White Coat Underground

Health care reform, part III

OK, in parts I and II we talked about health care problems specific to patients and to medical science. Now, on to the providers themselves. Before you start whining about how doctors need to suck it up, remember that you are entrusting your lives to us, and that you should want good people to go into medicine and stay there.

Physician-related problems

  • Medical education: It is long and very costly. In the U.S., we do not follow a vocational model as many other countries do. Here you must complete a four-year university degree, a four-year medical degree, and a residency program (at minimum). This is payed for by the students themselves, so that it is not unusual for a student to enter residency with 200K in debt. Residency, which is a minimum of three years, usually pays about 40K, so not much debt is being repaid (but interest is accruing on some loans). This means that an average doctor in the US needs to be paid A LOT just to maintain loan payments. Starting up a practice often isn’t an option, as there is no money left. This leads to additional problems/solutions.
  • Reimbursement: Doctors’ fees make up a small percentage of health care costs but it is often seen as low-hanging fruit. Remember though, that doctors are repaying enormous personal debt in addition to the usual work of raising a family and creating a career. Remember also that once a doctor is committed to a house, a debt payment, the costs of a practice, then drastic changes in payments will collapse the system. Doctors will lose their homes (yes, really), default on debts, and be unable to sustain their practices.

  • Financing education: unless the country decides to significantly subsidize medical education, including retroactive debt forgiveness, there is no way to significantly lower physician reimbursement. Most countries do this, and many, in return, demand a year or two of public service. Public financing of medical education, with a built-in expectation of military or public service, would mitigate the problem of underserved areas and the massive debt-burden of doctors.
  • Bureaucracy: If medical bureaucracy is overly burdensome, as is seen with many insurance companies, doctors will find new careers or refuse to accept insurance and demand payment out-of-pocket. My private practice does not accept HMO patients because we would have to hire more people just to do the paperwork involved with referrals and prior authorizations. It’s just not worth it.

There are no easy solutions to our health care problems, and we do have problems. Any person who is covered by decent insurance is going to be hesitant to risk a change, but we have to decide, as a nation, what we value. If we value our economic and physical health, we need a system that gives everyone access to preventative care, that encourages practices based on evidence, and that encourages our best people to practice medicine. Right now, we pay a huge amount for health care, so arguments that any change will cost more are ridiculous—it doesn’t have to cost more, and shouldn’t. It should cost different. If businesses are relieved of the burden of paying insurance (like overseas businesses), if less money is spent on administration, we will all benefit.

Whether a system is a patchwork of private insurers with citizens given tax-incentives or vouchers, or whether it is a single payer system, or whether it is the same system we have now with minor tweaks (which seems likely), we need to get comfortable with change, and do it soon. Any real change, change that actually accomplishes something, is going to hurt. It’s not going to be easy. Before you reject certain options out of hand remember this: our largest insurer in Medicare. Medicare is unassailable as a program beloved by people enrolled, and they are pretty easy to work with as a provider. Medicare for all is not such a bad idea. It would require giving up some things to gain others. There is no system that won’t require some sort of sacrifice. It’s time to step up.

Comments

  1. #1 Whitecoat Tales
    July 30, 2009

    not unusual for a student to enter residency with 200K in debt

    *cough* 230k to be exact (some of my friends will be as high as 280)*cough*
    /whine

    Incidentally, I just finished a month of rural general internal medicine. The patient population was very afraid of the healthcare reform.

    My attending reinforced the fear. Which was amazing, because he has among the most to gain from healthcare reform as the clinic had a significant uninsured population.

    Still, my favorite moment in the month was my last day, when he was discussing the upcoming “Socialized medicine problem” with a patient he said “just thank god for medicare. Medicare is awesome, but socialized medicine of any kind is crap!”

    After we exited the room, I asked him if he noticed any irony in his statement.

    He didn’t.

    I think we have a responsbility as physicians to be aware of these issues, the actual options on the table, and the ways they’ll affect our patients. I think we absolutely have a responsbility to educate our patients as to how this will effect them.

    So I was shocked to see a doctor so unaware of the system around him, and perpetuating such gibberish.

    He was a great doctor, which I guess goes to show that intelligence or awareness is often domain-specific.

  2. #2 Gray Gaffer
    July 30, 2009

    You missed one more financial drag on doctors:

    - #5: Malpractice Insurance.

    Until our legal system picks up on the UK practice of charging the loser in a case for court and legal costs of both parties, we will continue to have frivolous suits sucking money out of the system, and therefore out of all doctor’s pockets via their malpractice insurance premiums.

