Why have doctors been given a pass in the healthcare debate?

[brickbacon]

Most of the coverage of this issue seems to (deservedly) talk about how badly the public is being fleeced by lawers, Pharma, and big insurance companies, but the doctors get a pass. Why is that the case considering doctors are just as culpable. Consider the following:

I. 100k people die every year from infections picked up in a hospital. Obviously, not all of these death are avoidable, nor should they all be blamed on doctors, but there is culpability there. Keep in mind that fighting these infections costs between 4-29 billion anually, not including the resulting lawsuits and legal fees.

The most glaring example is the story of Peter Pronovost. This doctor created a simple list of things doctors should do to dramatically reduce the number of infections.

In the 2003 Michigan study called the Keystone Initiative these infections dropped at a typical ICU from 2.7 per 1,000 patients to zero. The Keystone Initiative published its results in the December, 2006 New England Journal of Medicine.[8] In the first three months of the project, the infection rate in Michigan’s ICUs decreased by sixty-six per cent. In the Initiative’s first eighteen months, they estimated that 1500 lives and $100 million were saved. These results were sustained for almost four years.[4]

Looking for a reason why these protocols have not been instituted everywhere? The common reasons researchers give are the following:

1. Many physicians do not like being monitored by nurses or otherwise being forced to follow a checklist;

2. A wish to avoid standardized tasks and bureaucracy; and

3. A focus by researchers on "more exciting" issues such as disease biology and new treatment therapies

In response to much of what's listed above, Pronovost said the following:

The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is ensuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.

So we are wasting billions of dollars, and killing people because doctors don't like being told to follow a checklist.


II. Pharma essentially bribes doctors to prescribe medicine. We only hear about the most egregious examples, but the subtle influence is there. Even JAMA says doctors should stop accepting bribes. Drug companies spend 13k per doctor per year to influence their habits (20+ billion/year). This is all reflected in the costs of medicine to the consumer. We subsidize their dinners and golf outings, and in many cases, are told to get drugs and treatments that are less effective or unnecessary. JAMA said, "doctors in teaching hospitals should lead the way in refusing to take gifts from the pharmaceutical and medical device industries, because it damages the reputation of the profession".

III. Doctors are often crappy business men who offer really crappy customer service. I can do almost everything online, except make an appointment at my doctor's office. I get there at the scheduled time; I wait, then I go to wait in a smaller room. There is almost no adherence to the schedule.

Many still give sloppy, hand-written prescriptions that often create more work and confusion. Why has their customer service not advanced at the same rate. Why aren't their records computerized in a uniform fashion?

Doctors also haven't done much to collectively lower their overhead. Many complain about how they must hire people to bicker with insurance companies all day just to get paid. However, I don't see many of them trying to streamline the process through collective bargaining. In states where there are multiple insurers, why don't doctors collective bargain so that they have more power than any one insurance company?

IV. Doctors (via the AMA, et al.) limit their numbers. They even stopped opening medical schools for years because they thought there would be too many doctors. Why shouldn't the market decide? Furthermore, they don't discipline the bad doctors. About 5% of all doctors account for 54% of malpractice payouts. Only 8% of doctors (1 out of 12) with 2 or more malpractice payouts have been disciplined by their state medical board, and only 17% of doctors (1 out of 6) who have made 5 or more malpractice payouts have been disciplined by their state medical board.

V. Doctors often take the easy, costly way; caving in to defensive medicine advocates and whiny patients. The problem goes further than just prescribing unnecessary antibiotics at the expense of public health. Doctors prescribe medicine and order tests just to avoid hassle or a lawsuit. Some firms have stated that more than half the 2.2 trillion dollars we spend on health care is wasted.

At $210 billion annually, defensive medicine is one of the largest contributors to wasteful spending, and it can manifest in many forms: unnecessary CT scans, MRIs, cardiac testing and hospital admissions. A 2005 survey in the Journal of the American Medical Association found that 93% of doctors reported practicing defensive medicine.

There is tons of compelling evidence that not ordering those test, etc. would have few measurable health consequences, and that not doing so would ultimately save boatloads of money even if lawsuits increased. Yet, common sense does not prevail.

I think we can all agree that doctors are generally good folks who provide a vital service, but their hypocrisy and complicity in health care fraud needs to be pointed out. Ultimately, doctors need to be the stop-gap that prevents consumers, producers, and middlemen (insurance companies) from ruining things for everyone else. They have failed to do so in almost every respect.

[gonzomax]

Lots of doctors buy up testing labs and run their patients through them. Oddly they seem to need a lot more of the tests they make money off than the stats would indicate are needed.
One third of American doctors are over 55 years old. We will have a real big shortage soon.

