Making it easier to become a doctor would improve things immediately (especially given the recent research that makes it clear that nurse practitioners do just fine).
The supply of doctors is not restricted by the AMA. The supply of doctors is determined by the number of residency spots available to new graduates; that number is entirely determined by the Centers for Medicare and Medicaid (CMS). Thanks to the Balanced Budget Act of 1997, Graduate Medical Education (GME) was dramatically slowed due to decreases in Medicare funding of residency positions. [1]
As long as we require physicians to be US trained and to have completed a US residency, the bottleneck will be GME funding. To fix that, the AMA or any other concerned citizen can lobby Congress for an increase.
[1]: http://jama.jamanetwork.com/article.aspx?articleid=182532
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.
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 government that is there all the time for us. For example, how about trying to bill Medicare for a surgery, when one phrase--one phrase-- is missing from the documentation, and I don't get a penny for a 4 hour surgery?
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.
Medicare is a monopsony. They represent such a large share of patients for many practices that they set their own prices. And when people expect medicare both to pay for their triple bypass and not to go broke at the same time, what we get bankrupt hospitals and over-worked doctors.
Being more responsible about the way we apportion healthcare is the only reasonable option.
To make matters worse, Canada is suffering the effects of the American system. Doctors licensed in Canada are encouraged to go to the USA (particularly specialists), by the allure of much higher salaries. In order to prevent a vicious brain drain, the Canadian Medical Association must pay doctors as much as they can to stay and practice in the country. As such, Canadian healthcare costs have been skyrocketing due to specialist salaries soaring ever higher to compete with American rates.
Comparing physician salaries in the US and Canada with other commonwealth countries like Australia and the UK provides a clearer picture as to what is going on. The American healthcare system is completely and utterly FUBAR. It needs to be torn down and rebuilt based on a functioning healthcare system from another country.
1. http://time.com/198/bitter-pill-why-medical-bills-are-killin... (Unfortunately, it is now paywalled)
As it stands there are no published prices (or they're bogus, if your published prices are 3x what insurance companies pay it's not a real price) for anything so nobody can shop around. That means there is no competitive pressure on the non-critical, non-life-threatening things that are expensive-ish but possible to pay out of pocket. And that means that nobody can circumvent insurance. And that means that doctors have to keep spending $58 to process a form that will net them a $20 to $30 copay and maybe another $50 worth of reimbursement? So the doc nets between $30 and $40. Call it $35 and multiply by 5 (12 min per patient) and the doc is billing out at $175 per hour provided he teleports from one exam room to the next.
There are a great many people who could afford to pay $100 cash (or equivalent) for a doctors visit, for say 30 minutes with a doctor. So that's $200 per hour.
Major medical plans (for big stuff) coupled with health savings accounts will empower patients to ask "do I really need this" with a price sheet in hand and a real conversation about the benefits vs the costs. Right now that happens approximately zero.
http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot...
I met a resident the other day, and they routinely get four hours of sleep or less and worked for shifts that are insanely long that are basically dictated by patient demand. Why not just hire more doctors, maybe lower salaries by increasing supply, and give them a healthier lifestyle? Maybe medical school prices would go down with additional scale.
Additionally, the work hour restrictions placed on residents over the last few years appear to have done nothing to reduce the overall number of medical errors.
(I am in favor of reducing medical work hours myself, but these are some of the data-driven reasons that it will be very difficult, not to mention the structural reasons inherent to the current system of medical training.)
So this is useful training, albeit at a cost. Although if they make a mistake that kills a patient during residency and learn they can't deal with the consequences of that, I suppose the earlier the better. They can of course move to less life and death specialties.
If your goal is to reduce medical errors, create systems that don't depend on a single person's fluctuating energy level (e.g. have two doctors responsible for each patient, keep patient loads low enough that they can deal, automate as much as possible with computer systems (e.g. billing), and delegate to e.g. PAs for mundane diagnoses). Exhausted people make mistakes, can't work or think as quickly, are less creative, and are generally less happy. All the technology in the world won't help you if the key decision makers screw up at the wrong time.
After all, coffee does exist for those times when your natural energy level won't do it for you. ;)
There's no justifiable reason to give a large, urban hospital an organization system fit to the battle field.
It seems like a bit of a chicken and egg problem. Medical school is already so expensive that the salaries are necessary in order for newly minted doctors to have the same disposable income after loan payments that, say, a programmer or chemical engineer who's 7 years younger has (4 years medical school + 3 years residency minimum). Who would make the sacrifices necessary to become a doctor, taking out massive loans, only for an income that won't sustain them comfortably?