    As for any other system than ours: pretty much all forms are in practice somewhere in the world, and AFAIK all of them perform better in terms of universal coverage and care than the US. They also all perform worse for their Insurance companies. Guess who pays our representatives the most?

  3. #3 PalMD
    July 30, 2009

    I did actually mention tort reform, but i didn’t expand on it much…thanks.

  4. #4 Yagotta B. Kidding
    July 30, 2009

    Out here, there are scary numbers of people who don’t even want to reform the batshit-insane way we’re dealing with people who can’t afford emergency treatment, even after the “shift the costs to the uninsured who aren’t bankrupt yet” problem is explained to them.

    All too often, on a subject where the current arrangements are just plain disfunctional, their response is that nobody should have to care for people who can’t prove ability to pay. WTF!?!?!?

    In a just Universe, people who take positions like that would be hauled into ER after a mugging with no way to prove insurance, and then tossed out into the street still bleeding. Good thing we don’t live in a just Universe.

  5. #5 catgirl
    July 30, 2009

    I think your last point is the most important one. Some insurance companies try so hard not to pay for claims that they will deny them on a technicality. In my case, they have always paid those claims eventually, but wasted much money by shuffling papers back and forth 10 times before anything was done about it. It seems like they waste so much money on trying to not pay any money.

  6. #6 antipodean
    July 30, 2009

    PAL

    Would you mind explaining what you mean by a vocational model of training and how it differs from what you practice in the USA in terms of physician training?

  7. #7 Catharine
    July 30, 2009

    I think subsidizing medical education is an excellent idea. But don’t pretend that physicians wouldn’t still balk at a corresponding salary cut. 200k sounds like a lot of money but the return on that investment is disproportionate. Compare the student loans/income of a physician to the student loans/income of a teacher or nurse (let’s say a loan of 40k for an undergraduate degree). The physician will likely be able to pay off her loan within ten years, perhaps cutting back a little on some luxuries, while the teacher will be making payments for decades, often living paycheck to paycheck. The teacher may have great insurance (for which he pays dearly), but he can’t afford to actually go to the doctor because he can’t afford the deductible/copay/treatments/prescriptions. So what good is the ‘great’ insurance? Physicians, who can actually afford medical care, still, as far as I know, have the luxury of “professional courtesy” — AND great insurance. My question for physicians is: How much money is enough?

    One more thing: Let’s not pretend that American education is truly democratic and every child has an equal chance of becoming (for example) a physician. American education is based on the “tracking” system which, oddly enough, generally corresponds to and perpetuates the child’s SES. Furthermore, let’s not pretend that every medical student is borrowing a ton of money to put herself through school. !!MANY!! students entering medicine (and this goes for any big bucks profession) have both their undergraduate and medical schools fully (or partially) subsidized by their parents. I know that there are exceptions. But I see the new interns year after year and I am the child, great-grandchild, niece and cousin (times two) of physicians. Not everyone is signing their life away in order to serve their fellow humans.

    The intelligence, commitment, sacrifice and goodness of physicians is nothing short of heroic. And they *do* deserve to be handsomely rewarded. However, it is morally indefensible that so many people work so hard, contributing to society in the best way that they are able, yet go without basic health care because they cannot pay. This is criminal negligence on a national scale.

  8. #8 PalMD
    July 30, 2009

    @antipodean: many other countries have people tracked into medicine shortly after high school, perhaps with 2 years of non-medical post secondary education, etc. In the US, you must complete a 4 year university degree as a prerequisite to apply to medical school. There is no applying until you are nearly done with university.

  9. #9 PalMD
    July 30, 2009

    I think subsidizing medical education is an excellent idea. But don’t pretend that physicians wouldn’t still balk at a corresponding salary cut. 200k sounds like a lot of money but the return on that investment is disproportionate. Compare the student loans/income of a physician to the student loans/income of a teacher or nurse (let’s say a loan of 40k for an undergraduate degree). The physician will likely be able to pay off her loan within ten years, perhaps cutting back a little on some luxuries, while the teacher will be making payments for decades, often living paycheck to paycheck.

    Unfortunately, many primary care physicians have similar problems. Average PCP salaries may be in the 140K range, but it takes years to get even close. After residency, if you go into private practice, you will make more or less zero dollars for months, until billing numbers, etc catch up to you. It will generally take a couple of years before patient visits generate a steady office income. Then there is the office overhead, and malpractice insurance. Being a doctor ain’t cheap.

