Health Care Thread

Grim1_sl said:

The problem is that there are not enough doctors to treat everyone needed.

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Really? I know I'm spoiled with my insurance (I get to see any doctor I want to), but I've never had a problem getting an appointment within a couple days with the first doctor I tried. Is this shortage actually an issue in cities, or are we talking about rural areas here? Because if 9m people are added predominantly in cities and there is no shortage of service providers there, then it's not at all an issue. I wouldn't be surprised if rural counties didn't have too many doctors around.

So what is your solution? Are you going to force doctors at gunpoint to do your bidding? Doctors are people too. They expect to get paid for their effort and all the sacrifices they made during their incredibley long (and expensive) time in school.

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Maybe treating it like Medicare would be a good start. Medicare outperforms private insurance in terms of coverage, yet it's just as much subject to government bureaucracy. Fun fact: private insurance companies tie their payment schedules to what Medicare pays. So it is the guys at Medicare (specifically the Center for Medicare and Medicaid Services) that determine reimbursement rates for all health care procedures. Simply increasing Medicare/Medicaid payments thus wouldn't do any good, because private insurance would automatically pay x% more than that, leaving in place the same gap as before.

If I got to design the health care system, I'd abolish both medicare and medicaid and replace them both with need-based subsidies for private insurance. There's absolutely no reason the government should pay for health care for a wealthy retiree, and similarly no reason why the government should run three separate insurance/health care systems (including the VA).

The fact that you have very good insurance that pays your doctor well doesn't answer the problem that the country is having as a whole, and especially Medicaid patients. Why would you think that your situation is normal for everyone? Especially poor people using Medicaid. Did you not read the NYTimes article? It goes against everything you claim with your anecdotal evidence.

From the NYTimes article:

"The Congressional Budget Office predicts that nine million people will gain coverage through Medicaid next year alone."

Perhaps you don't believe the NYTimes article. If so, do you have something to prove that the world we live in is all happy, happy, joy, joy time for everyone looking for doctors?

Really. If there is a doctor for everyone (especially those on Medicaid) who wants one then I would love to see the evidence that proves the NYTimes wrong.


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The basic problem is that there isn't an incentive for enough people to enter the medical profession anymore. The effort it takes to become a doctor doesn't offset the compensation or work involved once people actually become doctors. And therefore start getting a return on their investment in time (8 plus years of school) and money (hundreds of thousands of dollars).

There are a number of solutions possible. The obvious one is to pay doctors more. But that would increase the cost of health care and NOBODY wants that. Perhaps allowing people with less training to take over more of the burden would help. Nurses are very knowledgeable about basic health issues. But the problem with that is that more mistakes would be made and therefore more people would be diagnosed wrongly. NOBODY wants that either, especially since it would just make our medical malpractice problem a fucking catastrophe.

Or you can just enslave all doctors and make them work for nothing, 7 days a week, 24 hours a day.

Something has to give. But claiming Santa Claus will fix everything is not going to do it.

You're going to feel really dumb when Santa actuallydoesfix everything.

Grim1_sl said:

The fact that you have very good insurance that pays your doctor well doesn't answer the problem that the country is having as a whole, and especially Medicare patients. Why would you think that your situation is normal for everyone? Especially poor people using Medicaid. Did you not read the NYTimes article? It goes against everything you claim with your anecdotal evidence.

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My point was that this is not an inherent shortage of doctors that is causing the problem, but simply a result from Medicaidpaying significantly less than other insurance (including Medicare). This is a State issue, however, because the federal government doesn't determine Medicaid reimbursement (but does determine the rate for Medicare, which doesn't have the same shortage problem).

From the NY Times article:

On top of that, only about 57 percent of doctors in California accept new Medicaid patients, according to a study published last year in the journal Health Affairs - the second-lowest rate in the nation after New Jersey.Payment rates for Medicaid, known in California as Medi-Cal, are also low here compared with most states, and are being cut by an additional 10 percent in some cases just as the expansion begins.

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Yes, there will be a shortage of doctors accepting Medicaid patients. But a big part won't be because it's expanded to cover more people, but because the reimbursement rate is being cut. Note that this is completely unrelated to health care reform: those reimbursement rates have been cut before and have always been shitty.