[Algher]

I. Not all doctors are in the ER. Narrow your focus a bit on that one.

II. Golf is gone. Dinner is now limited. The Dinners serve to give the Docs information, along with the steak. If you kill the dinners, you had best have a suggestion of another way for the Docs to easily get information on new meds.

III. Docs are not trained as businessmen, and we yell at them when they try to act like businessmen. Now you yell at them for NOT acting like businessmen. Appointments are jacked due to the fact that the typical GP is paid for 7 minutes, including paperwork time. However, if they spend more time the schedule is fried. The system is designed to be messed up due to the complicated nature of the game. It sucks, and unless you go down the concierge care route - you won't see an improvement.

III. part two. Docs can't collective bargain - they run into anti-trust laws are accused of price fixing.

IV. AMA does limit, though we allow foreign docs in all the time so I don't know how relevant that is anymore. As for malpractice, you would need to determine how many of those were settlements first. Many insurance companies will force a settlement rather than fight. Docs might not lose their license, but if they can't get insurance they are as good as done regardless. I know two OB-GYNs that were thrown under the bus by their insurance companies and can no longer practice.

V. It is called defensive medicine for a reason - it slows down the lawsuits (they hope/think). If you don't order the test, and this is the 1%, then the first thing when your ass hits the witness stand is, "Why didn't you order the test?" I don't claim that Tort reform is a panacea, but there are certainly docs who over order tests just to be sure that they are covered. FYI - I was one of those 1% folks once, and I was happy that my doc ordered what should have been a excessive test.

[Algher]

Originally Posted by gonzomax

Lots of doctors buy up testing labs and run their patients through them. Oddly they seem to need a lot more of the tests they make money off than the stats would indicate are needed.
One third of American doctors are over 55 years old. We will have a real big shortage soon.

Some payments are tied to the test, with minimal reimbursement for interpretation. If you outsource the test, you get nothing. If you do the test yourself, you can make money.

[Fuzzy Dunlop]

Originally Posted by brickbacon

Most of the coverage of this issue seems to (deservedly) talk about how badly the public is being fleeced by lawers, Pharma, and big insurance companies, but the doctors get a pass. Why is that the case considering doctors are just as culpable. Consider the following:

Apparently the collective coverage you and I are reading differs but in my experience most of the pro-reform push this time around has been talking about how badly the public is being fleeced by insurance companies, largely ignoring everyone else. I would say that malpractice lawyers, the pharmaceutical industry and doctors/hospitals have all been spared a lot of attention. I think this is for 2 reasons 1) the reform being proposed is actually predominantly about the health insurance practice. In spite of the dirty lies nobody is talking about the government forcing doctors to treat people according to its whims. And 2) The biggest hospital groups, the AMA and PhRMA were all smart enough to side with Obama and only the health insurers are getting people angry by lying to them about murdering grandma and other manufactured astro turf.

[TheMightyAtlas]

Originally Posted by Algher

Some payments are tied to the test, with minimal reimbursement for interpretation. If you outsource the test, you get nothing. If you do the test yourself, you can make money.

I am looking at a bill from my last doctors visit and the follow-ups.

$315 for an annual physical (less than 15 minutes with doctor)
$95 for EKG (done by Nurse)
$85 for EKG interpretation (I wasn't there, nothing was communicated back to me except the bill)
$1102 for nine tests. One ($700) done by a doctor, who spend about 30 minutes with me. It took about 5 weeks to get this test scheduled. The guy is booked solid, eight hours a day, five days a week.
$180 for interpreting various tests done by the doctor (I had to call three times for the doctor to speak to me about the test results)

Total $1177, reduced to $547 by my insurance, out of which I paid $477, $400 for annual deductible, $77 for co-pays.

I changed from insurance that used to pay for virtually everything at 100% to insurance with a deductible and % copays for everything other than doctors visits, which are a flat $25.

You bet next time I am going to ask the doctor to explain exactly what he expects to do with each test, the significance of each, and if he doesn't give me answers I am satisfied, I will be looking for a new doctor. When I had more comprehensive insurance I didn't care. I have borderline hypertension, but no other health issues. Damned if I know why I needed all those tests. Maybe the doctor had a boat payment due.

I've said this before on two threads. I don't buy the cries of poverty from PCPs. I have a cousin who is a PCP. He spends much more time on tax "planning" than on keeping up with his profession. His continuing educations choices are thinly disguised vacations. Another PCP plays on my tennis team. His house and car are fabulous even by our relatively affluent standards. He has more free time than any other working professional I know.

Maybe we can solve the doctor shortage by lowering physician compensation. They will be forced to work longer house to make their $250k per year. Boo hoo.

[gonzomax]

Originally Posted by Algher

Some payments are tied to the test, with minimal reimbursement for interpretation. If you outsource the test, you get nothing. If you do the test yourself, you can make money.