    The teacher may have great insurance (for which he pays dearly), but he can’t afford to actually go to the doctor because he can’t afford the deductible/copay/treatments/prescriptions. So what good is the ‘great’ insurance? Physicians, who can actually afford medical care, still, as far as I know, have the luxury of “professional courtesy” — AND great insurance. My question for physicians is: How much money is enough?

    Newsflash: professional courtesy died years ago (at least financially—i can still get another doc on the phone when i want to). Depending on how it is handled, professional courtesy can actually be illegal. As for insurance, a small private practice (mine employs, including the docs, seven people) cannot usually get a good deal on health insurance. We renegotiate every year or so and usually can afford only one of the high deductible plans. Doctors have no special “in” for health insurance.

    One more thing: Let’s not pretend that American education is truly democratic and every child has an equal chance of becoming (for example) a physician. American education is based on the “tracking” system which, oddly enough, generally corresponds to and perpetuates the child’s SES. Furthermore, let’s not pretend that every medical student is borrowing a ton of money to put herself through school. !!MANY!! students entering medicine (and this goes for any big bucks profession) have both their undergraduate and medical schools fully (or partially) subsidized by their parents. I know that there are exceptions. But I see the new interns year after year and I am the child, great-grandchild, niece and cousin (times two) of physicians. Not everyone is signing their life away in order to serve their fellow humans.

    When I wrote of 200K debt, I was speaking of average debt. The median is likely different, but that changes little. Most students have significant debt. Medical school tuition alone is usually in the 40K per year range, and you can’t work your way through med school.

    No one would argue that education is completely democratic—there are SES differences, but also pre med and med school are HARD. I don’t want it to be entirely “democratic”, but rather meritocratic.

    The intelligence, commitment, sacrifice and goodness of physicians is nothing short of heroic. And they *do* deserve to be handsomely rewarded. However, it is morally indefensible that so many people work so hard, contributing to society in the best way that they are able, yet go without basic health care because they cannot pay. This is criminal negligence on a national scale.

  10. #10 antipodean
    July 30, 2009

    Thanks PAL

    By way of clarification in Australia and New Zealand there is now a move toward graduate medical entry. Some universities have only graduates in their medical training programs. Others still have entry directly into undergraduate medicine but increasing proportions of these students have already gained degrees or are retraining.

    So some of the same problems with large debt at graduation are beginning to occur here as well. In order to become Staff Physicians many (at least in my neck of the woods) are now also routinely completing PhDs as well, which further compounds the problem.

    But at least we have healthcare…

  11. #11 Catharine
    July 30, 2009

    My point about education is that the opportunity for accomplishment based on merit is lost in a system that labels kids as “gifted” or “slow” from the get-go. And that these labels correspond more closely with the child’s SES than intelligence or potential. Instead of opening doors for children, education (as it is) generally perpetuates the previous generation’s misfortune.

    As for the rest of it, feh! You’re probably right.

  12. #12 Whitecoat Tales
    July 30, 2009

    @Catharine

    I’d also argue that a teacher is the wrong comparison.
    Most people considering medical school, if they didn’t go into medical school would have gone into a professional school, business school, or graduate school. The corresponding paybacks on THOSE degrees are generally higher than medicine actually.

    so,

    How much money is enough?

    Enough that, dollar for dollar, doctors earn similarly to MBAs, lawyers, graduate educated engineers, and PhDs after you take into account all of their various overheads, and debt.
    Even though PhD salaries are generally lower, they generally accrue much less debt during education. MBAs, and Lawyers have fewer years of training, at lower tuition rates, in the case of MBAs, often partially subsidized by companies employing the individual.

    Or if you prefer, enough that I can stow away college money for the kid’s i’d like to have, while attempting to sustainably live in a decent community somewhere that I’d enjoy practicing, while working few enough hours (lets say, less than 60) that I can still enjoy the family life I’d like to have.

  13. #13 D. C. Sessions
    July 30, 2009

    IIRC Whitecoat Tales has an engineering degree. He could have been making $60K – $80K starting out of his Bachelor’s degree. That money is gone, lost, never happened. Add it to the direct educational costs (living expenses don’t need to be doubled.) By the time he’s in residence, he could have had at least one, probably two, raises in grade. Add another $10K – $20K per year.

    I work with several 30yo engineers making upwards of $100k per annum, and they were getting paid (if not much) during grad school on their way to an MS (PhD isn’t a big benefit for most engineers.)

    That’s all lost opportunity cost. Anything over that is available to retire the loans and lost earnings. I’ve worked the numbers, using Department of Labor numbers for physician earnings and unless you’re in a rockstar specialty like anaesthesia, you’ll never make it up.

