not a good sign

by russell

From today's Globe, more doctors gravitate toward boutique practice.  The nitty gritty at a glance:

• six doctors in MA will be converting to a concierge practice this year
• "concierge practice" means unlimited access to the doctor for an $1,800 rider above your insurance coverage
• two of the doctors profile will be reducing their patient load from 3,000 to 600, each
• at 600 patients, the $1,800 rider is $1,080,000.  A third goes to a services outsourcing company that administers the practice, the docs get $720,000 each to pay salaries etc.  That's *on top of* any and all reimbursements from insurance

Two doctors - six in the whole state - is not a lot.  But it's a trend, and a growing one.

The things that stand out to me are these:

3,000 patients per doctor?  How the hell does one doctor provide good general practice care to 3,000 people?  Are there enough doctors in this country?

If the price of admission to get from 3,000 people per doctor care to 600 people per doctor care is $1,800 per year, not everyone is going to be able to play.

If enough doctors reduce their patient load from 3,000 to 600, there are going to be a hell of a lot of 2400 patient cohorts looking for a doctor.

With a $720K carrot dangling in front of them, along with an 80% decrease in patient workload and the opportunity to provide really thorough, personal care to the 600 they end up with, what incentive is there for docs to say "no"?

Hard to find a really bad guy here, but it's also hard to see how this trend isn't going to harm a lot of people.

Comments

[Countme--In]

Ah, yes, boutiques.

Meanwhile, we remove the decorative ficus from the death panel chambers to save money.

There will be blood.

[bobbyp]

It's all about the money.

A quick and dirty google shows we have a population of 308,000,000 and nearly a million doctors, a third of which are primary care physicians (about 950 citizens/doc). So those guys with 3,000 patients must really need the money because that's still an average of 1 1/2 hours per patient based on a 2,000 hour work year. A relatively healthy person needing no more than an annual checkup sees the doctor for about 20 minutes (my guess).

Perhaps we should try importing some doctors to get the numbers up (and the cost down)...or subsidize medical training and take it out of the hands of the AMA.

Dean Baker also has an idea to allow US citizens to participate in the health care systems of other countries. Check it out.

Thanks.

[russell]

It's all about the money.

To be honest, if the doc is going from 3,000 patients to 600, even with the substantial additional revenue from the rider I don't think it's all about the money. They're walking away from insurance reimbursements from 2400 people.

It could also be that they simply aren't happy with the 20 minutes per person / per year arrangement either.

I have pretty good insurance, and I probably see my primary care physician something like 20-30 minutes a year. Most visits, I see a nurse practicioner.

That's fine, I actually have no complaints because I'm healthy, and the nurse practicioners are great. But I can also understand a doctor wanting to get out from under a 3,000 patient workload.

Even if you see everybody on average twice a year, that's something like 120 patient visits a week. 20 a day, six days a week.

If everyone gets a half hour, that's a 60 hour week. Before paperwork, research, professional development to keep up with what's new, etc etc etc.

It's hard to blame the doctor. Or, I find it hard to put all of the blame on the doctor.

It just seems to me that the trend is toward an increasing divide between haves and have nots.

[Tony P.]

First, what the hell is a "services outsourcing company", and what exactly does it do for its 33% vig?

Second, "unlimited access" is surely a scam, but I don't know whether it's the "services outsourcing company" scamming the docs, or the docs scamming the patients, or what. When 600 rich hypocondriacs fork over $1800 each for "unlimited access" to one doctor, the likeliest outcome is that one lawyer (actually, two lawyers) will end up with all the money.

Third, according to this chart, MA is the state with the highest number of "non-federal" physicians per capita. We have 4.5 physicians per 1000 people. If some of those docs have 3000 patients each, there must be a fair number of docs playing golf all day.

I'm confused. No, I'm tired. The medical care financing system is confused.

--TP

[chris y]

Are there enough doctors in this country?

I understand the number of medical school places in the United States is constrained by the AMA. This is a restrictive practive which would not be tolerated or even legal in many countries.

[Hartmut]

Over here there are some residency limits, the universities have filters (numerus clausus plus an extremly challenging test (iirc six hours under stress)). But the residency limits are more self-protection against oversupply. E.g. a dentist on our block did not get a permit because there were at least 3 others within spitting distance already (and usually 2-3 doctors share a practice). the trouble is that in the cities there is an oversupply while in the country general practicioners are or got scarce. There are currently serious discussions about incentives (maybe even a requirement) for doctors to serve in rural areas at least temporarily.

[yods]

"There are currently serious discussions about incentives (maybe even a requirement) for doctors to serve in rural areas at least temporarily."

This is already the case in South Africa.
Everyone doing any kind of medical degree have to serve a year in rural disadvantaged areas immediately after graduation.

[Countme--In]

Have we ever noticed how freedom-fry loving, Frog-hating American entrepreneurs suddenly begin speaking French after they read "Atlas Shrugged" and other American founding texts.

Off they go to establish boutiques, concierge services, and Dagny Taggert's trains all contain high-end bidets, in case she accidentally loses ideological control and has sex with a prole conductor in a cracker state that criminalizes birth control and fellatio.

Egalitaire, of course, causes a speech impediment among these ilk.

Guillotine comes in very last in their French lessons, and they usually only get half the word out before shock sets in.

