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.
- 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.