Do we have enough medical training for UHC?

[Ludovic]

Assume for a moment that we pass single-payer, truly America-wide universal health care in the USA. This means that all of the currently uninsured will suddenly become effectively insured, and thus be able to be treated. Which will increase the total amount of health care provided in America.

If we have enough personnel to provide it, that is! I don't see any underemployed physicians and skilled nurses and technicians hanging around doing nothing. So I don't think we have an oversupply of these currently, so any truly universal plan would have to take into account the training of massive amounts of medical personnel.

Would the current medical training capacity be enough to train the new physicians and other personnel that would be required under the greater demand for medical services? Or would we have to open -- and accredit -- new schools for this purpose? Would we even be able to accredit new schools in time to get qualified personnel in the pipeline in time to provide the care that all Americans need?

I forsee this as being even more important than who pays whom for what, because if the supply is simply not there it doesn't matter how much you are willing to pay for it (if it takes a fixed amount of lead time, around 6 years or so if not more, to provide the supply.)

[gonzomax]

Our medical schools restrict students from medicine. A kid I play rackeball with waited for over a year to get in. He was rejected the first time and he graduated college with a high GPA. His dad is a dentist. He thought the first year was tough. the second a lot easier.

[Johnny L.A.]

Most people don't go to a doctor for fun. I have insurance, and I can't remember the last time I went to one. Sure, there will be people who will get the treatment they need; but I don't think demand will outstrip supply. If it does, it solves another problem: unemployment. If more nurses are needed, then there will be people who will fill the positions.

Do we have an oversupply of nurses? It depends on who you ask. Some nurses find it very difficult to find a position. A friend has been a nurse for over a dozen years, and nobody in Seattle was hiring. Roomie has been a nurse for one year. She got a position at a rehab place. But they were quite understaffed and it was easy to get a job there. With UHC, I suspect that the places that are understaffed would be more willing to hire more nurses.

I know the OP ask specifically about doctors, but many people don't need doctors to treat them.

[Sage Rat]

From statistics that I've seen, the US has an equivalent number of doctors, nurses, and hospital beds per capita as any other modern nation. Since those other nations do have universal health care, and seem to be handling it, yes, we factually have the manpower.

http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT

This makes sense since we do have universal health care already -- every hospital has an emergency room, and there are free clinics everywhere. We just don't have official universal health care. Not that the distinction matters greatly so far as most debates go.

[USCDiver]

There are nowhere near enough primary care providers for everyone who wants one right now, much less when everyone has insurance. The total number of doctors may be adequate right now, but not enough are going into primary care fields, partly because the pay is lousy compared to the amount of training and debt required. When I was in medical school we ran the numbers for a solo doctor in a primary care clinic estimating overhead costs etc and it came down to something like 40 patient's per day for the doctor to take home $85k. Economies of scale can work to some extent with multiple providers under one roof, but in the end, you can still only spend about 10-15 minutes with each patient regardless. Not too many doctors want to work in that kind of environment for that kind of pay.

[USCDiver]

This makes sense since we do have universal health care already -- every hospital has an emergency room, and there are free clinics everywhere. We just don't have official universal health care. Not that the distinction matters greatly so far as most debates go.

This is a simplified, naive and inaccurate description of our current health care system. There are millions of uninsured/uninsurable patients who do not have access to ANY health care outside of the ER where they are not getting the preventative or primary care expertise they require. I am trained to manage the stroke you had from uncontrolled hypertension, but I am not trained to manage your chronic hypertension to prevent that stroke in the first place.

USCDiver, MD
Emergency Physician

[Sage Rat]

who do not have access to ANY health care outside of the ER
That's...what I said?

[Sage Rat]

Couldn't edit in time:

I made no aspersion that ER is a good system, just that it employs a significant number of physicians -- who would presumably be moved over from emergency medicine to preventative if our system changed. That would require retraining time, but we do have the physical manpower to swing into place quickly.

Your point that people are uninsured isn't very meaningful. Personally, I would rather have unlimited, entirely free, highest quality health care than health insurance. That's not practical of course, but that doesn't mean that a good universal health care system relies on an insurance scheme. (Probably it will, but that's just limiting your thinking to approach the question from that angle.)