[wj]

Before we get too worked up about the amount the concierge doctors are apparently "making," I'd like to know two things:
1) How much were the doctors making, exclusive of insurance payments, with the previous patient loads? Take-home pay, after figuring all their overheads, etc.
2) What all does that services outsourcing company do, and what is left for the doctor to pay for out of the $720K -- office space, office staff, etc.? In short, how much of that $720K is actually take-home pay for the doctor?

Then we can combine the average insurance payment with the patient loads to figure out what the financial difference is really. At this point, all I can see is "headline" numbers which, in my experience, frequently have little to do with reality.

As for the limited supply of doctors, I agree that raising the supply (and thus dropping the price) of medical care would be a good thing. But to my mind, the bigger problem is not the price (even though that is a problem), but the fact that a big part of the care most people actually receive is from "residents". Not that residents are not good doctors, but just that the current approach to "training" (actually, from what I can see, more like an embedded, but traditional, form of extreme hazing) involves making these folks work extremely long shifts. And whether the AMA admits it or not, very tired people are proven to make bad decisions.

[Spiny Adagio]

Paperwork has increased exponentially since health insurance got involved in basic care. When a doctor needs a receptionist and a person who deals with nothing other than insurance companies, and the insurance companies tell them what prices they may charge, doctors are employed by insurance companies. It is a business, not a service. The insurance companies are making money. Doctors can no longer count on paying back their student loans in a reasonably amount of time, and can no longer count on the kind of lavish consumerism doctors enjoyed in the 1970s. The cost to the patient has increased horrifically. The patient receives precious little face time, and the kind of care mandated by the insurance companies.
It has gotten to the point where it costs $150 to walk in the door at a doctor's office. That is more than a part time minimum wage worker takes home in a week. There is a crisis in health care. It is that it is a business, that the practice of medicine today bears very little relation to the way it was practiced even 50 years ago, when a doctor got to know his patients and could , in normal conversation, pick up on a number of clues to illness that never made their way into text books.

Boutique doctoring is an alarming but not unexpected development. Right now, only the very wealthy and the very poor can afford doctors.
Yes, the system is in crisis, and will eventually collapse.

[GoodOleBoy]

Before criticizing anyone for their choices regarding how to organize for their delivery of medical services to their patients, should not the issue of a possible shortage of medical practitioners be examined to determine why this might be true?

I'm trying to think of the players who, in concert, might be contributing to this state of affairs:

1) Federal and State government

2) Trade and/or Professional Associations

3) Educational institutions

Can anyone here expand this list or knock anyone off the list?

Are there things any of these groups can do or stop doing to make things better?

[Turbulence]

And whether the AMA admits it or not, very tired people are proven to make bad decisions.

Perhaps we should make doctors fly on planes piloted by people who have gotten as much sleep as the average medical resident. I mean, they're quite certain that working for 48 hours with no sleep doesn't impair cognitive ability, so there's no reason they should benefit from the FAA's crazy crew-rest regulations.

Doctors can no longer count on paying back their student loans in a reasonably amount of time, and can no longer count on the kind of lavish consumerism doctors enjoyed in the 1970s.

Do you have any cites for that? The doctors that I know don't have this problem at all.

It has gotten to the point where it costs $150 to walk in the door at a doctor's office.

If you think that's expensive, you should see how much it costs to walk into the office of a good body shop, or a second tier university lecture hall; you don't want to even guess how much it costs for a good plumber to walk into your office. My point is: medicine is a very high-skill practice, so the fact that spending time with a doctor is expensive is not surprising at all. Medical insurance costs a lot more than $150 per year.

[Phil]

You forgot insurance companies, GOB. Who often make medical decisions for patients, when those should be reserved for doctors, not bean-counters. (e.g., When my doctor wanted to prescribe me a month's worth of Ambien and insurance said I could only have 14 pills. Or when a doctor decides a certain treatment is medically necessary but insurance won't cover it because it isn't "customary and usual.")

[Countme--In]

The problem is licensing.

A free people should be able to come to me for brain surgery.

Until word gets around.

Not word mandated by the government. Free market skywriting by word of mouth for those who still have the capacity to speak after experiencing my boutique services.

But then I could lower prices and keep them coming for quite awhile.

[GoodOleBoy]

'You forgot insurance companies, GOB.'

Yes, I did, and they are a big part of the overall problem and maybe even employers.

[GoodOleBoy]

So here's a question? We have a large number of Mexican nationals recently emigrated to the US, and many other Latinos as well. Do we make it easy for medical practitioners from Mexico to come to the US and set up medical practice? Does anyone know? Of course, my query would apply equally to any other country where someone has already been trained and would emigrate and practice here.

[Slartibartfast]

I understand the number of medical school places in the United States is constrained by the AMA.

I don't understand that, but would like to. Can you provide a cite for this claim?

Perhaps we should make doctors fly on planes piloted by people who have gotten as much sleep as the average medical resident.

That doesn't sound practical, legal or sensible.

But I agree that putting chronically sleep-deprived people in a position where they routinely make life-and-death decisions is probably not sensible, either.

[Anarch]

The last I checked (which was some years ago) was that the problem wasn't a dearth of doctors per se; it was a dearth of GPs. IIRC, we're actually facing a glut of specialists.

