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How Being a Doctor Became the Most Miserable Profession

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Re: How Being a Doctor Became the Most Miserable Profession

#121

Earlier quoted context omitted.

Anecdotally, nonpayment is a much bigger problem than lawsuits. I remember listening to the CEO of Carle, a large Central Illinois healthcare chain, talking about this, and saying that "we expect to collect 60 cents of every dollar we bill". 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 th…

so what you're saying is no matter how the healthcare system is designed, the healthy (or maybe just wealthy?) always end up paying for the rest?

In practice, this is exactly what happens. Many hospitals have a mandate not to deny treatment, so many people come to the hospital (especially to the emergency room, where care is known to be more expensive than non-emergent settings) and simply don't pay after the fact.

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.

Re: How Being a Doctor Became the Most Miserable Profession

#122
post #102
post #98

Earlier quoted context omitted.

Why exactly must the government pay for it? It seems obvious if it's a net cost it really should be paid for by the students. 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.

Well, someone has to pay the salaries of medical trainees. Who would you suggest do it? 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…

> Well, someone has to pay the salaries of medical trainees. Who would you suggest do it?

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.

Re: How Being a Doctor Became the Most Miserable Profession

#123
post #68
post #7

The biggest problem is just the AMA. They limit the number of doctors in America, so there are just too few. This drives up the salaries for the few doctors who live the tell the tale (but certainly don't want to go into primary care, when other more lucrative jobs are on offer), and drives up the hours for everyone. Making it easier to become a doctor would improve things immediately (especially given the recent res…

I am a doctor, an anesthesiologist. I don't like AMA. But to blame AMA is a complete nonsense. (AMA really is just an insurance and loan agency, just like AARP.) 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 go…

I don't believe you.

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.

Re: How Being a Doctor Became the Most Miserable Profession

#124
post #110
post #108

Earlier quoted context omitted.

If there doing useful work that offsets the need to supervise them then the patents should foot the bill for the net benefit. If there not doing useful work then there is no need to pay them. 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 mont…

Removing the need for undergrad does nothing to increase the supply. I also fail to see how it reduces costs. Everything is bottlenecked at the residency step. 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…

Granted, it's not going to make a difference for ~30 years but by allowing doctors to start younger means some of them will work as a doctor for longer periods of time. Most importantly your adding time at the end of their career when there most capable. (Perhaps add a specific associates degree as an acceptable alternative as even 1 or 2 years times a few 100k doctors adds up.)

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.

Re: How Being a Doctor Became the Most Miserable Profession

#125
post #102

Earlier quoted context omitted.

Well, someone has to pay the salaries of medical trainees. Who would you suggest do it? 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…

> Well, someone has to pay the salaries of medical trainees. Who would you suggest do it? 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 infl…

1. New schools are being built and they aren't cheaper. Quinnipiac University is the newest medical school to open (accepted its first class in 2013) and it is just as expensive as any other private medical school.

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.

Re: How Being a Doctor Became the Most Miserable Profession

#126
post #63

Earlier quoted context omitted.

give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. 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 -…

Healthcare has been such a regulated industry in every aspect that anecdotes like these do little to discredit free markets.

People who have to solve problems in the pragmatic world, like my QA friend above, are poorly served by your ideology. At least anecdotes are a reference to a real-world event; blindly sticking to ideology is pure fantasy.

Re: How Being a Doctor Became the Most Miserable Profession

#127
post #63

Earlier quoted context omitted.

give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. 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 -…

I worked in a hospital, and saw similar things, but I think the moral of the story is that huge organizations operate internally more like a feudal oligarchy. They crystallize, regardless of the external market.

This one certainly was. Another story of my friends was sitting in on a meeting, where one of the old-school specialists of nearly 30 years experience made a snide remark about 'newcomers not understanding how things are done'. The target of the remark responded 'I've been here 17 years...'.

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?

Re: How Being a Doctor Became the Most Miserable Profession

#128
post #97

Earlier quoted context omitted.

>Granted, the salary will probably hit $200k with some years of experience More if they're specialty and/or surgical. One of the side effects of most hospitals being organized as non-profits is that they have to disclose the compensation level of their five highest-compensated, non-board/officer employees. I know at my hospital (mid-size, 250k metro area, ~$35k median income) that number ranges from $750k-1.2M. Grant…

Those top 5 have nothing to do with doctor salaries. The top 5 at any software company of 1000+ engineers to better than that.

[deleted]

Re: How Being a Doctor Became the Most Miserable Profession

#129
post #124
post #110

Earlier quoted context omitted.

Removing the need for undergrad does nothing to increase the supply. I also fail to see how it reduces costs. Everything is bottlenecked at the residency step. 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…

Granted, it's not going to make a difference for ~30 years but by allowing doctors to start younger means some of them will work as a doctor for longer periods of time. Most importantly your adding time at the end of their career when there most capable. (Perhaps add a specific associates degree as an acceptable alternative as even 1 or 2 years times a few 100k doctors adds up.) As to reducing costs, undergrad is not…

you're not required to get an undergraduate degree. you are only required certain courses and the MCATS.

Re: How Being a Doctor Became the Most Miserable Profession

#130
post #120
post #77

Earlier quoted context omitted.

The Association of American Medical Colleges (www.aamc.org) sets number of medical students, and not AMA.

The number of medical students is wholly irrelevant to the conversation at hand. We currently have more residencies than medical students, so spots are filled by foreign medical grads. 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 stu…

last year there were more grads than residency spots.
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