[Raskolnikov]

doesn't matter b/c it will never happen. Our "liberal, socialistic" President just passed the republicans sloppy seconds counteroffer from the 1994 debate.

[hogarth]

Note that universal health care countries like Canada and England tend to have waiting lists for non-essential surgeries, for instance. So it might be a matter of doing more serious operations and letting the less essential stuff slide for a while.

[Sage Rat]

Note that universal health care countries like Canada and England tend to have waiting lists for non-essential surgeries, for instance. So it might be a matter of doing more serious operations and letting the less essential stuff slide for a while.
The number of actual elective surgeries in the US is lower than the number performed in other countries, with official UHC.

http://www.oecd.org/dataoecd/31/10/17256025.pdf
http://www.nationmaster.com/graph/hea_pla_sur_pro_percap-plastic-surgery-procedures-per-capita

You would need to compare the elective surgery count to the numbers of doctors in the nation to determine whether freeing up manpower from elective surgeries would be particularly meaningful.

[Broomstick]

When I was in medical school we ran the numbers for a solo doctor in a primary care clinic estimating overhead costs etc and it came down to something like 40 patient's per day for the doctor to take home $85k. Economies of scale can work to some extent with multiple providers under one roof, but in the end, you can still only spend about 10-15 minutes with each patient regardless. Not too many doctors want to work in that kind of environment for that kind of pay.
But Og bless the ones who do.

I think an erroneous assumption the OP is making is that the first day UHC is instituted you will NOT see every potential patient in the US show up at a doctor's office for a checkup. There are plenty of people with health coverage who delay and delay going to a doctor.

[Der Trihs]

Note that universal health care countries like Canada and England tend to have waiting lists for non-essential surgeries, for instance. So it might be a matter of doing more serious operations and letting the less essential stuff slide for a while.As opposed to our system, where for many people only immediately lifesaving procedures that an ER can handle are done and long term problems (including fatal ones) aren't ever fixed. It's not like we don't already have rationing, and more of it than most countries would put up with.

[Sateryn76]

I think the problem will not be a lack of training facilities, but a lack of people who want to give up that many years of income, work that hard and incur that much in loans to earn what they would under a UHC system.

As stated above, PC doctors are already lacking, and many more are starting to drop Medicare/caid patients because of the awful reimbursement rate.

Do we have any estimates of what the service compensation would be under UHC?

[John Mace]

Our medical schools restrict students from medicine. A kid I play rackeball with waited for over a year to get in. He was rejected the first time and he graduated college with a high GPA. His dad is a dentist. He thought the first year was tough. the second a lot easier.

And one time, in band camp..

As for the OP, if you take any large system, like the US health care system and radically change its structure overnight, how could you not have a short term under-supply of some things and over-supply of other things?

[USCDiver]

Couldn't edit in time:

I made no aspersion that ER is a good system, just that it employs a significant number of physicians -- who would presumably be moved over from emergency medicine to preventative if our system changed. That would require retraining time, but we do have the physical manpower to swing into place quickly.

Your point that people are uninsured isn't very meaningful. Personally, I would rather have unlimited, entirely free, highest quality health care than health insurance. That's not practical of course, but that doesn't mean that a good universal health care system relies on an insurance scheme. (Probably it will, but that's just limiting your thinking to approach the question from that angle.)

I think we are on the same side here. I inferred from your earlier post that you felt the current system of "universal" healthcare (ie "just go to the ER" as GWB said) is adequate which I think everyone agrees is not.

Your second point about retraining ER docs may be little shortsighted though. Every estimate I've seen anticipates increased ER volumes with more insured patients. We won't be scaling back our staff anytime soon. Also I specifically chose do to ER medicine because I did not want to do primary care. I don't think you are going to find too many emergency physicians willing or able to jump ship like that.

[Simplicio]

There are nowhere near enough primary care providers for everyone who wants one right now, much less when everyone has insurance. The total number of doctors may be adequate right now, but not enough are going into primary care fields, partly because the pay is lousy compared to the amount of training and debt required. When I was in medical school we ran the numbers for a solo doctor in a primary care clinic estimating overhead costs etc and it came down to something like 40 patient's per day for the doctor to take home $85k. Economies of scale can work to some extent with multiple providers under one roof, but in the end, you can still only spend about 10-15 minutes with each patient regardless. Not too many doctors want to work in that kind of environment for that kind of pay.