[GoodOleBoy]

'The last I checked (which was some years ago) was that the problem wasn't a dearth of doctors per se; it was a dearth of GPs. IIRC, we're actually facing a glut of specialists.'

If this is the case, costs should come down, unless someone is fixing prices.

[GoodOleBoy]

We likely have too many plastic surgeons, allergists, and dermatologists.

[CCDG]

Two years ago I had to change primary care physician because mine quit being one. He had taken a new job as a hospital based GP. When I asked what that was he told me that he would do rounds for all of the doctors in his doctors group so they didn't have to go to the hospital to visit patients, and he didn't have to go to the office. It was much more efficient that way.

I asked what the patients would think about not seeing their doctor and he said it would be much more effective because all their doctor did at the hospital was coordinate between the various specialists and since he would be there all the time he would be better equipped to do that for them.

Again I asked what about them wanting to see their doctor and he looked at me very quizzically and asked for what? I said, so they would feel like the person who understands their medical history etc. is overseeing their care and he shrugged it off and said that all that is in the records.

I never have really cared about my primary care physician since.

[Turbulence]

If this is the case, costs should come down, unless someone is fixing prices.

First, prices are fixed in the sense that we have a cartel that restricts the supply of doctors. Foreign doctors can't practice medicine in the US without passing a grueling set of exams whose difficulty may have more to do with restricting competition than with ensuring physician quality.

But even if that weren't the case, there's no reason to expect costs to come down. Medicare and other insurance companies pay less for time spent with primary care doctors than with specialists. Specialists are people who have sunk a large chunk of time and money into become specialists in the expectation that they will make lots more money than primary care doctors.

Insurance companies cannot pay more to primary care doctors and less to specialists because it is politically infeasible. If they tried, specialists would lobby Congress or start lobbying patients directly. If you think insurance companies are hated now, look what happens when specialists start dropping out of networks because they're not getting paid what the specialists think they're owed.

[GoodOleBoy]

'First, prices are fixed in the sense that we have a cartel that restricts the supply of doctors. Foreign doctors can't practice medicine in the US without passing a grueling set of exams whose difficulty may have more to do with restricting competition than with ensuring physician quality.'

Well, I knew this. My point is that there are many things wrong in the practice of medicine by physicians and hospitals that could be improved for the benefit of the patient populations if the government would stop facilitating the establishment of these obstacles to entry and, instead, do the opposite and facilitate competition. I am certain the same can be applied to the relationships between governments and health insurance suppliers, i.e. that whatever actions are taken usually increase the costs of doing business rather than reduce it.

[wj]

How much influence of the difference in pay between primary care doctors and specialists comes from our system not being set up to value prevention? Primary care doctors are much more likely to look at prevention, whereas specialists almost always are looking at problems after they have occurred. (For that matter, how would you go about putting a value on various preventative medical efforts? I freely admit that I don't have an instant solution either.)

Note that I mean prevention of disease, not prevention of law suits (specifically law suit losses) -- for which we are all set up to spend lots of money on tests that are of marginal use outside a malpractice courtroom.

[russell]

if the government would stop facilitating the establishment of these obstacles to entry and, instead, do the opposite and facilitate competition.

GOB, it's unclear to me which of the various problems here are solved by increased competition, or how exactly it is that competition solves them.

Could you possibly expand this?

[GoodOleBoy]

'GOB, it's unclear to me which of the various problems here are solved by increased competition, or how exactly it is that competition solves them.

Could you possibly expand this?

'First, prices are fixed in the sense that we have a cartel that restricts the supply of doctors. Foreign doctors can't practice medicine in the US without passing a grueling set of exams whose difficulty may have more to do with restricting competition than with ensuring physician quality.'

The above from Turbulence at 2:03 PM.

There are serious barriers to entry to medical practice in the US, by Federal and State governments and universities, mostly due to the political influence of the AMA and other professional groups. State mandates on health insurance companies reduce or eliminate opportunities for competition in offerings among providers of insurance. I think some localities have restrictions on technical capabilities offered by hospitals. Most of these business operations view competition just like most other business people: get the government to get rid of the competition if you can.

[Turbulence]

There are serious barriers to entry to medical practice in the US, by Federal and State governments and universities, mostly due to the political influence of the AMA and other professional groups.

I think you're missing the real problem: voters trust doctors and defer to them. This is what happens when lawmakers propose making it easier to license foreign doctors or reducing Medicare payments to specialists: voters get angry because doctors tell them that doing so will compromise patient care. And most people find doctors a lot more credible than politicians, even if the politicians are right.

But this problem is not limited to the government: private insurance companies have the exact same problem! When private insurance companies in Massachusetts decided that the giant super-fancy hospital network was charging too much money (especially since they weren't doing a better job than other cheaper hospital networks), they were unable to negotiate lower prices. Why? Because the fancy network refused and consumers went crazy at the thought that they wouldn't be able to go to fancy-network doctors. The lesson was learned and now all the big insurance companies have to pay whatever the fancy network demands. The Globe explains here.

State mandates on health insurance companies reduce or eliminate opportunities for competition in offerings among providers of insurance.

I don't recall seeing any of the healthcare economists I've read claim that increasing provider competition by eliminating mandates would reduce healthcare costs. I mean, if you allow insurance companies to make states race to the bottom regarding insurance regulation, you'll end up with the same situation we have for credit card companies and South Dakota: very bad regulations that allow insurers to screw customers. That doesn't actually reduce healthcare costs; it just shifts them to consumers who end up paying for insurance "coverage" that doesn't cover what they think it will and then have to pay out of pocket when they need medical services.