They outsource to the lab they own. They schedule a ton of tests and collect both ways.

[Tom Tildrum]

Originally Posted by gonzomax

They outsource to the lab they own. They schedule a ton of tests and collect both ways.

Note that as a general rule, it's illegal to bill Medicare for referrals to a lab where the doctor has a financial interest. There are a lot of permissible exceptions, however.

[fuzzypickles]

Originally Posted by TheMightyAtlas

Maybe we can solve the doctor shortage by lowering physician compensation. They will be forced to work longer house to make their $250k per year. Boo hoo.

If we're ever going to fix the health care crisis in this country, this is something that definitely needs to be addressed. Doctors in countries with socialized health care don't earn nearly the salaries that American doctors make.

[furt]

The OP might find this article interesting.

[Chief Pedant]

There are a host of things wrong and dysfunctional with the American healthcare system.

Medicine has become increasingly effective and increasingly dangerous at the same time.

From my perspective as a physician, the current mess is exactly indicative of what happens when big government tries to make anything work. That is of course a personal perspective, but medicine has more regulation and regulatory bodies than anything I know, and look at the result...

I have a personal opinion of what the various issues are, and you touch on some of them. However I think the current "healthcare debate" involves trying to find mechanisms to broaden coverage, not reduce cost or increase efficiency or improve care or caregivers. It is not fundamentally a debate about what's wrong with the healthcare system itself (other than how to pay for it).

It is for this reason--putting the cart before the horse--that I think all the current efforts completely miss the point about what is wrong with healthcare. We are taking a bizarre and overly complex healthcare system and expanding it mindlessly. Nice.

You may be surprised to learn how little control doctors have over healthcare delivery and how plenty annoyed most of them are at the current system.

[shiftless]

The current debate over healthcare has all of its focus on finding a way to get care for those who can't currently afford it. Good ideal except that part of the reason so many can't get the healthcare they need is because the system is so broken and needlessly expensive. Chief Pedant sums up my opinion very nicely. Any reform of healthcare in American needs to focus on fixing the system, not just finding more money to pour into it.

While the amount of money doctors make does kind of stick in my craw, that isn't where the real expense of healthcare is. Check your bill at a hospital sometime - $10 for a cotton swab, $50 for the little package with the plastic water pitcher you cannot refuse....... This stuff is mostly hidden and adds up to huge amounts.

[Ruken]

Originally Posted by brickbacon

IV. Doctors (via the AMA, et al.) limit their numbers. They even stopped opening medical schools for years because they thought there would be too many doctors. Why shouldn't the market decide?

I'd like more information on this. I googled, but the first few links didn't tell me a whole lot. Do [AMA, doctors, someone else?] argue that increasing the number of doctors would lower their quality? That is, are there not enough qualified candidates? AFAIK, the non-complete rate in med school is pretty low, i.e. there are few "admissions mistakes". I think the difficulty of medical training gets exaggerated, given the tales I've heard (anecdote warning) from chemistry MD/PhDs and chemistry grad-school-dropouts-now-med-students who have experienced both worlds.

[Sam Stone]

The reason is purely economic. By limiting the number of doctors, they keep salaries of doctors high.

This is a very common form of regulatory capture. Many of the regulations you think are passed to help the public are actually passed to help existing special interests erect barriers to entry for others. You see it in building codes, where many regulations are set up simply to prevent pre-fab manufacturing and force the hiring of plumbers and electricians and such. You see it in certification standards that are needlessly complex, and faculty entrance requirements which demand unreasonably high grades. You also see it in regulations which require increasingly high levels of education for the same job.

For example, it used to be common for working nurses to have a one-year diploma. Then came the 2-year RN diploma. Now a lot of jurisdictions require four-year degrees for nurses.

In education, the teaching certification requirements are becoming increasingly byzantine and arbitrary.

All of this is done with the approval of existing professional groups and unions, or even at their behest. Because of course, current members are always grandfathered in when such changes are made. The rule is, get in the door, then slam it shut behind you before anyone else can come in and compete with you.

[Chief Pedant]

=Sam Stone;11561952]The reason is purely economic. By limiting the number of doctors, they keep salaries of doctors high.

Who is "they" and how are "they" doing this?

Over the course of my career as a physician, I've interacted with hundreds of doctors. I've never heard this expressed directly or indirectly, in public or in private, by any physician. There is some sort of secret cabal to limit our numbers? A quiet conspiracy, perhaps, of which none of us are aware?

I've always assumed that states and/or the Federal government might create a drive to increase the number of doctors in some way, but I guess I actually have no idea. I don't think most physicians are actively agitating for more doctors, but neither are they conspiring to limit them.

