No no don't let the Physician cartel get out of this.
Year over year they get at least 5% pay increases with US tax dollars. Not to mention, they get private pay increases by weaponizing the ACGME to keep residency slots low.
Residency does not need to be paid. Outside of the Medical industry, people pay for their college. For some reason Physicians make tax payers pay for their education and a decent salary.
Medical school is education, and in the US it’s astronomically expensive (some people graduate with half a million dollars of debt).
Residency is more like on-the-job training (a hospital still makes money when a resident sees and treats you). It just takes longer to train a physician because there are human lives at stake.
Yes, teaching fellows and others in academia are often taken advantage of and work for free, but that doesn’t mean physicians are evil for getting paid during residency.
>It just takes longer to train a physician because there are human lives at stake.
Airbags?
Our electrical infrastructure?
Our plumbing?
Please, there are plenty of of industries that have lives at stake and we don't have a cartel controlling the supply of people. The issue is that we don't have enough Physician(By design), so they need to operate independently. Any other industry has multiple layers of qualified people checking to make sure things are safe.
I kind of dream of a world where you'd have 1 physician and a physician manager and a physician director all looking at your paperwork. Instead you get 1 total.
I don’t want to trivialize the amount of work that goes into airbags, electrical infrastructure, or plumbing.
However, the human body is much more complicated. Would you trust the life of a loved one who, God forbid, has cancer or needs surgery to a person with a fraction of the education and training physicians receive?
By the way, I’m reminded of a joke: a doctor called a plumber for a faucet leak. The plumber fixed it in 5 minutes and charged $175. The doctor said “how can you charge that much for 5 minutes of work? I spend a whole hour with a patient and charge less!” The plumber said “that’s exactly what I used to say when I was a doctor.”
> Would you trust the life of a loved one who, God forbid, has cancer or needs surgery to a person with a fraction of the education and training physicians receive?
False dichotomy.
Right now the ACGME limits the number of residents. This causes a lower supply, so instead of having 6 surgeons working on you, you have 1-3. Do you only want a few people fresh from residency working on you? Or a bunch of physicians with various experience?
Also, plot twist, we own a medical company. (not physicians, but a different cartel that is paid way less and got a pay cut since 2016) You can treat 7 people per 37 minutes, each paying between $40-$125. Physicians is way worse, you can charge $250 for 5-10 minutes.
(Note that this ignores documentation costs/times, but it should give you an order of magnitude to play with.)
We don't do that blatant 7 people per 37 minutes, its more like 1 person per every 60 minutes, but as the clinic grows we've had 2 people per 60 minutes out of necessity. The hospital/other clinics do this.
I need to do an AMA on owning a medical clinic. My wife, the primary doctor, isnt exactly happy that I bite the hand that feeds. We already lost our chiropractor referrals because I couldn't handle their mysticism and spoke out against it.
How does this actually work? I have never worked in a medical context and am ignorant of their internals so this is a genuine question.
I _have_ been a patient going to a specialist appointment where the only doctor I saw was a resident, and I don't think I or my insurance were charged any less. So if their work brings in the same amount of revenue for the same services, and if resident often do a lot of hours (I seem to recall several years ago their hours were capped to not be _dangerous_ but are still a lot), and they're paid less during their residency than after it ... why _don't_ hospitals make money off residents? Is there some training going on parallel to seeing/treating patients which is really expensive?
My source is my father who is a physician who chairs a residency. He’s always complaining about the business analysts wanting to cut the program because it’s not making enough. My understanding is that yes there are a lot of highly paid doctors at the residency who are basically just supervising the residents so you end up in a situation where you have just as many full doctors plus the resident costs to treat the same number of people. The residency also does a bunch of non revenue generating stuff like retreats and training every Friday which hurts margins.
I looked for a credible source for this claim. Hospitals say they’re losing money on residencies but there doesn’t appear to be an easy way to verify this. What if the federal government is falling for/complicit in a big lie (wouldn’t be the first time, see PPP “loans” when COVID started)?
Residency is not college, residents are practicing physicians that are providing considerable value to society and in many cases they are paid appallingly little for the amount that they work.
I think I understand where you're coming from, but even ignoring resident salaries the majority of other healthcare spending is already government-funded, and in my ideal world all of it would be, so it's hard for me to be upset about this.
I don't understand your point about scientific knowledge, in my mind keeping people alive is at least equally as important as advancing scientific knowledge.
> Physicians are not advancing scientific knowledge.
Yes, but they are providing a similarly valuable service. And, in fact, almost all medical practice contributes to the development of knowledge as well. Lot's of physicians (even residents) write papers.