[Chris J]

Full disclosure -- I'm a physician (pediatric critical care, which makes me a subspecialist)

Many commenters make the assumption that standard supply and demand economics applies to medical care. There's a lot of research that shows that it doesn't. Increasing the supply of doctors (and hospital facilities and imaging facilities, etc) actually tends to drive costs up. This was recognized long ago -- I believe in the 1960s. I don't have the cite -- it was preinternet -- but could probably find the seminal paper (by an economist) if folks are interested.

What seems to happen is perfectly understandable to those of us in the biz. Doctors do stuff. It's the stuff we do that drives costs -- and for many of us is how we get paid. If you have twice as many cardiologists, you'll get twice as many cardiac caths. In fairness, this isn't all money-grubbing; it's also just docs doing what docs do. It's also what Americans want. They want us to do stuff.

Nobody really knows what the optimal number of physicians is per unit population. Most pediatricians I know have a panel of anywhere from 2000 to 3000 patients, most of whom are healthy most of the time.

And the AMA does not control either medical school or residency slots. The AMA is getting progressively more toothless -- only about 20-25% of physicians belong these days. I've been a doc since 1978 and I've never belonged.

My solution is to sharply curtail (or eliminate) fee-for-service as the way docs get paid. If the insurance companies are allowed relentlessly to ratchet down what a doc gets paid to see a patient, that doc will usually up the number of patients he or she sees to keep income unchanged. That's not a good thing. Of course I'd prefer single payer, too, and that's a pipe dream. At least until our present nonsystem crashes into a brick wall, which I think it ultimately will.

[Hartmut]

Single payer systems and fee for service are not mutually exclusive.
---
Over here there have been several inept attempts to deal with the problem of doctors 'maximizing' services by increasing the throughput. What we have that works most of the time (except at the end of quarters) is putting a lid on the sum of services (set by the state, not insurance companies). If a doctor exceeds that quarterly budget, he has to either pay out of his own pocket until he can justify the presciptions to the insurer (I hear that is lots of paperwork) or the prescription has to wait until the beginning of the next quarter. Usually doctors are able to calculate how many patients (s)he can take to stay within that limit but patients are often asked to avoid expensive stuff near the end of the quarter so as to leave the doc an emergency reserve.
This system can work well provided the quarterly limit is set reasonably.
Attempts to go into more detail backfired. Imagine this conversation:
Patient: I have terrible pains in my legs and my right hand
Doctor: Since both are broken that seems natural. I can only treat the hand at the moment though because I used up the budget for legs already. My colleague two blocks away had two leg treatments left the day before yesterday. If you run fast, you may be there before he spent them on others. Otherwise I'll have to try to trade my 3 unspent collarbones for a shinbone treatment with yet another colleague and get the insurer and the district to sign off on that. It would of course be easier, if you could come back in 9 days when the new quarter has started.
Patient: Are these the only choices?
Doctor: I never used any of my amputation budget and it may be cut in the near future, if that does not change. Second leg will be even at a discount. Like to try?

[McKinneyTexas]

3,000 patients per doctor? How the hell does one doctor provide good general practice care to 3,000 people? Are there enough doctors in this country?

Depends on how much time the doc spends with the patient. I am guessing not half hour per visit. Maybe 5-8 minutes with a nurse in attendance jotting notes. If you schedule a patient every 15 minutes, that 24 in the morning and another 24 in the afternoon. Lot's of people work 10-12 hour days. No sympathy here on that limited point.

If the price of admission to get from 3,000 people per doctor care to 600 people per doctor care is $1,800 per year, not everyone is going to be able to play.

It's called the market, despite what Dr. Chris says. The docs I know want to make a decent living. Under HCR, as the cost curve is bent downward, fees will be reduced and services curtailed. Will those with the means opt into concierge? Silly question.

It just seems to me that the trend is toward an increasing divide between haves and have nots.

That is exactly what HCR will eventually create, not unlike the UK, with National Health for the proles and private clinics for those with means.

Foreign doctors can't practice medicine in the US without passing a grueling set of exams whose difficulty may have more to do with restricting competition than with ensuring physician quality.

Really, how does one test to limit competition without also testing for higher levels of competence? You want lower levels of competence? Try this out, back when I did a fair amount of medical product liability work, the overwhelming majority of bad docs were third world country trained who passed these exams.

Maybe what we could do is have two exams for docs: the current regimen and Doc-Lite for those who passed the easier exam only. Then everyone who wants to make their political point can go to Doc-Lite. There's a confidence booster ("Doc, I don't know, that mole doesn't look so good to me"--"No, it's ok, I took a two week seminar (pass/fail) in dermatology. You are good to go.")

Young mothers will be especially pleased to have their children treated by Doc-Lites.

Turb's very wrong statement compliments the equally erroneous view that we can 'make' more doctors. Sure, Russell, you are now a doctor, have at it. It takes talent and a very strong work ethic coupled with sustained capacity for gratification deferral.

My internist is thinking about going concierge. I'm all for it. More care at a flat fee. I'll take that deal.

[Turbulence]

Under HCR, as the cost curve is bent downward, fees will be reduced and services curtailed. Will those with the means opt into concierge? Silly question.