I would be willing to bet, however, that increasing the number of doctors simply increases the total cost of healthcare without having much effect on improving it. Another thread, perhaps. I am unaware of instances where bringing in more physicians lowered the cost of healthcare, and in fact I'd guess physicians tend to concentrate where the paying patients are rather than any other single driver. I am reasonably sure the least expensive care (in terms of physician charges) is probably in rural areas where the physician supply is also the lowest...

[foolsguinea]

Originally Posted by Fuzzy Dunlop

In spite of the dirty lies nobody is talking about the government forcing doctors to treat people according to its whims.

This sentence can read two ways. It confused me at first.

But I take it to mean, "In spite of dirty lies on the part of reforms' opponents, no one in Congress is planning to have government force doctors to treat people according to its whims." Right?

[NajaNivea]

Originally Posted by Sam Stone

In education, the teaching certification requirements are becoming increasingly byzantine and arbitrary.

All of this is done with the approval of existing professional groups and unions, or even at their behest. Because of course, current members are always grandfathered in when such changes are made. The rule is, get in the door, then slam it shut behind you before anyone else can come in and compete with you.

In our state NajaHusband, biology PhD, isn't "qualified" to teach high school bio. Two years of unpaid servitude, $30k and a teacher's union card would fix that, though.

[Algher]

Someone commented that the AMA doesn't do much to discipline docs. I am not aware of any professional groups or unions that do more the lip service in the disciplining of their members. This is teachers, cops, firefighters, brokers, attorneys, etc.

Stopping the bad ones will always come from outside.

[NajaNivea]

Really? Protecting your own always comes before collective integrity? You'd think internal policing would be the most effective, that good doctors (cops, etc.) would stand up against the bad ones the strongest. I would think they'd be the most sensitive about what it means when one of their own fucks up; even if only to avoid guilt by association.

[DoctorJ]

Someone commented that the AMA doesn't do much to discipline docs. I am not aware of any professional groups or unions that do more the lip service in the disciplining of their members. This is teachers, cops, firefighters, brokers, attorneys, etc.

Stopping the bad ones will always come from outside.

The AMA is a voluntary advocacy organization for physicians. It has no power to discipline anyone. That's up to the state medical boards, who can and often do discipline physicians who act irresponsibly.

[NajaNivea]

Err, please excuse the ; that went astray up there.

[Qadgop the Mercotan]

Originally Posted by Algher

Someone commented that the AMA doesn't do much to discipline docs.

The AMA is a lobbying group for physicians, and fewer than 1/3 of US physicians/medical students belong to it. (I'm not a member either). I'm unaware of any lobbying groups with statutory responsibility to police a profession.

Discipline is left up to state medical examining boards, which are operated by the state government and generally have both physician and non-physician members on it.

And as for producing more docs, we recently had a thread on that topic. Contrary to the assertions of many, it is neither easy nor cheap to create more slots to train competent physicians.

[Qadgop the Mercotan]

Great minds think alike, DoctorJ!

_{of course, fools seldom differ, too}

[DoctorJ]

Pharma essentially bribes doctors to prescribe medicine. We only hear about the most egregious examples, but the subtle influence is there. Even JAMA says doctors should stop accepting bribes. Drug companies spend 13k per doctor per year to influence their habits (20+ billion/year). This is all reflected in the costs of medicine to the consumer. We subsidize their dinners and golf outings, and in many cases, are told to get drugs and treatments that are less effective or unnecessary. JAMA said, "doctors in teaching hospitals should lead the way in refusing to take gifts from the pharmaceutical and medical device industries, because it damages the reputation of the profession".

You're about 20 years out of date on this one. We still have dinners, but they have to be accompanied by educational programs (which are highly regulated) and a doc can't bring his non-doctor family, so they're a lot less popular than they used to be. Drug reps can't even bring us pens and note pads anymore.

My institution (a large university) has gone a step further and banned all pharma logos and all drug rep contacts with residents and students. Even faculty are not supposed to go to the dinners, which doesn't matter because I don't anymore anyway. The only reason we still see drug reps at all is because they wanted to still have sample medications available, and I pushed against that--I think samples just encourage us to use expensive drugs rather than cheap generics.

So while I'm on board with most of your OP, this is significantly overstating the case.

[gonzomax]

Doctors have great press, TV. Since its inception TV has had doctors solving complex cases in one hours time. They never worry about money, costs of tests or anything else. They are beautiful. handsome and in great shape. All they care is saving the patient at all costs.
In the beginning it was Marcus Welby then came
Dr. Kildare, Emergency, MASH, House, Northern Exposure, and many many others.

[crazyjoe]

Originally Posted by NajaNivea

In our state NajaHusband, biology PhD, isn't "qualified" to teach high school bio. Two years of unpaid servitude, $30k and a teacher's union card would fix that, though.