Currently, in the United States, we believe all of the following things: (1) Human physicians, are the only qualified parties to diagnose, treat, and/or recommend courses of action related to health (not nurses, physician's assistants, computer programs, etc.), (2) everyone has a fundamental right to healthcare, (3) health professionals must undergo expensive, lengthy, difficult courses of study and training, and (4) we reimburse for procedures, not pay for outcomes.
Given these incentives, it's not hard to see why doctors are some of the most overworked, stressed-out, and generally miserable professionals out there. They're at the nexus of a crushing conflict between keeping people healthy, a management system that demands more revenue (and remember that revenue=procedures, because we reimburse for procedures, so the only way to increase "productivity" is to do more, faster, with fewer breaks and longer shifts), and a legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study.
I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. I believe this outcome is inevitable, but will take a decade or more to surface, because it requires major shifts in how doctors and insurance companies think about billing, greater human trust in computers and recommendation systems, and a collective realization that the current state of healthcare is untenable.
I am an MD and have a degree in CS. Expert systems are not remotely there yet for this purpose. On no planet would I trust care of my patients to a computer. Far too many subtleties involved in accurate diagnosis and treatment that are not encoded in a machine-readable format.
> legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study
Good reasons for this - it actually takes that lengthy course of study to safely perform many procedures, and, more importantly, to fix things when they go wrong.
NPs and PAs are helpful but based on the quality of care that I personally observe they should not function without physician oversight.
There is no escaping that medicine is an extremely complex field, and it is only getting more so. Not long ago, many of the people who today are restored to their usual state of health would simply have died. The sicker a patient is, the more complex and difficult to manage they are. By definition a doctor is the one who is able to do so.
I am still waiting to meet a patient who comes to the hospital and prefers to have their care rendered by non-physician providers over physicians, or would even settle if there were an option.
US medicine has been very successful at creating a guild system that's prevented lower-cost provision of care for decades, all under the concern of "it'll lower the standards of patient care." End result has been millions of people who can't afford medical care at all.
One anecdote: for a time I was splitting living in the UK and the US and had health care experiences in both places. It was fascinating to see the differences in treating my (very ordinary) health issues. One time I came down with a mild rash that rebounded a few times before it finally went away. In the UK, the GP looked at the rash, punctured the pustules with little pokey thing so they'd drain, and they cleared up in a few days. In the US, the dermatologist wheeled in a big machine filled with liquid nitrogen and froze the pustules; they went away in a few days after that too. End result the same; cost to administer - orders of magnitude different. In the US, it seems like there's no medical treatment that we can't make more expensive by requiring more specialists with more years of training, using ever more expensive machines and medications.
I love modern medicine. My dad's a retired doctor and I almost became an MD myself. But the system we've created has costs out of control while simultaneously creating worse societal health outcomes than other countries.
Attach a price tag to each and find out. Maybe someone who couldn't afford a $500 consultation with an MD could settle for a $250 or $100 consultation with a PA, or an expert system. You really don't know until you experiment, and find out.
But still due to huge resistance by doctors, who like the autonomy of the job, such systems are rarely used.
I could only imagine how rapidly such systems would improve if the backbone of medicine would be dependent on them, and enough revenue would be shifted towards them.
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 - every doctor had their preferred provider, sometimes from merit, sometimes because they liked the shiny goodies that the sales reps brought.
All the individual systems interoperated very poorly, and none of the physicians would budge, and the hospital administration could not force their hand. Any time admin tried to regularise something, the affected physician would just state "If we make this change, children will die". It didn't matter that everyone at the table new that this was a total lie, because the official authority for that department (or speciality) was that specialist. They got their 'free market', being able to use their preferred products for each individual specialist, for personal preference at the cost of better overall treatment. The whole was very much less the sum of its parts.
Another friend became a sales rep for a pharma company. The rep she took over from was a fairly standard rep, but she was quite ethical, and would only allow her 'freebie' budget to be used on things that developed the practise. Some doctors already do this. Others were more like "ah, well, the ride is over with this rep". Some were absolutely outraged that she should dictate to them what this 'extra income' was spent on - how dare she suggest medical charts instead of football tickets?
I myself have personally seen a specialist in a field report on some clinical studies so badly that we technicians had to go to other specialists and get them redone. That specialist didn't get any more of that kind of work at our practise, but his utter incompetence was never followed up beyond "don't hire him again".
I guess the moral of the stories are that freedom to run practises as you see fit does not mean ethical (or even ethically neutral) behaviour, and that an environment where every physician uses their preferred products does not mean better care is delivered.