Bending the cost curve downwards does not mean that all fees and services will be uniformly reduced. For example, all the provisions in the ACA that are designed to reduce hospital infections will reduce the number of hospital re-admissions; those changes save money but don't detract from useful face time between doctors and patients (unless you really value face time with a doctor whose incompetence caused you to get a multidrug resistant infection which required you to be readmitted to the hospital).

That is exactly what HCR will eventually create, not unlike the UK, with National Health for the proles and private clinics for those with means.

Current American healthcare practices are completely unsustainable. This is not up for debate: healthcare costs have grown significantly faster than inflation for many years and will continue to do so. If you don't like the ACA, that's fine, but everyone should acknowledge that absent major changes in the health care sector, it is going to completely bankrupt the entire country.

Really, how does one test to limit competition without also testing for higher levels of competence?

Easy, just test for knowledge that does not materially improve patient care. I mean, my university rejects most applicants. Does that mean that the top rated people who were rejected are any less qualified than the ones who got in? Of course not. They're almost identical, but since the university needs to cut, they'll find some meaningless filter.

Maybe what we could do is have two exams for docs: the current regimen and Doc-Lite for those who passed the easier exam only. Then everyone who wants to make their political point can go to Doc-Lite.

This is the system we have today. You go to the doctor, deal entirely with a Physician's Assistant or Nurse Practitioner who is "supervised" by a physician that you never see. That's what going to the "doctor" is like for many people. That's what we have right now.

[cleek]

That's what going to the "doctor" is like for many people.

yup. i haven't seen (medically or optically) my actual doctor in many years. instead, i see one of the ever-changing cast of PAs or NPs that work in the office. i don't even know if he still works there. for all i know, i might have been transferred to some other doctor in the practice, who i also never see.

doesn't really matter. as long as they can re-up my prescriptions every 6 months, i don't care who i see.

[Hartmut]

A student of chemistry could easily devise a test that most of his professors would fail (if not allowed preparation) but many students would pass. Question #1: What is the correct order of the rare earth metals? Question #2: What is the standrad enthalpy of formation of the most stable modification of phosphorous?

[Countme-In]

My doctor has a consigleire instead of a concierge.

I ask him to palpate my tumors and he says "Let's you and me go for a ride. You sit in front."

I ask, how much will this cost?

He waves the question away and answers "Let Mr Market decide, shall we. Turn into this clearing over here."

McKT, I would prefer that the cost curve be bent upwards to permit all of us getting the latte with the colonoscopy and the doctors a decent living.

But we're not allowed to raise taxes.

The market has decided there is no deal for lots of people.

RandCare posits less care for more cost. Unless your Ayn Rand, in which case Medicare at the last minute is the parasite's choice. Friedmancare posits little or no licensing or entry requirements to reduce costs.

Under Milton's Chilean scheme, the concierge in my building (I don't have one of those either) could check my moles.

I'll admit your tumors are better than mine, but mine are going to have a fu*king attitude.

[McKinneyTexas]

Easy, just test for knowledge that does not materially improve patient care.

Is the "not" meant to be a part of this sentence?

[Rob in CT]

Chris J - thanks for your perspective. That makes a lot of sense to me. Then again, it would, since I agree with you on both fee-for-service and single-payer.

[Turbulence]

Is the "not" meant to be a part of this sentence?

Yes. The point is: just ask hard questions whose answers don't correlate with improved patient outcomes. I mean, you could ask candidates to recite Gray's Anatomy from memory and then declare that the top 10% of candidates pass. A doctor who has memorized Gray's Anatomy has more "knowledge" than one who hasn't, but it is not knowledge that translates into better patient care.

[Phil]

The docs I know want to make a decent living.

Janitors and secretaries and teachers and grandmothers and file clerks and fast food workers et al., of course, DON'T want to make a decent living, which is why it's OK if they have to go bankrupt when they get sick, right?

It's called the market, despite what Dr. Chris says.

I'll bet you my car that, under an extremely wide set of circumstances, the demand curve for medical care is perfectly cost-inelastic.

That is exactly what HCR will eventually create, not unlike the UK, with National Health for the proles and private clinics for those with means.

And yet, even their proles get better, more efficient coverage and better outcomes. Quelle surprise.

[McKinneyTexas]

The point is: just ask hard questions whose answers don't correlate with improved patient outcomes. I mean, you could ask candidates to recite Gray's Anatomy from memory and then declare that the top 10% of candidates pass. A doctor who has memorized Gray's Anatomy has more "knowledge" than one who hasn't, but it is not knowledge that translates into better patient care.

Turb, the specialists I know well trained hard in their speciality. They weren't asked to name state capitals or recite from rote memory. The training is classroom and practicum oriented, with tons of hours spent following other docs around, watching, learning, etc. That's why our docs are so good. They are. Outcomes are better here, surgery more quickly available with better results, etc.

janitors and secretaries and teachers and grandmothers and file clerks and fast food workers et al., of course, DON'T want to make a decent living, which is why it's OK if they have to go bankrupt when they get sick, right?

Apparently not enough to go through college, med school, residency, etc. Work hard, stay in school longer = better pay. Fact of life.

And yet, even their proles get better, more efficient coverage and better outcomes. Quelle surprise.