The basic problem is that there isn't an incentive for enough people to enter the profession anymore. The amount of time and money it take to become a doctor doesn't offset the compensation or work involved once people actually become doctors and start getting a return on their investment in time (8 plus years of school) and money (hundreds of thousands of dollars).

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The admission rate at US medical schools is less than 9%, and less than 4% at the most competitive places (2% at George Washington) (Source), so there clearly are a lot of people still who want to become doctors. I suspect the bottleneck is with residency programs, but I don't really know. Besides, there is some evidence that increasing the number of doctors increases the cost of care without improving outcomes (Switzerland instituted a ban of opening new practices that stopped dead the number of new doctors -- reduced costs but didn't make a dent in outcomes). A lot of medical services can be supply induced. e.g. if you have a new MRI, you shift people from getting x-rays to getting MRIs even when not necessary, which increases costs but doesn't lead to better diagnoses. Similarly, young, healthy adults don't need an annual check-up, but if you have an open schedule, there's no reason not to get your patients to do it.

If you're a doctor, you fill your schedule. If you're a patient, you do what your doctor tells you to do. That's an incentive problem...

There are a number of solutions possible. The obvious one is to pay doctors more. But that would increase the cost of health care and NOBODY wants that. Perhaps allowing people with less training to take over more of the burden would help. Nurses are very knowledgeable about basic health issues. But the problem with that is that mistakes would be made and therefore more people would be diagnosed wrongly.

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I'm not opposed to increasing medicaid reimbursement rates. Unfortunately, the poor don't have a strong lobby. I wonder if there really would be more mistakes when you expand who can provide certain services. For a long time, pharmacists couldn't give you a flu shot in New York and I haven't heard of any negative outcomes since they changed that. The same could and should be true for a lot of primary care... do I really need to see someone with an MD to do a routine blood screening? (No, I can have some doctor do it on the internet, go to a testing center, and get the results for less than $100 vs. the $600 otherwise charged). I've also found I get by far the best (routine) care from students in university hospitals. I've had far more thorough evaluations there than with highly qualified doctors, presumably because the student (and the faculty who checked their work) both had bigger incentives to be thorough. I don't suppose this could scale very much, but I wish I could get more services through this. As it is, it's limited to things like eye exams.

Most health care is really simple routine stuff that doesn't require someone with years of training and a decade of experience in a specialty.

Medicaid paying less for treatment is probably the most significant issue. I agree with you there. But I don't see how there is a fix possible given the current political climate. Obama is not willing to pay doctors for the work they do, and Republicans are not willing to help Obama.

There is a huge shortage of doctors compared to past decades, and part of that is because of the relative lack of compensation in our times. The incentive for young people to become doctors is much less than it was in past decades. It's just basic supply and demand economics. Unfortunately, those economics have been tampered with by government intervention to such an extent that the incentive factor has been compromised.

I personally also think that the amount of schooling necessary to become a practicing physician is excessive. There are two reasons for that. One is the "close the door behind me" syndrome that happens in every profession where the existing "experts" make access harder for those coming up the ranks. But the other is the malpractice problem where every licenced professional (especially doctors) in America has to be an expert in every fucking thing on earth, or he will get sued. Both issues feed into each other.


So (imo) the commen sense solution is to allow less qualified individuals (like nurses) to do much more of the basic work for people with sniffles, broken bones, etc. And then let the doctors treat, and focus on, the truly sick. That would alleviate a huge amount of the pressure on the doctor shortage problem, and not cause costs to rise out of the stratosphere like they are now. But that will only be possible if there is major reform in the malpractice litigation portion of the issue.

None of that would work because of the AMA.

Grim1_sl said:

Obama is not willing to pay doctors for the work they do, and Republicans are not willing to help Obama.

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This has nothing to do with Obama. Reimbursement rates are set by the states, not the federal government. This is why I'm being pedantic about the Medicaid/Medicare distinction: reimbursement rates for the latter are set by the federal government and the program doesn't suffer from the same problems.

There is a huge shortage of doctors compared to past decades, and part of that is because of the relative lack of compensation in our times. The incentive for young people to become doctors is much less than it was in past decades. It's just basic supply and demand economics.