Well they are right, he's not. Just knowing a subject backward and forward means nothing in terms of being able to teach it, especially to immature teenagers. Since most public schools are tested to see how effective they are at getting students to actually learn, and not how much their teachers know, to a certain degree this makes sense.

The difference between high school teachers, who by and large had to follow certain guidelines and be educated in how to teach, and college professors, who simply had to be educated in their subject matter, was very stark for me as a student moving from HS to college. Put most of those college profs in High School and they would have been lost in about 5 minutes, and fired in a couple of weeks.

[NajaNivea]

Originally Posted by crazyjoe

Well they are right, he's not. Just knowing a subject backward and forward means nothing in terms of being able to teach it, especially to immature teenagers. Since most public schools are tested to see how effective they are at getting students to actually learn, and not how much their teachers know, to a certain degree this makes sense.

I would be inclined to agree with your point if there was some sort of provision for ascertaining whether or not he's qualified to teach. For example, if he was allowed to demonstrate his considerable experience and proficiency at teaching his subject to immature teenagers. The gist of what he was told is "sure, we'll observe you teaching and qualify you as a teacher. It takes two years, over the course of which you'll work as a teacher and pay us $30k for the privilege". No classes, no education on education, just two years of indentured servitude which costs thirty thousand dollars.
You'd imagine if we really were hurting for qualified teachers, we'd be doing something helpful to fast-track educated and people into the profession. He doesn't mind working for crap pay because he both enjoys and is good at teaching kids, but just didn't feel like the system anything to do with proving his qualifications as a teacher so much as joining the club and paying $30k worth of entrance fees.
ETA: for the record, I had the opposite experience from you. The difference in going from people who had been trained to manage behavior and answer questions out of a book to people educated in the topic they were passing on was very stark to me, as a student moving from HS to college. Some of my HS teachers were educated in their topic, but most were just assigned to teach in whatever department they were needed. It's not that they were bad teachers, just that most of them couldn't really have a discussion on the topic beyond what was in the textbook or affiliated materials.
[/hijack]

[RTFirefly]

Originally Posted by Chief Pedant

I think the current "healthcare debate" involves trying to find mechanisms to broaden coverage, not reduce cost or increase efficiency or improve care or caregivers.

One of the effects of the "public option" that you've probably heard mention of would be to reduce costs. Ditto "comparative effectiveness review" which wouldn't have done so directly, but would have given doctors unbiased info on which treatments were the most effective relative to their cost. I'm not positive, but this may have been the genesis of the BS story that Obama was going to put your granny out on an ice floe. I believe it also got characterized as 'rationing health care.' Between the smears, I think this sensible approach to reducing costs has died a quiet death.

This is the problem, of course: any cost-cutting measure can be construed/smeared as 'rationing' in some way, shape, or form. Maybe if Republicans could stop using such smears, and engage in some honest debate...?

And maybe there'll be a breakthrough on cold fusion next week that simultaneously ends any worries about climate change and energy shortages forever.

We are taking a bizarre and overly complex healthcare system and expanding it mindlessly. Nice.

Mindless expansion and added complexity. (Baucus plan version; House bill has subsidies up to 400% of poverty.)

[ToeJam]

Originally Posted by Ruken

That is, are there not enough qualified candidates? AFAIK, the non-complete rate in med school is pretty low, i.e. there are few "admissions mistakes". I think the difficulty of medical training gets exaggerated, given the tales I've heard (anecdote warning) from chemistry MD/PhDs and chemistry grad-school-dropouts-now-med-students who have experienced both worlds.

The main problem is not that there's a secret group out there that enforces limiting numbers of medical students- it's the facilities themselves. In fact, there are states out there that are trying to promote the growth of medical schools by providing budget incentives to their state funded medical schools if they can provide more students over the next few years. Who doesn't want free money from the state if they can get away with it. The problem though?
The schools themselves.
My current medical school has an entering class of about 110 students. They want to update themselves though to try to get to 150 students. The problem? We simply don't have the facilities and the budget, however the school did manage to set aside it's budget and now we're under construction of a new facility to not only update our aging classrooms (we only have 2 "real" lecture halls for the First and Second year Classes right now) and our labs, but also to update our technology, equipment, and hiring the new competent professors and staff for the school as well- the cost though? It's going to take over 250 million dollars being applied over the next 4 years for the construction to finish, and already they've had budget problems with using just that much money and have had to raise tuition for us and will probably continue to do so.

So that's 4 years of construction, and 250 million dollars just to try to update the facilities all with the long term goal of basically expanding to accommodate 50 more students.