Show me a valid longitudinal study of US vs. UK cancer and surgical outcomes, including time from diagnosis to treatment/surgery. The only ones I've seen are cancer related and the US kicks the UK and the rest of Europe in the donkey. My orthopedic buddy has patients from Canada and the UK who fly here and pay good money for surgery today that is either denied or delayed 6-8 months back home. Plus, he's a damn good cutter, so the results are uniformly top quality.

[Turbulence]

Turb, the specialists I know well trained hard in their speciality.

My father in law is a physician who teaches in medical schools and has wrote several books in his specialty. I am quite familiar with the rigors of medical education in the US.

Outcomes are better here, surgery more quickly available with better results, etc.

Cite please?

[McKinneyTexas]

Cite please?

I can't do links, but a quick Google search on cancer outcomes US vs. Europe will support what I said re cancer survival. I found one article on comparative surgery outcomes for cataract surgery where the US came out on top. We don't have valid comparative surgerical stats because it requires docs to self report bad or suboptimal results. Personal experience, i.e. people coming here from Canada and the US for orthopedic surgery implies that the waits are too long. If you google wait times for "elective" surgery, the US wins. I am fairly sure "elective" means something different from boob jobs, more like "non-emergency" such knee replacements, back surgery. One article claimed that after hours care in Europe was more available, but to achieve that result, it excluded US emergency room.

[russell]

It's called the market

Yeah McK, that's the point.

The trend is for market dynamics to make medical care increasingly inaccessible to folks who don't have a lot of money.

Saying "that's called the market" is like saying "that's called gravity" if you're discussing people falling out of tall buildings.

Yes, we know gravity, and the market, are operative. The question is how we address the problems they cause.

Or, at least, since all problems related to accessibility to health care aren't necessarily caused by the market, the question is how we address the problems they fail to address.

If people fall out of windows in tall buildings, we don't stand around with our hands in our pockets saying "that's called gravity". We do something about it.

Outcomes are better here

Some are, some aren't. We pay about twice what everybody else pays for ours.

[Turbulence]

McTex, I've been reading about healthcare economics and international comparisons for years. And my summary is 'what russell said'; on some measures the US is a bit better, on some a bit worse, but given how much money we spend, we're getting really mediocre care. If you want to discuss this in a serious way, I'd suggest you read something a little more focused than a random google search, for example, this series.

[ptl]

My orthopedic buddy has patients from Canada and the UK who fly here and pay good money for surgery today that is either denied or delayed 6-8 months back home. Plus, he's a damn good cutter, so the results are uniformly top quality.

the British ones are insane (my apologies to your buddy), there are very fine orthopaedic surgeons, trained at the top medical schools. in my British city whom I can see on the NHS (with a wait, for an elective op) or privately (quickly). There is no need to pay US-type fees to avoid a wait.

The cancer stats are changing (but the US is still better, though outcomes differ cancer by cancer).

Diabetes? Chronic illness? The UK is better. One theory -- other variables having been excluded -- rests on the greater availability, and use, of NHS primary care.

As for "with National Health for the proles and private clinics for those with means", one of our allegedly A-List celebs was rushed to a top private hospital, then when she proved very ill, transferred to a top NHS hospital. David Cameron's first child, born grievously disabled, was cared for by the NHS. What kind of hospital saved Johnny Depp's child? An NHS Foundation Trust.

[Chris J]

"GOB, it's unclear to me which of the various problems here are solved by increased competition, or how exactly it is that competition solves them."

Yes. As I pointed out upthread, the situation at least for specialty care (which seems to be what Americans want) is that increased access (i.e., more and more docs) drives costs up, not down. Supply drives demand, not the other way around.

Fee market ideology doesn't help us here. We need to know the optimal number of physicians needed per unit population. Much as conservative republicans hate the NHS in Britain, the experience there can at least give us a handle on that question.

Again, if you reward docs financially for doing stuff, they will do more stuff. You could easily improve matters by making the financial reward skew toward not doing stuff -- talking to people, for example -- but the proceduralist lobby among physicians is very, very strong. It has and will prevent Medicare or anybody else from shifting reimbursement from procedure-based specialists to primary care.

[Phil]

Apparently not enough to go through college, med school, residency, etc. Work hard, stay in school longer = better pay. Fact of life.

Wow. I'm speechless. Even if true, somebody's still gotta sweep the f***ing floor and answer the f***ing phones in your law firm offices and ring up your groceries and shine your shoes. Should they go bankrupt because they get sick? Or because their kids get sick? Or because their mothers have strokes? All because they didn't have the good ol' rootin'-tootin' American gumption to become doctors themselves? (Or lawyers, I suppose.)

Yeah, yeah, I know, you're the friggin' Candy Man when it comes to being a boss. Not everyone is like you.

This country is doomed, and it's not because of liberalism, it's because of the glib Dr. Panglosses of the world who think we've got everything pretty much worked out if we can just cut spending to nothing and get the top marginal rate down to about 10%.

[Phil]

I mean, I literally can't think of a word in English to describe how much McKinney's comment disgusts me.

Hey, guess what? Some people are never going to be smart enough to go to college, let alone join the ranks of management.

Some people are going to be permanently constrained by circumstances, some the result of their choices, some not.

Some people work their asses off and bankrupt themselves to go to school but for a variety of reasons find themselves unemployable, or at least have to accept long-term underemployment.