  14. #14 Donna B.
    July 31, 2009

    Maybe I’m just an old grouch, but it seems that the first two years of a bachelor’s degree are learning what one should have learned in HS.

    As Whitecoat Tales pointed out above, intelligence or awareness is often domain-specific.

    So, I must ask myself — how important is it that my doctor have a college-educated appreciation of music and literature? Why is that BS degree so important?

    I haven’t a clue about medical school curricula, but perhaps some of you who do can tell me if there are “silly” requirements there too? It would seem that residency is where a doctor actually learns… am I wrong?

    The first step in reducing the cost of a doctor’s education is in defining what a doctor must know and how he can get that information in the least amount of time for the least amount of money.

    I really like the idea of public service to pay for education expenses.

  15. #15 Whitecoat Tales
    July 31, 2009

    Hm, i’ll be honest, my college education didn’t involve any music appreciation. My program allowed us to do our humanities work in areas of interest, so I had bioethics, philosophy and ethics of technology, my sociology stuff involved alot of class and race background that I use pretty regularly in discussing interventions with patients whose SES I probably wouldn’t have related as well too before, etc.

    But I think the biggest reason that a degree is required before med school is problem solving and critical thinking. Most good premed educations will involve a heavy amount of those skills and once you get into med school stuff, there just isn’t time to learn those – either you have them or you don’t.

    The requirements in the preclinical med school years are all basic science, anatomy/physio/pharm/histopath style things. You really can’t get by third year without that stuff.

    It would be like trying to write the great american novel without having first mastered the english language – you may not remember every specific grammar rule or use every stylistic piece, but your fluency in the language is what allows you to interface with the rest of the job.

    The clinical years on the other hand, are a completely different game. You need to use those critical thinking skills, and the preclinical knowledge, and learn to apply it to the patient in front of you. Third year to me, was learning how to recognize the patterns we see in medicine that let us diagnose patients quickly, learning how to catch myself before making up patterns that aren’t there, and learning how to communicate that effectively to a medical team.

    So far fourth year seems to be reinforcing those third year concepts, with a greater focus on procedural skills, and alot more working independantly.

    My impression of residency is that there is alot more learning advanced, domain specific skills, and fine tuning, getting the reps in to be as good as we must be,because the allowable margins of error are so small in practice.

    I don’t know how much of that is my personal experience. Any of the doctors out there, want to let me know how far off base I am?

  16. #16 Catharine
    July 31, 2009

    @White Coat: the comparison to a teacher is still valid. It’s not the profession, per se, but the education, debt accrued, and time that it will take to pay the money back. Sure, you can compare a MD to a lawyer or MBA, and you will still find that MD’s on average make more money and are able to pay back their loans more quickly. That’s laboring under the (big) assumption that there *is* a huge debt to pay. Most MD’s come from privileged backgrounds, do not pay for all of their school, which is also the case for most JD’s and MBA’s. I know both of my siblings were (parent) subsidized through undergraduate, law (private) and post-graduate specialty certificates. The kids I see entering the system as new interns every year are overwhelmingly NOT people who have ever (or will ever) have to struggle financially.

    Of course, what doctor is going to admit that s/he is paid too much? Examples of 140k notwithstanding (140k is NOT the average salary of a doctor), you guys feel a sense of entitlement to the money you earn, which is why so many physicians feel personally threatened by HCR.

    Scientists (and I consider a PhD a higher level of education than a MD) will never even come close to what you earn.

  17. #17 D. C. Sessions
    July 31, 2009

    Catherine: http://stats.bls.gov/oco/ocos074.htm

    See table 2.

    Bear in mind that the numbers are for median income, so half of all physicians make less than the numbers given. Also bear in mind that there are moderately strong regional variations (available elsewhere from the BLS.)

    Median salary for all primary care physicians is about 160K — and they make up about 40% of all physicians. If you do the calculation I suggested above, you’ll find that the odds are that WCT will, quite simply, never make back the difference vs. going to work as an engineer straight from his BS.

    As for “Mommy and Daddy paid for it all,” it makes no difference. That $200K or so could have been invested and, again, the long-term value would be greater.

  18. #19 PalMD
    July 31, 2009

    Maybe we’re not reading the same thing. Your link says that a family doc in practice more than 3 years who doesn’t deliver babies avgs 135K.

  19. #20 Catharine
    July 31, 2009

    A typo maybe? That same FP w/o OB STARTS at 161k.

  20. #21 D. C. Sessions
    July 31, 2009

    Your link says that a family doc in practice more than 3 years who doesn’t deliver babies avgs 135K.