Physicians are some of the larger victims of this inflation, no? Also “they” are not doing anything with ACGME in general, that’s an entirely separate issue.
Note for this article that private colleges have the highest drop out rate, and Minnesota's plan excludes such institutions:
> Qualifying students would have to attend a two- or four-year school in either the University of Minnesota or Minnesota State systems, or a tribal college. Private college tuition would not be covered.
> From 2008 through 2009, enrollment in private for-profit colleges rose disproportionately compared to private non-profit and public colleges. Private for-profit colleges have extraordinarily high rates of default, near 16% of borrowers default within 3 years.
Agreed, but they're forgoing college because they better opportunities without acquiring the traditional credential(s) due to a tight labor market, demographics and older folks retiring making trades and non college paths more lucrative, etc. The debt load is not worth the potential opportunity benefit.
The whole "get a college degree if you want to be middle class" scam is evaporating, which results in your observation.
Funding directly by issuing a blank check to the vendors? No, it won't.
Funding directly by setting a price cap, and paying vendors that amount for services rendered? Seems to work for almost every other developed country in the world.
With the monetary savings of #2, it could even give every medical student a fully free ride.
I love when someone says "seems to work". In the strict sense, that only ever means "does something". Not necessarily "does what someone wants"... and never "does what I want".
When it works for those other countries, does it "do what you want"? Because it doesn't "do what I want" at all.
> With the monetary savings of #2, it could even give every medical student a fully free ride.
Won't someone think of the millionaire heart surgeons in the 1%? They obviously needed free rides back when they started, it's why they're only single digit millionaires!
> Funding directly by setting a price cap,
Starving the people you want to provide your medical treatment isn't the brightest strategy. Increases to price caps are always reactive, after they've been complaining for years. The bureaucracy demands that it take years more to raise the price caps. And by the time that happens, they've been bleeding money the whole time. It's a strong incentive for them to do all sorts of things that you don't want... and if you do it for any length of time at all, it trains them to do these bad things so even if you realize the error of your ways and withdrawn the bad policy, they keep on doing the bad things.
Quite clearly, the problem with health insurance is that we need a gigantic insurance company larger than any other in history, and that it needs to be managed by the paragons of competency, the federal government. Of course, they'll need to staff up... and with all the layoffs in the private insurance industry, we'll hire all those empathetic, kind-hearted subject matter experts.
Should be the best thing ever. I can't possibly see anything that might go wrong.
The US's healthcare system is so bleak because we quite literally fund healthcare for the rest of the planet. Taxpayers in the US get access to the best treatment decades earlier if they're rich enough. Prices are increased on US citizens to account for the strong arming other governments do to get prices lower for their citizens. If the pharma companies couldn't do this, for example, they'd refuse to negotiate with other countries. A microcosm of this behavior is medicare here is the US. Yes, the US taxpayers even have to be charitable to them.
IMO, if the US decided to actually help its citizens every country the average progressive considers "great at healthcare" would likely implode under the sudden increase in cost. The cost of medication alone would likely nearly bankrupt several governments. Imagine if the price of insulin, almost completely funded by US citizens paying absurd prices, went up to its US price.
Much like with defense, the US taxpayer is the hero of the rest of the world's healthcare. Without US tax cattle the rest of the world would not be as nice as it is. It's just like when prices go up at your favorite store due to theft. The US is punished by insurance companies because other countries refuse to pay more.
Almost everything you have said here is untrue. Pharma companies still make profits in other countries, they just make much more profit in the US. Much of medical research is in fact funded by the government to begin with.
By removing the for-profit system, you would actually be removing rampant rent-seeking on something that should be a human right.
> Imagine if the price of insulin, almost completely funded by US citizens paying absurd prices, went up to its US price.
A very strange example to select, considering it was first discovered by Canadians and the patent was later sold for $1. US citizens are certainly not "subsidizing" insulin elsewhere.
Sure bud. What is it about HN'ers talking with such confidence they legitimately have no idea what they're even talking about? I googled it for you, and gave you two sources are probably amicable towards - there are THOUSANDS more[0][1]. It's exhausting that everyone here talks like they are an expert at everything. I thought I left that when I came here from reddit.
The example you selected with insulin does not support your argument.
Of course, anyone can do a google search and find some opinion pieces confirming their world view, that doesn't make it true.
The post article in particular just looks at the total revenue and essentially says "look how big it is compared to other countries, we must be subsidizing them". But this just justifies the extreme profit-seeking already in the sector, it's not an argument that it's necessary for innovation.