Some people find themselves out of a job late in life and, thanks to our cultural biases against hiring over-40s (let alone over-50s), will never work again.

Some people are caught up in our prison-industrial system's constant urge to criminalize (and especially to felonize) everything and couldn't get a well-paying job if their lives depended on it.

There are poor people. There are always going to be poor people, for all kinds of reasons that have nothing to do with the laziness and lack of ambition you want to assume.

And they need the goddamned doctor just as much as you do.

And your response is to tell them to suck it.

There's not a death painful enough to wish on a person who thinks that way, so I won't even bother.

[Chris J]

"It's called the market"

Yes, it is. And "the market" is an excessively expensive, inefficient, unfair, and immoral way to deliver healthcare. Our ideology prevents us from looking at the situation and devising a system with appropriate expensive and which is efficient, fair, and moral.

[Phil]

The best part is that I bet all these SOBs who think the penalty for being stupid or poor instead of being a Galtian Master of the Universe should be that you don't get to see doctors call themselves "pro-life."

[trevayne]

You know, I have always wondered about those waiting time comparisons. AFAIK they are all based on people who actually get the procedure done. I wonder how the US looks if you include all those whose waiting time stretches to never, because they do not have insurance, make too much to qualify for medicaid, and are too young for medicare.

[CCDG]

"I wonder how the US looks if you include all those whose waiting time stretches to never, because they do not have insurance, make too much to qualify for medicaid, and are too young for medicare."

Or wait so long in other countries they just die. Works both ways.

[hairshirthedonist]

Wait times are relevant to the extent that they affect outcomes. So cut out the middle man and look at outcomes.

[Turbulence]

If you want to learn about how the US compares with other countries in terms of wait times, you can start with this post and the addendum. Basically, compared with peer nations (the G8 minus Russia), the US does better than Canada but generally has high wait times. Plus, the US has fewer doctors per capita than most other countries and significant fewer general practitioners than any other country. This is all very surprising since the US spends much more money on healthcare than these countries; you'd think that for all that money, we'd at least get comparable let alone better stats.

[CCDG]

Turb,

While I can't get to the actual data behind some of the graphs, the abstract says it is survey data based on insurannce experience? So on wait times I am unconvinced.

Even though the graphs in the addendum only have the US behind SWI and Ger in wait times to see a specialist. The longer wait times issue, going back to the IIRC standard, was with various testing as opposed to seeing doctors.

[Turbulence]

While I can't get to the actual data behind some of the graphs, the abstract says it is survey data based on insurannce experience? So on wait times I am unconvinced.

If you find the data available to be inadequate, then you'd be justified in saying 'we cannot say anything about whether wait times in the US are better or worse than in peer nations'. In that case, logical consistency would require you to disbelieve McTex's claims about wait times. After all, he could only cite a google search while I presented a health care economist who cited published research.

The longer wait times issue, going back to the IIRC standard, was with various testing as opposed to seeing doctors.

Ah, OK then. I'll consider that goalpost moved.

[CCDG]

Closer or further away?

I'm ok with McTex needing more detail also.

[Chris J]

I'm with Hairshirt -- I'd like see a comparison of wait times vs outcomes. That's what matters, but I can't see how we can even get the data.

I would assume wait times relate most closely to access. But in the US "system" that metric is so clouded by other things, such as in network, out of network, need for a referral, geographic location, that I don't know how anything like an average waiting time could be calculated meaningfully.

[Hartmut]

[snark] Are the mandatory waiting periods for abortions included in the statistics[/snark]
Btw, it's an decades old joke that pregnancy tests take on average 9-10 months to be processed.

[McKinneyTexas]

After all, he could only cite a google search while I presented a health care economist who cited published research.

Turb, I read the ten articles you linked to. First, the writer is not a health care economist. Second, at first blush, his stats are internally contradictory in many, many ways. For example, although we have less beds and doctors, we have many, many more out patient surgical procedures. We have many, many more high end diagnostic machines, yet countries with considerably fewer manage to diagnose and treat at a faster rate? Another issue: the author counts hospitals and beds without defining either. Why isn't an outpatient surgical center a hospital and why aren't its beds counted? Another fault, among many, is that the author disallows ER's in considering the availability of after hours care and treatment, with the result that the US scores lower. Why is this a valid alteration in metric? Finally, the issue of wait times, outcomes and the elastic meaning of "elective" surgery. What we learn from the study is that no one in any country considered has to wait appreciably for 'emergency' surgery. The default category seems to be 'elective', which includes most procedures that are medically necessary to treat an existing, usually painful if not debilitating condition, e.g. hip replacement. I did not see any valid numbers--but if I missed them, please point them out--comparing wait times for diagnosis (less MRI machines, more time to stand in line for limited use) and treatment of non-life threatening conditions between the US and Europe/Canada/Australia. Nor did I see comparative data on outcomes.

[russell]

Why isn't an outpatient surgical center a hospital and why aren't its beds counted?

I can speak to this one.

My wife had her gall bladder removed last month. Laparoscopic procedure, outpatient surgery, 2-3 hours post-op recovery at the surgical center, then home with a fistful of Vicodin.

She had an unusual reaction to the surgery, and experienced an extreme amount of pain. By "extreme" I mean writhing around in bed trying to find a position in which she could rest without experiencing pain that the Vicodin did not make a dent in.