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But then wouldn't we see a decline in applications to medical schools, rather than an increase? More and more people are applying to med school, but they're not accepting/graduating more. That suggests to me a very different issue.

Also, the number of doctors per 100,000 population depends very much on the state. Take this table from 2007:State Rankings--Statistical Abstract of the United States--Doctors per 100,000 Resident Population

Massachusetts has 470 doctors per 100k, New York has 400. Mississippi has 180, Idaho has 170 (the US average is 270). This would suggest that doctor shortages vary by state, with probably no shortage in the first two states and probably some issues finding care in the last two states.

So (imo) the commen sense solution is to allow less qualified individuals (like nurses) to do much more of the basic work for people with sniffles, broken bones, etc. And let the doctors treat the truly sick. That would alleviate a huge amount of the pressure on the doctor shortage problem and not cause costs to rise out of the stratosphere.

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I definitely agree with this.

But that will only be possible if there is major reform in the malpractice litigation portion of the issue.

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Tort reform may lead to a one-time decrease in costs than that could be pretty significant -- but the real problem with health care is the growth of expenses, and tort reform wouldn't do anything for that. Let's be generous and say it saves $100bn (I don't think I've ever seen such a large estimate), that'd be eaten up in a year just from regular cost growth.This articlesays that insurance rates have dropped considerably over the past couple years. The examples they give at the end show just how huge the range is from one state to another. e.g. for internists in Miami-Dade, Florida, the insurance rate is about $48,000 per year -- in Minnesota, the same coverage costs $3,400. For OBGYNs it ranges from $228,000 to $16,000 (the latter in California). I'm really not a malpractice insurance specialists, but this at least implies that there are some major local differences... it's not like you can't sue in the red states of Minnesota and California.

Actually, the coolest (imo) study on the topic found that there was no correlation between a doctor's degree of fault and whether they got sued (e.g. they did nothing wrong and there were no complications vs. they fucked up and the patient suffered from it -- equally likely to get sued). I don't even know how you can get sued if nothing bad happened (no adverse event, as they call it), but there you go. Assuming hospitals are aware of this (and they must be), they wouldn't push defensive medicine but rather price into all procedures some risk of getting sued. So savings would be about equal to the amount of malpractice payments,

Grim1 now upset because people getting insurance for free may not get the quality of care that someone paying does. He really is a democrat.

Administration says that healthcare.gov is now fixed for the most part.Administration: We Have Met Our Goals For Fixing HealthCare.gov

Big Phoenix_sl said:

Higher tuition and insurance rates will fix that problem.

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Well, we may be able to do somthing about that, but SOCIALISM!!!1

Soriak_sl said:

This has nothing to do with Obama. Reimbursement rates are set by the states, not the federal government. This is why I'm being pedantic about the Medicaid/Medicare distinction: reimbursement rates for the latter are set by the federal government and the program doesn't suffer from the same problems.


But then wouldn't we see a decline in applications to medical schools, rather than an increase? More and more people are applying to med school, but they're not accepting/graduating more. That suggests to me a very different issue.

Also, the number of doctors per 100,000 population depends very much on the state. Take this table from 2007:State Rankings--Statistical Abstract of the United States--Doctors per 100,000 Resident Population

Massachusetts has 470 doctors per 100k, New York has 400. Mississippi has 180, Idaho has 170 (the US average is 270). This would suggest that doctor shortages vary by state, with probably no shortage in the first two states and probably some issues finding care in the last two states.


I definitely agree with this.


Tort reform may lead to a one-time decrease in costs than that could be pretty significant -- but the real problem with health care is the growth of expenses, and tort reform wouldn't do anything for that. Let's be generous and say it saves $100bn (I don't think I've ever seen such a large estimate), that'd be eaten up in a year just from regular cost growth.This articlesays that insurance rates have dropped considerably over the past couple years. The examples they give at the end show just how huge the range is from one state to another. e.g. for internists in Miami-Dade, Florida, the insurance rate is about $48,000 per year -- in Minnesota, the same coverage costs $3,400. For OBGYNs it ranges from $228,000 to $16,000 (the latter in California). I'm really not a malpractice insurance specialists, but this at least implies that there are some major local differences... it's not like you can't sue in the red states of Minnesota and California.