Per the American Academy of Physician Assistants: "PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling and make rounds in hospitals and nursing homes. All 50 states and the District of Columbia allow PAs to practice medicine and prescribe medications."
http://www.aapa.org/the_pa_profession/what_is_a_pa.aspx
Disclaimer: I work for the Physician Assistant Education Association.
I agree completely, but you forgot to add under what we believe: (5) "government has the solution for everything." At least that's what it feels like lately.
The cynic in me says that the healthcare industry will continue to get worse for some time before it gets better, if ever. We may see complete nationalization because the government must swoop in and "save us" from the monster it has helped to create through misguided regulation.
Americans actually display stunning recalcitrance towards this fact, and as a result we have an incredibly polarized debate which has led to a bastardized and amalgamated system comprised of several other, and often conflicting, constructs.
Holy meaningless platitudes Batman. How do you have a system that is simultaneously profit driven and that allows everyone a fundamental right to healthcare? Short answer: you can't! You can either have a system that avoids treating the most expensive (free market), or you have a system that ensures a certain level of care for all (socialism), or you have some bastardized hybrid that costs ungodly amounts of money and does not serve the sick and poor well. (the system we have).
[1] http://en.wikipedia.org/wiki/Conditional_cash_transfer
See also: http://www.economist.com/news/international/21588385-giving-...
EDIT: In the essay I describe why it can become so hard to leave medicine after one has invested more than a year or two in med school because of student loans; that may help explain the suicide issue: people who feel trapped may in turn feel like death is the only way out.
A surprisingly large number of doctors hit residency and realize they don't want to become doctors. In most professions that's not a tremendous problem, but in medicine the only way to pay back $100 – $250K in graduate student loans is by becoming a doctor.
To be clear, it's a huge problem, and we shouldn't have this sort of debt loads on those who want to educate themselves. It also weakens the broader economy and drives up professional services costs. But to say people are killing themselves because of student loans is a mistake.
Further, implying that Doctors are willfully ignorant of loan financing options is...interesting. All Federal borrowers are required to complete exit loan counseling upon graduation from medical school. That counseling includes discussion of the various repayment options (Standard, Extended, ICR, IBR, PAYE, and forbearance).
OP missed a perfect headline opportunity: "9 out of 10 doctors recommend not becoming a doctor."
But seriously, we wonder what's wrong with healthcare. I seriously believe it's because of the lawsuit-happy nature of patients nowadays. Yeah, something could go wrong during your surgery, or your diagnosis for that matter. But that's an inherent risk in having something wrong with you that you need checked out.
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 the table the org could use to cross-subsidize non-payers.
you have to be careful with that statement since it can be a clever way of talking about what insurance agrees to pay with the chain versus the "retail" rate the doctors charge.
my father is a general practitioner and I was always amazed when he started saying about 25 years ago that he wouldn't let me become a GP if I had gone into medicine. and this article covers all of his concerns well.
malpractice is a big part of the issue and it varies state to state. for example, in pennsylvania malpractice insurance is amazingly expensive. and people sue all the time, which is sad unless it is gross incompetence, since every doctor I've met is trying their best.
The problem is that management is filled with perverse incentives. It looks good on the books to have fewer employees - until you realize you have highly trained specialists spending hours per week working on paperwork or rushing their actual job and increasing long-term costs.
It's amazing that the billing costs in the US are a factor of magnitude higher.
I know that compared to much of first world Europe, our nurses and doctors often make two to four times as much as their counter parts there. Wonder if that's true compared to Canada as well.
http://www.health.gov.bc.ca/msp/legislation/pdf/bluebook2012...
The average for Family Doctors is around $240,000 CAD and for specialists is about $430,000.
Average registered nurse salary in BC is about $61,000 CAD.
Doctors in Europe live quite well, and don't have as ridiculous workhours as the numerous USA examples listed, or the suicide problem.
http://en.wikipedia.org/wiki/Canadian_Medical_Protective_Ass...
I'm curious how the arithmetic on that works out. The median pay for medical assistants is $14.12/hour [1], which means that assuming the assistant is handling the insurance form, that works out to just over 4 hours per patient encounter. There might be some fixed costs (filing space, for instance, is not free), and some costs associated with communicating with the insurance company, but it's really not obvious to me how any of those can add up to $58/visit.
[1] http://www.bls.gov/ooh/healthcare/medical-assistants.htm
That just sounds crazy. Can you imagine if your car insurance had to pay less if you complained about your mechanic? Not to mention that medicare is for the elderly who tend to have a lot to complain about anyway.
Can I pay my taxes based on my satisfaction with the government?
There's also this: http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-sh...