After about 24 hours of this, we called the surgeon. He saw her the next AM, and immediately admitted her to the hospital.

48 hours of morphine drip + hands-on nursing care and she was fine.

The difference between an outpatient surgical center and a hospital is that the latter has staff who can make a good real-time assessment of your recovery, who are trained in how to physically handle people post-op to minimize their pain and discomfort, and who have access to medications and practices that will speed and ease the recovery process.

Unlike spouse-who-is-taking-the-day-off-to-try-to-be-helpful.

I have similar stories from other family members who have had surgery and other bigger-than-a-breadbox procedures under both the hospitalization vs send-you-home-with-some-meds approaches to recovery.

If you think all of this is irrelevant to outcomes, I beg to differ.

[Slartibartfast]

I keep thinking that what this post needs is pictures. But that's just my quirky sense of humor at work, I think.

[Turbulence]

the writer is not a health care economist.

My apologies; most of the posts at TIE are by Frakt who is a healthcare economist. On the other hand, the series was written by Carroll who, while not being a healthcare economist, seems to have pretty good qualifications:

Aaron E. Carroll, MD, MS is an associate professor of Pediatrics and the associate director of Children’s Health Services Research at Indiana University School of Medicine. He is also the director of the Center for Health Policy and Professionalism Research. He earned a BA in chemistry from Amherst College, an MD from the University of Pennsylvania School of Medicine, and an MS in health services from the University of Washington, where he was also a Robert Wood Johnson Clinical Scholar.

For example, although we have less beds and doctors, we have many, many more out patient surgical procedures.

I don't see a contradiction here. One reason the US has lots of outpatient surgical centers is that they're more profitable compared to hospitals: fixed costs are a lot lower and you can offer "services" that you know to be most profitable. That's great in a business sense but not necessarily great for community health or systemic efficiency.

We have many, many more high end diagnostic machines, yet countries with considerably fewer manage to diagnose and treat at a faster rate?

That's not quite true: Japan has significantly more than us. As to the apparent contradiction, I can offer you a guess: the US has a lower population density than many peer nations, so that might require lots of fancy diagnostic devices that must sit idle. I mean, a major hospital in a rural county can't just tell people "you have to spend eighteen hours traveling in order to get an MRI", but they might not have enough cases on hand to keep their own MRI utilized.

Why isn't an outpatient surgical center a hospital and why aren't its beds counted?

Hospitals have to fulfill certain requirements. Outpatient surgical centers do not have to fulfill those same requirements. Wikipedia explains some of the requirements here. Outpatient surgical clinics are generally open for limited hours; they don't typically have many medical specialists available and they generally lack sophisticated imaging and lab functions. If you suffer a major accident, the EMTs will bring you to a hospital rather than an outpatient surgical center because the outpatient center (if it is even open) doesn't have the staff and facilities needed to keep you alive.

Also, I'm not just talking about medical requirements. Hospitals in the US are expensive to build and run because they're designed to withstand earthquakes much more than other buildings. They're required to have redundant power and water. This isn't cheap, but it is necessary because you really really don't want your hospital to stop functioning during a natural disaster.

[Amanda]

Do we make it easy for medical practitioners from Mexico to come to the US and set up medical practice? Does anyone know?

No, it is not easy. It is lengthy, expensive, and complex. Internationally-trained MDs must undergo a multi-step process of application, examination, *and a residency*. It takes at least 3-5 years to become licensed again in the US, and often more for specialists.

Reasonable people can disagree on the appropriateness of each of these requirements. Certainly we want any doctors practicing in the US to be competent, both linguistically (able to speak English with their colleagues and patients) and professionally.

How that competence is determined, and whether it should include an additional residency period even for doctors who have been practicing for years in their home countries, could be a matter of debate.

At present, it is largely not debated, at least as a matter of policy. International medical graduates are all funneled through a single agency (Educational Commission on Foreign Medical Graduates) and often languish without license to practice because there are limited residency slots available for US- and internationally-trained doctors alike.

[Countme-In]

Consider this:

http://allbleedingstops.blogspot.com/2011/04/why-patients-are-not-consumers.html

Cut and paste, please, with my apologies.

[Countme-In]

Medical concierge services for some, to which I would have said "more power to them" not too awfully long ago when the social contract was still operative.

But now Idaho Governor Butch Otter is proposing genocide for his state's Medicaid patients.

The death of the social contract will cut both ways.

[russell]

The death of the social contract will cut both ways.

That is a fact, Jack.

Why should people be concerned about what happens to their neighbors?

Because you are going to have to live with them. That's why. When people start dying, all kinds of rubber are going to meet the road.

Societies do fall apart. We're not only not immune, we've come damned close, more than once. It's no joke.

[GoodOleBoy]

'How that competence is determined, and whether it should include an additional residency period even for doctors who have been practicing for years in their home countries, could be a matter of debate.

At present, it is largely not debated, at least as a matter of policy. International medical graduates are all funneled through a single agency (Educational Commission on Foreign Medical Graduates) and often languish without license to practice because there are limited residency slots available for US- and internationally-trained doctors alike.'

If the US is having difficulty getting enough medical practitioners in the needed specialties and geographical service areas, does not our current practice with respect to allowing qualified professionals from other countries to emigrate and set up practice here work against solving that problem?