Actually, the coolest (imo) study on the topic found that there was no correlation between a doctor's degree of fault and whether they got sued (e.g. they did nothing wrong and there were no complications vs. they fucked up and the patient suffered from it -- equally likely to get sued). I don't even know how you can get sued if nothing bad happened (no adverse event, as they call it), but there you go. Assuming hospitals are aware of this (and they must be), they wouldn't push defensive medicine but rather price into all procedures some risk of getting sued. So savings would be about equal to the amount of malpractice payments,

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Excellent post. A few points. I wasn't claiming that there is a decline in doctors, only that the rate of those coming in isn't keeping up with demand. Which has been an ongoing issue for some time. It is less attractive being a doctor in today's environment for all the reasons stated.

As for Tort reform, that may or may not be necessary. My point was that if less skilled and trained people like nurses were allowed to take over more of the load then there would be an increase in people getting the wrong care and mistakes made. That would necessarily cause a huge explosion in malpractice litigation. For nurses to be allowed to practice they would need some form of protection in the form of legislation or the idea could never take hold.

But as Vaclav stated, the AMA would never allow it to happen. And furthermore neither would the ABA.

So we are left with increasing the rate of pay so as to attract more talent to the doctor pool. Which is going to increase the cost of healthcare. We have added millions upon millions of people to the patient pool, who generally avoided doctors before except during emergencies. They now expect to get all the services you and I enjoy. Also, the population (specifically the baby boomers) is getting older as a whole. Old people go to the doctor a lot more than young people do. That is also putting pressure on doctor pool.

It's not an unsolvable situation, but the new rules have suddenly made it much worse. So it will have to be addressed soon.

Big Phoenix_sl said:

Higher tuition and insurance rates will fix that problem.

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Higher insurance rates and requiring a 20% cap on administration really shouldn't increase doctor payments at all, right?

PS Nothing in the ACA or otherwise increased schooling costs.

Decline in doctors isn't as bad as you imply though - tech improvements make it easier to have quicker visits.

I remember simple checkups being an hour to 90 min as a kid. (3 hrs for my one nasty burn for each post treatment session!) Now my current doctor in a state of the art practice tied in with Mercy Hospital can diagnose and run every test he needs under the sun in 15 min unless I need to get sedated for it or its radiology testing.

My quality of care is just as high as ever (better IMO) but he's handling 4-6 times the patients since he can get everything done quick and easily.

Tech must always be factored into such things.

Supposedly I'm signed up through the federal exchange and will be getting a notice about starting my payment. Not holding my breath.

Vaclav_sl said:

Decline in doctors isn't as bad as you imply though - tech improvements make it easier to have quicker visits.

I remember simple checkups being an hour to 90 min as a kid. (3 hrs for my one nasty burn for each post treatment session!) Now my current doctor in a state of the art practice tied in with Mercy Hospital can diagnose and run every test he needs under the sun in 15 min unless I need to get sedated for it or its radiology testing.

My quality of care is just as high as ever (better IMO) but he's handling 4-6 times the patients since he can get everything done quick and easily.

Tech must always be factored into such things.

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I'm just going by the NYTimes article in this discussion. So you are saying that they are wrong? Why so? Because of tech? Tech doesn't solve all issues. There is a limit to how many patients a doctor can see in an hour, regardless of the tech involved.

Cad_sl said:

Medical schools are kept artificially small by the AMA to keep doctor shortages constant and keep salaries high. There aren't enough doctors to fill the residencies and jobs made available each year. Every year residencies go vacant.

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Oh there are enough doctors to fill the slots, the ones that go unfilled are shitty programs in shitty areas with shitty specialties. Many of the people that don't scramble into a slot will take a research year so they can try and match into something which will pay 2x to 3x what primary care docs make.

Grim1_sl said:

I'm just going by the NYTimes article in this discussion. So you are saying that they are wrong? Why so? Because of tech? Tech doesn't solve all issues. There is a limit to how many patients a doctor can see in an hour, regardless of the tech involved.

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There's a manpower REDUCTION, but there's a lower mapower per patient requirement now.

It's a multiaxis equation not a single axis one, they're not wrong - they're just painting a partial picture. One that I'm not 110% sure where it ends up lying but it's not as simple as an analog of "less doctors = less treatment available" like many simplify it to.