THAT'S the problem. It's money, resources, and manpower that has to be put towards the task of trying to train the medical students. That burden tends to fall on the schools that have to often deal with those burdens- there's nothing from the AMA, the state boards, or some other secret Medical Cabal that's limiting us from expanding our intake (already the class size has increased from 110 students to 115 students this year from the last- they are trying to expand slowly but surely as there is a state incentive to do this (though these incentives were all before the state had budget problems of its own and decided to cut back on said budgets, and hence my rise in tuition- but that's neither here nor there) ).

The problem mainly is the fact that TRAINING the doctors cost money.
People expect their health care providers to have a certain standard of competency and knowledge and so there are nationalized exams that every US trained doctor must pass (USMLE I, USMLE II, USMLE III), and the medical schools must train to not only try to train their students to be able to pass those exams, but also to try to instill in their doctors a sense of ethical responsibility, responsibility, and a proper bedside manner and patient interaction skills.

Needless to say, that's a daunting task, and it's not as easy as just opening up the floodgates to allow more students to enter a school- you have to have trained people who can effectively teach the students, and you have to have the facilities to even accommodate the students. It's no easy task and that's mainly the problem for why more doctors AREN'T just being churned out- it costs money, and 250 million (as we're finding out) isn't going to cut it even to raise up 50 more students over 4 years.....

How can we afford to increase the amount of students a medical school can train without diminishing too much the quality of training that the patients come to expect of certified doctors? There's the trade off and the dilemma.

[Fiveyearlurker]

Originally Posted by Chief Pedant

Who is "they" and how are "they" doing this?

The Association of American Medical Colleges (AAMC) more or less sets the number of physicians by determining how many students a given school can enroll and determining how many schools there are that are accredited to hand out an MD.

[Chief Pedant]

Originally Posted by Fiveyearlurker

The Association of American Medical Colleges (AAMC) more or less sets the number of physicians by determining how many students a given school can enroll and determining how many schools there are that are accredited to hand out an MD.

I am not aware that the AAMC externally limits a given programs's enrollment (outside of having an interest that a school not expand beyond its capacity to teach adequately). To the extent that they can, they have recommended increasing the number of physicians to meet projected shortages. They are not involved in promoting a reduced number of physicians for the purpose of maintaining higher compensation.

[Chief Pedant]

Originally Posted by RTFirefly

One of the effects of the "public option" that you've probably heard mention of would be to reduce costs. Ditto "comparative effectiveness review" which wouldn't have done so directly, but would have given doctors unbiased info on which treatments were the most effective relative to their cost. I'm not positive, but this may have been the genesis of the BS story that Obama was going to put your granny out on an ice floe. I believe it also got characterized as 'rationing health care.' Between the smears, I think this sensible approach to reducing costs has died a quiet death.

This is the problem, of course: any cost-cutting measure can be construed/smeared as 'rationing' in some way, shape, or form. Maybe if Republicans could stop using such smears, and engage in some honest debate...?

And maybe there'll be a breakthrough on cold fusion next week that simultaneously ends any worries about climate change and energy shortages forever.


Mindless expansion and added complexity. (Baucus plan version; House bill has subsidies up to 400% of poverty.)

I will go on record as saying categorically that no healthcare plan in this country is going to effect a net savings. The government may be very sincere about trying but it will not happen. Perhaps a different thread would be suitable to expand that discussion.

While the idea of an unbiased effectiveness review is appealing, carrying it out in practice has proven to be exceedingly complex. 25 years ago there was a nice study suggesting that coronary artery bypass did not result in much prolongation of life. The problem is that as soon as you do the study, the methods which went into that study are already antiquated.

In general, the expensive concept we have is that our healthcare should not be constrained by cost. A study might show your kid has only a 0.1% chance of dying if I don't CT his busted head, but when you are in my ED both of us want to CT his head. Neither of us wants to be wrong and neither of us are concerned about some cost-effectiveness study. A crude example, but you get the principle, I hope.

[DSeid]

1) No, doctors are not being "given a pass". Much of what is included changes how they are paid and what they are paid for. They (we) are probably not going to come out so bad providing we adapt well but then no major player is going to be hurt so bad.

2) They are not being attacked much because they have been fairly cooperative (most of us see the need for major changes), because patients like their docs mostly and it is hard to paint them as Stanley Whiplashes (as you can villify a nameless insurance exec), and because many angry docs would be a powerful anti lobbying force. It would be a poor tactic.

3) Questions about physician numbers and compensation were addressed in this recent thread. As linked to there physician supply has been steadily increasing. The problem, as documented in that thread (see post # 48 and 49), is that the nature of the beast (what gets incentivized and what not) means that the lion's share goes into specialty medicine in urban centers, less into primary care, and least into underserved areas' primary care. And those perhaps less than absolutely required tests get accidentally encouraged. Thus costs increase.