Which is why the ACA included several provisions to increase the number of Primary Care Doctors (primarily by paying them more and giving Med school aid to Med students dependant on their practicing Primary Care for X number of years).

[Jackmannii]

UHC + not enough doctors = massive importation of foreign MDs. If you're a forward-thinking patient you'll learn another language (you don't want to waste time explaining that no, you don't need a prescription for hay fever, you're having a baby. Your best bets are probably Hindi, Urdu and Chinese.

[Implicit]

I think the problem will not be a lack of training facilities, but a lack of people who want to give up that many years of income, work that hard and incur that much in loans to earn what they would under a UHC system.

As stated above, PC doctors are already lacking, and many more are starting to drop Medicare/caid patients because of the awful reimbursement rate.

Do we have any estimates of what the service compensation would be under UHC?
Probably the same as it is now. Under a universal health care system Canadian doctors make pretty much the same as their US counterparts.
In general, the income differences between U.S. and Canadian physicians are not vast. Subspecialists do make less money in Canada, although they are still earning high salaries; additionally, primary care physicians are actually making more money in Canada than in the U.S., a force that might help cut down on this country’s current shortage of primary care doctors.link (http://student.pnhp.org/content/what_about_physician_salaries.php)

[cerberus]

One trend may be to shift routine care to PAs and APRNs under supervision of MDs.

In practice, what you can more easily see are PAs and nurses now anyway.

[Wesley Clark]

We have about 50 million uninsured with another 50 million underinsured in the US. On top of that medicaid pays such low rates that the 40-50 million who have that can have trouble finding doctors who will accept it. So over half the country has issues with medical access. Plus even if you have a good private plan, there is no guarantee they won't throw up as many roadblocks as possible if you try to get medical care.

Having said that, primary care is cheap. Even when I am uninsured, I am always able to find an MD or NP who would offer me primary care for $100 or less per visit.

I believe we have a shortage of primary medical professionals. But our system seems to really put up roadblocks in front of more than half of the country when it comes to access to medical care, so arguably nearly half the country isn't getting the quantity of care they/we might want otherwise if we had a system more like what they have in Europe.

[Wesley Clark]

UHC + not enough doctors = massive importation of foreign MDs. If you're a forward-thinking patient you'll learn another language (you don't want to waste time explaining that no, you don't need a prescription for hay fever, you're having a baby. Your best bets are probably Hindi, Urdu and Chinese.

There are tons of qualified applicants in the US who would make fine doctors but there is a cap system on how many the med schools will accept and how many residencies there are. So I don't see why importation is necessary if we need more physicians. Just lift the cap a bit.

Plus you have the moral issue of brain drain, drawing medical professionals from poor parts of Africa and Asia to work in the US. There are supposedly more Ethiopian physicians in Chicago than Ethiopian physicians in Ethiopia. With remittances maybe they can support their family, but you have to question pulling physicians out of a country with such major health problems so they can cater to a nation that already has a high level of medical care.

[artemis]

There are tons of qualified applicants in the US who would make fine doctors but there is a cap system on how many the med schools will accept and how many residencies there are. So I don't see why importation is necessary if we need more physicians. Just lift the cap

Increasing the class sizes of US medical schools (or building new schools) will cost more money than allowing foreign MDs to immigrate here. Guess which approach a system primarily concerned with controlling healthcare costs is likely to prefer?

[flickster]

I think the problem will not be a lack of training facilities, but a lack of people who want to give up that many years of income, work that hard and incur that much in loans to earn what they would under a UHC system.

As stated above, PC doctors are already lacking, and many more are starting to drop Medicare/caid patients because of the awful reimbursement rate.

Do we have any estimates of what the service compensation would be under UHC?

Valid point - fewer and fewer family care doctors will accept Medicare patients as it is.

Another consideration....how many senior/highly experienced doctors will decide time has come to just hang up the stethoscope rather than provide care under a UHC system?

[Asympotically fat]

I think there's already enough doctors in the USA for UHC. If you look at the 'phyusician density' in the US it's pretty simalir to many other Western coutnries which already have UHC. For example Canada actually has a slightly lower physician density than the USA.