This doesn't come close to supporting your claim that (most of?) the entire healthcare cost gap is due to subsidizing innovation, for the reasons I described in my other comment. (ie: Drugs are only ~10% of our healthcare costs.)
Even your own source [1] contradicts the idea that high costs are inevitably caused by this subsidization:
> Why doesn’t competition bring U.S. health-care prices down? The answer: America’s stagnant third-party payment system allows hospitals and doctors to avoid competing on price.
This could only be true if the majority of the healthcare spending diff came from payments to pharma/health dev cos, right? Do you know whether that's the case?
If we're paying more for nurse salaries, hospital administration, insurance company bureaucracy, and ineffective procedures near end-of-life with low probability of success, it's unlikely the cost diff is mainly due to "subsidizing innovation."
People making this argument tend to want 'better health outcomes for millionaires/healthy white collar people', either because they are one, or they think they will be one.
What I always point out is that markets are a form of rationing too. They are just form where people with money are allocated more goods than people without it, sometimes to the total exclusion of large parts of the population. Given that we set up polities for the common good, I'd argue that any necessity which markets fail to deliver to everyone should use some other kind of rationing strategy.
> If "better health outcomes per dollar" is not "what you want" -- how come?
Because I don't confuse "individual" with "group".
The fallacy here is to tally up every dollar spent on medical treatment in a given year, then saying "here we spent X on medical treatment, but it could only be 0.7X if the government were in charge".
But you never asked me how much I spent on medical treatment. What if I spent 0?
Well then, your plan has me spending more than I used to, to get me something I didn't want/need. It's not a good deal for me. And if it's a good deal for someone else, it's only because you shackled me up and made me work the fields for their benefit. No thanks.
Even if I was the sort to engage in that non-sense, the problem itself is insurance. And that holds true whether some private company (or many) is in charge of the insurance, or the government is in charge of it. You think BCBS rejects claims, but that the feds don't reject them? Wow, do I have a bridge to sell you.
When someone wants a good or a service, and they pay for it themselves, they are price-conscious. When they don't pay for it themselves (because the insurance company does, or the government), they aren't price conscious. But this encourages the goods-provider to raise their prices... even discourages them from keeping them low. Low prices signal low quality. This encourages the payers to reject claims, then once more the goods-providers to raise prices again to cover for all the rejected claims (bonus if they can go after the goods-buyers for the price too!).
And it all spirals out of control. There is nothing in this mechanism that makes it less ridiculous if the federal government owns the insurance company, and it is the only insurance company permitted by law.
I take that back, there is one thing different. Now you can introduce price caps, woohoo! That will certainly fix the problem. Some committee 2000 miles away and months-distance from the facts can magically determine a fair price for all physicians and surgeons nationwide for some procedure's medical code (not the procedure itself, these are always unique... but the little alphanumeric codes, nice and uniform so they fit in the database).
That definitely won't cause further meltdowns. Will it be blamed on nefarious capitalists hiding in the woodpile? Will it just be chalked up to disappointing reality "there can be no other way"? Probably will depend on just where we're at in the election cycle.
If you want to see prices drop (plummet really), outlaw all insurance. Make people pay cash, out of pocket, for everything. You starve if you can't sell your stuff to people who want it, and if those people only have 1/100th of what you used to ask, then you either learn to live with the 1/100th, or you starve. No one gives out bank loans for heart transplants.
> Won't someone think of the millionaire heart surgeons in the 1%? They obviously needed free rides back when they started, it's why they're only single digit millionaires!
> Starving the people you want to provide your medical treatment isn't the brightest strategy
Gosh, it's almost like I pre-empted the latter complaint with the note that you've responded to above...
Expanding the number of doctors, and lowering doctor pay and workload, and lowering the cost of becoming a doctor will produce better health outcomes for everyone. Yes, some people will stand to lose from this, just like the current bloat of worthless administrators and billing clerks and other paper-pushers will stand to lose from a cleanup of the system.
I don't care about their well-being.
> I love when someone says "seems to work". In the strict sense, that only ever means "does something". Not necessarily "does what someone wants"... and never "does what I want".
> When it works for those other countries, does it "do what you want"? Because it doesn't "do what I want" at all.
This exact criticism can be levied on the current US system.
> Expanding the number of doctors, and lowering doctor pay and workload, and lowering the cost of becoming a doctor will produce better health outcomes for everyone.
So go do it. No one's cockblocking you. Well, except the AMA. Or are you saying that you'll only do this if you get your socialized medicare-for-all quackery?
Wouldn't be shocked if it was held hostage like that, but no thanks.
> This exact criticism can be levied on the current US system.
I never said it worked. Wouldn't catch me saying that ever.