    ObStatsWonk: that’s median, not mean.

  21. #22 WcT
    July 31, 2009

    Teachers are the wrong comparison because teachers go to four years of undergrad, and possible 2 years of grad school. They do not generally go 4 years of undergrad, 4 years of grad, 3 years of training on top of it.

    Most MD’s come from privileged backgrounds, do not pay for all of their school

    I call bullshit.

    According to financial demographic information for my medical school class, 85% of us have taken out the maximum amount in subsidiezd and unsubsidized stafford loans, and 70% of us have taken out additional loans on top of that. That doesn’t leave alot of room for mommy and daddy to be paying for anything unless half my class is secretly living in penthouses that just LOOK like crappy apartments in the inner city.

    I disagree with your assertion that most doctors come from privelaged backgrounds, the majority of my class is middle class, the same demographic information says that about 35% of us are from blue collar families. Now perhaps low SES is underrepresented, but certainly not moreso than lawyers, a and MBAs.

    Scientists (and I consider a PhD a higher level of education than a MD) will never even come close to what you earn.

    Why? Both are doctorates. They require similar time in training. One is a generalist applied science degree, the other is a science degree.

    You seem to have alot of anti-doctor rage, why is that?

  22. #23 hiphop
    July 31, 2009

    Hi, again, Rebecca, I’m so glad to read not only this blog entry, but the article in Slate. I was appalled when this gene patenting began with .

  23. #24 Theodore
    July 31, 2009

    Thank you for bringing this up WcT. I am an MS1 soon to be MS2 and a hesitant albeit supporter of health care reform, and my reluctance certainly doesn’t come from some mystical fear of socialism. We keep hearing the same catch phrase “other countries have socialized medicine why can’t America?”, but in this discussion how those same ‘other countries’ have tuition expenses covered never seems to come up in proposals.

    I am a CO resident going to the University of Colorado and my 2009-2010 bill will be more then 60,000$ of that only 5,000$ will have subsidized interest till I graduate, and my parental support tuition and living expenses will be 0$. If anything I wish I could help them to not lose their house. A problem for a lot of the middle class these days. For the unfamiliar I will be living below the poverty line for the first four years of school. And the $40k future salary of a resident is hardly comforting knowing that I will be doing 80hrs a week, and since I have graudated 0$ of the 200k+ student loans will be subsidized. So you can just cut 6,000$ off that starting salary as the cost of not just accruing more debt. How can you argue that is fair? My class stats for average debt and contribution are very similar to the ones referenced by WcT above. It just seems that there is such a minority of people lobbying about this issue that it gets washed out. We can’t even get the interest on our loans covered for the 11 years that we are in training.

    You are right Catherine, about a lot of good people not being reimbursed, and I am certainly all for paying nurses and other clinical staff more for their time and also subsidizing their education (reimbursing doctors a higher amount per visit also means that the doctor can then pay their staff more as well). Though try to imagine someone from that low SES that you keep referring too. Say my Hispanic parents were very impoverished, or I had family of my own (not that uncommon for someone already in their mid 20s) there would be no way I could wait another seven years after getting my first bachelors to start helping them out. Maybe the reason why so many of these free-ride interns which you seem to be seeing is because others can’t afford tuition and certainly can’t afford the MD wait?

    Besides it is silly anyway. Think of that block of people making money off my student loan interest. That will indirectly come out of your health care dollars, insurance premiums and/or taxes. As far as I see it those creditors contribute very little and just bled the system of that much more cash.

  24. #25 Blake Stacey
    July 31, 2009

    “Pardon me, Dr. Asimov, but are you a PhD or a real doctor?”

    — said to Isaac Asimov by a student at Boston University School of Medicine

  25. #26 Donna B.
    July 31, 2009

    WCT — thanks for the overview of your undergrad education and the explanation of the MD program.

    At the local universities, music appreciation or its equivalent is required of all graduates.

  26. #27 Ali
    August 2, 2009

    The University of Melbourne is switching their program from a vocational to a graduate style right now. This year’s students are the last intake for the vocational program (a 6 or 7 year degree, I believe, and it’s all of undergrad and med in one). In 2011 they begin the graduate/American style medical school. I hope to be in the class startin 2013.

  27. #28 military wife
    August 5, 2009

    US education is suffering because of de-tracking. Tracking went out of vogue about 20 years ago.

    And none of my fellow teachers avoided going to the doctor because they couldn’t afford the $20 copay or the prescription copay. That’s absolute nonsense, as is most of the other stuff Catharine said.

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