[Asympotically fat]

I think the problem will not be a lack of training facilities, but a lack of people who want to give up that many years of income, work that hard and incur that much in loans to earn what they would under a UHC system.

As stated above, PC doctors are already lacking, and many more are starting to drop Medicare/caid patients because of the awful reimbursement rate.

Do we have any estimates of what the service compensation would be under UHC?

In the UK medicine is the hardest course to get on at university, due tot he number of people who want to do it.

A doctor in UHC has a gu\ranteed very good income and whilst they might not earn the mega-bucks that are possible in private healthcare (though remember UHC does not mean that private healthcare does not exist in parallel), it's still worth the time.Plus I think it's wrong to think purely about money, if you're purely motivated by money you're not suited to medicine anyway.

[flickster]

I think there's already enough doctors in the USA for UHC.

Based on the lead time already required to make an appointment to see one, I have to disagree. But I guess I'm old hat in wanting to see the same doctor every time instead of just going to the Concentra type drop-in clinic and take your chances.

[WhyNot]

Do we have enough medical training for UHC? No, probably not. But that's okay, because we don't have enough medical training in some areas (http://www.cadenagramonte.cu/english/index.php?option=com_content&view=article&id=6524:lack-of-doctors-in-us-rural-areas&catid=3:world&Itemid=14)for the system we have now. No matter what happens with the economics and politics of health care in this country, we've got to address the PCP (http://money.cnn.com/galleries/2009/news/0907/gallery.healthcare_nurses/index.html)gap sooner or later. And, as already mentioned, Physician Assistants and Advanced Practiced Nursing (http://www.reuters.com/article/2010/10/05/usa-nursing-idUSN0518768220101005)are on the rise, precisely because there aren't enough GP's and FP's with MD's to go around.

The debate over whether or not there's a nursing shortage still going on is hot, and it really depends on how you define "shortage". When I decided to go to nursing school 5 or 6 years ago, there was no doubt that there was a shortage - new graduate nurses were being given ridiculous signing bonuses because nurses were in such high demand and they just needed people with a pulse on the floor. Now...not so much. But it's not because there's a glut of nurses and the hospitals don't need to hire more - they do need to hire them. But they have no money to pay them. Nearly all of the hospitals around here still have some form of hiring freeze or extreme slow down, despite the need for more nurses. And it's even worse for new graduate RNs, who are, for once, experiencing the same "I need experience to get a job, but I need a job to get experience!" dilemma that other fields see. I've had no nibbles on my applications so far. Even knowing someone doesn't always help; one of my RN friends has been begging me to apply at her ER because they're short 6 nurses. I did, and now her manager is telling her, "Look, I'm not hiring any new grads anymore. They come, they get their year of ER training and experience and they quit. I can hire an experienced nurse, and she'll probably quit in a year, too, but I won't have to pay to train her."

Why are more experienced RN's looking for work now than were 6 years ago? Many of them have been retired or semi-retired or working Registry for the last 10 years, and now have to look for full time work as their spouses are laid off or their retirement investments tanked.

So...the answer to the question in the OP is not a simple one, and it doesn't have to do only with medical training and UHC, but with our current economic crisis, as well. Nurses and doctors do not work and live in a vacuum.

[The Flying Dutchman]

Assume for a moment that we pass single-payer, truly America-wide universal health care in the USA. This means that all of the currently uninsured will suddenly become effectively insured, and thus be able to be treated. Which will increase the total amount of health care provided in America.

If we have enough personnel to provide it, that is! I don't see any underemployed physicians and skilled nurses and technicians hanging around doing nothing. So I don't think we have an oversupply of these currently, so any truly universal plan would have to take into account the training of massive amounts of medical personnel.

Would the current medical training capacity be enough to train the new physicians and other personnel that would be required under the greater demand for medical services? Or would we have to open -- and accredit -- new schools for this purpose? Would we even be able to accredit new schools in time to get qualified personnel in the pipeline in time to provide the care that all Americans need?

I forsee this as being even more important than who pays whom for what, because if the supply is simply not there it doesn't matter how much you are willing to pay for it (if it takes a fixed amount of lead time, around 6 years or so if not more, to provide the supply.)

What a timely question.
I just caught this bit of news about a University of Toronto study (http://www.torontosun.com/2011/08/05/us-health-care-system-less-efficient-study) on the Google News Summary this morning.