4) Further decrease payment for primary care doc visits and you would perversely increase the costs to the system. They would be pressured to see more patients in a shorter period of time which would result in more mindless test ordering rather than more tedious good history taking and detective work. Procedures and in-office testing would become a more important source of income than it is for some of them now and those who currently do not do those things would be pressured to do so. Bad idea.

4) CP's last point is major and we have discussed it before: we (still under any proposal, lies about "death panels" notwithstanding) irration care according to payment source or lack thereof, rather than rationally decide that we have to say no to some absurdly expensive technologies of very limited benefit. This is not going to change.

[gonzomax]

Doctors and hospitals charge for services performed, not necessarily results. Cranking out tests and procedures will make money for them. The tests do not have to be justified.
The argument of defensive medicine is interesting, but do doctors actually get sued for not doing enough tests?. They escape negligence because you have great difficulty getting expert testimony to counter a doctors defense. Most jurors would not have the expertise to make a proper decision. The medics also have the resources to get top defense lawyers,
I disagree with a cap on medical damages ,caused by doctors errors. How much does it cost to take care of a kid through his lifetime that a doctor's mistake left him mentally of physically impaired.
Doctors cover up mistakes. bad doctors are defended by the AMA. It is difficult to find information about a bad doctor. Like the police who cover up bad apples, the associations don't realize that the whole profession is harmed by covering up for the incompetent.
The successful lawsuits against doctors generally have a non disclosure agreement of guilt or amount of damages the case resulted in. People can not readily find out how good or bad a doctor is. You can not find out how often or how successfully he was sued. It should be public knowledge.

[brickbacon]

Originally Posted by Algher

I. Not all doctors are in the ER. Narrow your focus a bit on that one.

Fair enough. I don't think most would assume I was talking about ALL doctors though.

Originally Posted by Algher

II. Golf is gone. Dinner is now limited. The Dinners serve to give the Docs information, along with the steak. If you kill the dinners, you had best have a suggestion of another way for the Docs to easily get information on new meds.

Fair point, but I the golf/dinner things were mostly random, common (albeit incorrect) examples. But, it must be noted the outright bribes some doctors receive could be used for anything. Plus, that those taking bribes are unlikely to follow rules restricting golf outings or dinners.

If doctors need information on new drugs, why don't they set up an industry website outlining the drugs, etc. They could have doctor patient feedback in several fora, and an informal feedback source.

Originally Posted by Algher

III. part two. Docs can't collective bargain - they run into anti-trust laws are accused of price fixing.

I don't mean so much fixing prices, but freezing out insurance companies that consistently jerk them or their patients around. I don't think they would violate anti-trust laws that way. Or they could just be more open about what they pay to other doctors so insurance companies can't take advantage of the information asymmetry.

Originally Posted by Algher

V. It is called defensive medicine for a reason - it slows down the lawsuits (they hope/think). If you don't order the test, and this is the 1%, then the first thing when your ass hits the witness stand is, "Why didn't you order the test?" I don't claim that Tort reform is a panacea, but there are certainly docs who over order tests just to be sure that they are covered. FYI - I was one of those 1% folks once, and I was happy that my doc ordered what should have been a excessive test.

But there doesn't seem to be any evidence that this defensive medicine is saving them any money in the long run. It certainly costs us collectively, but it may not even be an effective strategy on an individual level.

Originally Posted by Chief Pedant

Medicine has become increasingly effective and increasingly dangerous at the same time.

Can you elaborate on this?

Originally Posted by Chief Pedant

You may be surprised to learn how little control doctors have over healthcare delivery and how plenty annoyed most of them are at the current system.

In light of what you said above, it what ways should doctors have more control of how healthcare is delivered? In what ways is the current amount of control lacking?

[Syntropy]

Originally Posted by brickbacon

In light of what you said above, it what ways should doctors have more control of how healthcare is delivered? In what ways is the current amount of control lacking?

For all that people insist they don't want a bureaucrat 'coming between' them and their doctor, it is in fact already happening. Insurance companies have far more say over whether or not a patient gets a specific treatment than the patient and doctor do.

If a patient requires a specific treatment, many insurance companies will insist that all 'less invasive' (read: less expensive) treatments be used first. Then and only then if those treatments are not effective will they consider the original course of treatment. Of course by that time the problem has advanced well beyond the simple fix that was needed and additional treatment is required and the cycle starts all over.

Of course, patients are welcome to go ahead and have whatever procedure they need performed, they'll just have to pay for it themselves. At which point the insurance company will promptly disallow any and all issues pertaining to that problem saying it was not medically necessary. All of which rather invalidates the reason for having insurance in the first place.

