I would certainly find it questionable, at best. It may help allay a shortage of doctors, but could potentially flood the market with providers of dubious quality.
4) Medicine’s lobbying body, the AMA, is heavily weighted toward procedure-based specialists, who favor perpetuating our current procedure-based compensation scheme. People go into procedure-based subspecialties because that’s where the money is.
5) The loan repayment you get for working in an underserved area is a pittance compared to what you get if you go into a lucrative career in a saturated area.
6) So long as we have a procedure-based system of compensation, providers will be drawn to do the things that get them paid. Changing this will require a wholesale reevaluation of how medical care is paid for, and is likely to meet with a lot of resistance from providers who are heavily invested in the status quo.
7) If we want to lower health care costs, people will need to get used to the idea of getting less. People may not get the world’s most sophisticated tests, or see the specialist of their choice. They may not get the newest prescription, no matter how much they are exhorted to “Ask your doctor.” But there really is room for trimming. Lots of people get more medical care than they need, and turning an honest eye to this fact will be vital.
8) Cutting reimbursement for Medicare/Medicaid care will hurt the patients. I’ve posted about this myself. Doctors want to get paid, and if they don’t get paid they’ll find a way of denying the services. Period. (FWIW, I favor a single-payer system.)
9) People who make a career in geriatrics will find a way to make it profitable. If we want the elderly to receive good care, then we can’t expect to squeeze all the savings out of paying for it.
10) No arguments from me on this one. I agree completely.
(I apologize if this response seems a bit scattered. I’ve been trying to compose my reply in between patients.)
I also have no idea how I inserted that random smiley face.
The numeral eight followed by the closed parenthesis is frequently the shorthand code for that particular smiley.