In Canada, most health costs are covered under provincial medical plans, which means that most of the time, there's just one payer to deal with.

In the U.S., every patient pays differently, either individually or through health insurance, and each health-insurance company has its own policies for billings and submissions. The paperwork associated with payment can pose a huge burden....

..."Something that often isn't said is that physicians in Canada do spend a lot of time with their patients because they don't have to deal with these administrative problems, and I think that is a benefit of working within the Canadian system."...

..."If you think about it, clinicians, physicians and nurses are best suited to actually provide care to patients," said Morra. "What we found in the U.S. was that actually a significant amount of time spent is spent not dealing with patient care or health issues, but rather just dealing with paperwork associated with multiple different insurance companies."....

...What's more, nurses and medical assistants in the U.S. spend 20.6 hours per week on administrative duties associated with payers and health insurers, whereas in Ontario, that work amounts to just 2.5 hours....

-bolding mine to point out that if the US goes to single payer, doctors will have more time for their patients.

[Really Not All That Bright]

UHC + not enough doctors = massive importation of foreign MDs. If you're a forward-thinking patient you'll learn another language (you don't want to waste time explaining that no, you don't need a prescription for hay fever, you're having a baby. Your best bets are probably Hindi, Urdu and Chinese.
We already have massive importation (http://immigrationpolicy.org/sites/default/files/docs/Critical_Care.pdf) of foreign MDs, and it's pretty fucking crass to pretend they don't speak English, especially for someone like you who is already in the industry.

[Asympotically fat]

Based on the lead time already required to make an appointment to see one, I have to disagree. But I guess I'm old hat in wanting to see the same doctor every time instead of just going to the Concentra type drop-in clinic and take your chances.

Living in a country with approximately the same number of doctors per head and UHC I have to disagree. I've seen the same doctor (the only exceptions were when he was on holiday and I wanted to see another doctor) for the last 28 years and I can usually arrange an appointment for the next day.

I honestly don't see what the debate is here, there's no real disparity between the USA and many other western countries with UHC in terms of the number of doctors per head. Are there enough doctors in the USA for UHC? - Yes.

[Raskolnikov]

I think the problem will not be a lack of training facilities, but a lack of people who want to give up that many years of income, work that hard and incur that much in loans to earn what they would under a UHC system.

As stated above, PC doctors are already lacking, and many more are starting to drop Medicare/caid patients because of the awful reimbursement rate.

Do we have any estimates of what the service compensation would be under UHC?

seriously? doctors in Britain make more than their American counterparts,

oh, and they're not government employees either

and there is "private insurance" in countries like Britain and Germany etc as well

the awful reimbursement rate is b/c Medicare doesn't think a 10 minuet MRI is "worth" $1,500

UHC + not enough doctors = massive importation of foreign MDs. If you're a forward-thinking patient you'll learn another language (you don't want to waste time explaining that no, you don't need a prescription for hay fever, you're having a baby. Your best bets are probably Hindi, Urdu and Chinese.

my Indian doctor speaks perfect english, it is after all the language of most university and business in India

[Really Not All That Bright]

seriously? doctors in Britain make more than their American counterparts
No, they don't, and I can speak with some authority here since both parents have practiced medicine in the US and UK.

General practitioners earn significantly more in the UK, at least under the Primary Care Trust system. However, specialists in almost every field earn significantly less.

[Broomstick]

You know what? I'd be totally OK with that - we should be paying our primary care docs more to make that specialty more attractive, because we need more of them. Paying the specialists a little less, and making those areas just a bit less attractive, might also help tip the balance.

[The Flying Dutchman]

my Indian doctor speaks perfect english, it is after all the language of most university and business in India

I believe you, but can you understand exactly what he is saying given that Indian accent ?

[Broomstick]

I've had probably a half dozen Indian doctors over my life. The only time I ever had trouble understanding their English was when I was 6 and unfamiliar with the accent. I just don't perceive it as a problem.

Now, my current doctor, who is Indian, has English writing I can't distinguish from Sanskrit. That could be a problem, except it's the pharmacist who has to read the Rx, not me, and she seems to manage fairly well.

[Sateryn76]

In the UK medicine is the hardest course to get on at university, due tot he number of people who want to do it.