[Foxy40]

Originally Posted by fuzzypickles

If we're ever going to fix the health care crisis in this country, this is something that definitely needs to be addressed. Doctors in countries with socialized health care don't earn nearly the salaries that American doctors make.

This is the attitude that truly needs to be changed. Doctors no longer make the huge salaries they did in the past. Physician reimbursement has gone down each year since 1999 and continues to do so. The average primary care doctor makes considerably less than 200K which is far less than the CEOs of the insurance companies that are the ones dictating your care expenses so they can get their big bonuses.

Since primary care doctors make so little money and have to put in so many hours, there is a shortage of those types of physicians. Do you think having them paid less is going to solve the problem? I don't think so. You may look around and there will be months to wait to get a simple blood pressure medication because no one wants the job anymore.

http://www.azcentral.com/news/articl...dents0206.html

[gonzomax]

Some doctors don't make as much as they did in the past. Some are cleaning up. But ,if you become a doctor ,you are assured of making a very,very good living.
We can make medical school a lot cheaper. We can make all colleges cheaper and we should. We have less respect for education than we do for making money off it. Education is like health care. It goes up every year far above inflation. It does not reflect the economy, just that they are taking advantage of a power position.
We insist on limiting med schools suggesting that controls the quality of doctors. Then we have to import doctors who graduate from med schools that we have no input in at all.

[psychobunny]

[quote=TheMightyAtlas;11560030]I am looking at a bill from my last doctors visit and the follow-ups.

$315 for an annual physical (less than 15 minutes with doctor)
$95 for EKG (done by Nurse)
$85 for EKG interpretation (I wasn't there, nothing was communicated back to me except the bill)
$1102 for nine tests. One ($700) done by a doctor, who spend about 30 minutes with me. It took about 5 weeks to get this test scheduled. The guy is booked solid, eight hours a day, five days a week.
$180 for interpreting various tests done by the doctor (I had to call three times for the doctor to speak to me about the test results)

Total $1177, reduced to $547 by my insurance, out of which I paid $477, $400 for annual deductible, $77 for co-pays.


QUOTE]

Can I ask where you live and what your insurance is? Because i want to move there!
Here are comparable payments for my area (major metropolitan area)

payment for physical: $120
EKG with interpretation $40
Lab drawing fee: $4

Total $164 for about 1.25 hours of work (45 minutes spent with patient, additional 10 minutes writing up report, 5 minutes to read and write up EKG, 5 minutes to review lab tests (that the lab gets paid for-we only get the drawing fee), 10 minutes to review results on the telephone with the patient. All this is exclusive of nursing salaries, expenses, etc.

[gonzomax]

Originally Posted by Syntropy

For all that people insist they don't want a bureaucrat 'coming between' them and their doctor, it is in fact already happening. Insurance companies have far more say over whether or not a patient gets a specific treatment than the patient and doctor do.

If a patient requires a specific treatment, many insurance companies will insist that all 'less invasive' (read: less expensive) treatments be used first. Then and only then if those treatments are not effective will they consider the original course of treatment. Of course by that time the problem has advanced well beyond the simple fix that was needed and additional treatment is required and the cycle starts all over.

Of course, patients are welcome to go ahead and have whatever procedure they need performed, they'll just have to pay for it themselves. At which point the insurance company will promptly disallow any and all issues pertaining to that problem saying it was not medically necessary. All of which rather invalidates the reason for having insurance in the first place.

A friend of mine has lymphoma. His doctor ordered a scan. The insurance company rejected it. They said it was not the right test. The doc said the test was meant to pinpoint radiation treatment and he wanted to run it. Now the patient has to come up with about 1200 bucks. The insurance company most assuredly comes between the doctor and patient.

[Chief Pedant]

Originally Posted by Chief Pedant:
Medicine has become increasingly effective and increasingly dangerous at the same time.

Originally Posted by brickbacon

Can you elaborate on this?

Example One: Drugs. I put you on warfarin because your condition of atrial fibrillation can produce clots that can cause a stroke. There is a net benefit. However a small number of people will die of bleeding or other complications from the drug.
Example Two: Procedures. You present with a torn aorta. I can repair it. Some patients will die from the procedure, even though it saves lives overall.

Originally Posted by brickbacon

In light of what you said above, it what ways should doctors have more control of how healthcare is delivered? In what ways is the current amount of control lacking?

Doctors have almost no control over the hodgepodge of regulation. They have little control over how healthcare is delivered inside many hospitals. They have no control over the ridiculous tort system which constrains their approach to care. They have little control over other bad doctors who hide behind lawyers and various other protections. They have little control over what systems are put in place by hospitals to track healthcare delivery and measure outcomes. They have minimal control over how their patients execute their advice. They are frequently constrained over who they can refer to, what drugs they can prescribe and so on. The list goes on.