A doctor in UHC has a gu\ranteed very good income and whilst they might not earn the mega-bucks that are possible in private healthcare (though remember UHC does not mean that private healthcare does not exist in parallel), it's still worth the time.Plus I think it's wrong to think purely about money, if you're purely motivated by money you're not suited to medicine anyway.


Do UK doctors have the same student loan burden when they graduate?

Not everything is about money, but I'd he wary of the skills of a doctor who incurs $200k in debt for an $80k yearly salary.

[clairobscur]

A doctor in UHC has a gu\ranteed very good income and whilst they might not earn the mega-bucks that are possible in private healthcare (though remember UHC does not mean that private healthcare does not exist in parallel), it's still worth the time..

Just to note that this is only true for the particular UK system of UHC. French doctors don't get paid (except in public hospitals, obviously), they're private practitionners.

It's good to remember that different countries have very diffferent UHC systems, although most people in the USA think of the British and Canadian model, since those are the countries they're the most familiar with.

[clairobscur]

Now, my current doctor, who is Indian, has English writing I can't distinguish from Sanskrit.


Mastering this secret ritual writing language is a requirement for medical license in all countries I've ever heard about. ;)

[Asympotically fat]

Do UK doctors have the same student loan burden when they graduate?

Not everything is about money, but I'd he wary of the skills of a doctor who incurs $200k in debt for an $80k yearly salary.

You'd really need someone who knows the intricies of UK medical education and it's fnding to know the exact situation, but suffice to say certainly it is not that way.

Only the very brightest and hardworking people in the UK can do a medicine degree in the UK. You need near-perfect grades to even stand a chance.

[The Flying Dutchman]

Just to note that this is only true for the particular UK system of UHC. French doctors don't get paid (except in public hospitals, obviously), they're private practitionners.

It's good to remember that different countries have very diffferent UHC systems, although most people in the USA think of the British and Canadian model, since those are the countries they're the most familiar with.

My Canadian doctor bills the government insurance provider for each and every visit just like a US doctor bills his host of insurance providers. He's not on any salary if that's where you are going with this.

[Really Not All That Bright]

Neither are most NHS providers. Way, way back (ending in about 1970 I think), doctors were employed directly by the NHS. Nowadays, medical practices are private enterprises, and the practice gets paid per patient by the NHS.

It's a very equitable system; patients choose their doctors, and if too many people choose the same doctor the level of patient care drops and some patients will go to other doctors with more capacity.

[clairobscur]

Neither are most NHS providers. Way, way back (ending in about 1970 I think), doctors were employed directly by the NHS. Nowadays, medical practices are private enterprises, and the practice gets paid per patient by the NHS.


But if I'm not mistaken, they're paid by patient, not per visit. So, the doctor will receive the same payment for a registered patient who never visits him and for a registered patient who comes every other day.

Or am I mistaking the UK system for some other country's?



(For the record, in France, you pay for your visit and are reimbursed later by the UHC system)

[Really Not All That Bright]

Well, that's no longer strictly true, thanks to a 2006 overhaul which rewards GPs for taking measures to get patients to come in (community awareness, leafleting and so on), but for the most part you're right.

I guess I don't understand what you mean by "French doctors don't get paid", though.

[alphaboi867]

There are tons of qualified applicants in the US who would make fine doctors but there is a cap system on how many the med schools will accept and how many residencies there are. So I don't see why importation is necessary if we need more physicians. Just lift the cap a bit...

Is there anything from stopping an individual state from saying "Screw the AMA" and just coming up with their own standards for residencies and licencing foreign MDs to practice? I mean obviously these doctors would run into issues moving out-of-state, but other than that.

We already have massive importation (http://immigrationpolicy.org/sites/default/files/docs/Critical_Care.pdf) of foreign MDs, and it's pretty fucking crass to pretend they don't speak English, especially for someone like you who is already in the industry.

...my Indian doctor speaks perfect english, it is after all the language of most university and business in India

Isn't medical school in India conducted entirely in English?

...I guess I don't understand what you mean by "French doctors don't get paid", though.

He means that French doctors are paid by the patient and the government reimburses the patient; it doesn't pay the doctor directly like in the UK.

[Really Not All That Bright]

Oh. I get it now. :smack: