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> Part of the problem is you can thank the stranglehold the AMA has around the US healthcare system to keep the number of doctors artificially low so their sala

> Part of the problem is you can thank the stranglehold the AMA has around the US healthcare system to keep the number of doctors artificially low so their salaries remain ridiculously high. The AMA is a common scapegoat, except that the AMA has literally nothing to do with the number of of doctors supply-side. You're probably thinking of the AAMC, which has nothing to do with the AMA, and is responsible for the number of medical students who graduate each year from the US. Except the AAMC has very deliberately and openly increased the number of medical student slots each year for over a decade, specifically with this goal in mind. But even this is a moot point, because the number of people gradating with MDs is not the bottleneck - the problem is that doctors can't practice medicine until they complete a residency program. We graduate more medical students every year than we have residency slots available, so increasing the number of graduates even further will have no effect. Increasing the number of residency slots is up to Medicare, because Medicare funds residency programs nationwide.

jessaustin 11y ago
Does this mean there is an ever-growing population of "post-doc" physicians, stuck in labs or other non-patient-facing situations? What numbers are we talking about?
- chimeracoder 11y ago
  > What numbers are we talking about? In 2015 there were 41,000+ applicants for ~30,000 residency positions[0]. I don't have the 2015 numbers for medical schools, but in 2014, there were 18,000 graduates in the US[1]. Increasing the number of medical school graduates in the US would mean that a larger percentage of residency slots are taken by people who went to school in the US but not the total number of residents. Ironically, this would actually be a bad thing cost-wise, since foreign medical schools are usually cheaper and students carry a lower debt load[2]. > Does this mean there is an ever-growing population of "post-doc" physicians, stuck in labs or other non-patient-facing situations? Yes. You are likely to see them take jobs in industry - e.g. at a pharmaceutical or insurance company, but on the business side, since they're not licensed to practice. (Nor are they even qualified - medical school teaches essential knowledge for doctors, but they receive basically no training on actual clinical practice. All of that happens during residency). It's worth noting that not all doctors want to practice medicine - for example, people in an MD/PhD program often go into research, and that's a good thing. But if we're talking about increasing the supply of practicing physicians, increasing the number of medical school applicants in the US makes literally zero difference. [0] http://www.nrmp.org/press-release-2015-residency-match-largest-on-record-with-more-than-41000-applicants-vying-for-over-30000-residency-positions-in-4756-programs/ http://www.nrmp.org/press-release-2015-residency-match-large... [1] https://www.aamc.org/download/321532/data/factstable27-2.pdf https://www.aamc.org/download/321532/data/factstable27-2.pdf [2] These aren't necessarily "foreign" students either; it's quite common for people in the US to go to medical school in the Caribbean and then come back for their residency.
maxerickson 11y ago
Why can't some other entity fund residency programs? What if the Gates Foundation decided it wanted to fund 1 residency position? Is there some structural roadblock in the way of its money?
- chimeracoder 11y ago
  I am not aware of any legal roadblock to this, though there may be one. (I wouldn't be surprised if there were - there are already plenty of laws restricting providers from taking money for the same kinds of services that Medicare funds, even if Medicare isn't actually funding that service, which is terrible for Medicare patients who want to pay out-of-pocket certain care above the limit for what their plan covers and discover that they literally cannot.) But besides that, the Gates Foundation has decided that the most effective way to spend its money, dollar-for-dollar, is on efforts like polio eradication and malaria research. You'd have to convince them that this would be the most worthwhile use of their money - and quite frankly, if I were in their shoes, I wouldn't. Even if lowering the costs of healthcare in the US were their explicit goal (it's not), it would be a rather inefficient way to go about it. And eradicating infectious diseases that largely affect the poor is a much bigger win for humanity than an ongoing subsidy[0] for medical care in the developed world. [0] This would require perpetual funding for it to be effective; as soon as they decided to stop funding residency programs, we'd go back to the status quo.
  - maxerickson 11y ago
    I knew labeling the pile of money was risky, I realize it is unlikely to do such a thing. But the point of using a concrete example was that it clearly could afford it, not to speculate about whether it would do it.
vonmoltke 11y ago
> Increasing the number of residency slots is up to Medicare, because Medicare funds residency programs nationwide. No, it isn't. Congress limited the number of residency slots Medicare could underwrite, but medical residency is not controlled by Medicare. Additionally, Medicare only pays for about 25% to the total costs incurred by residency programs. In fact, the law that created Medicare specifically stated it was to subsidize residencies “until the community undertakes to bear such education costs in some other way.” Understandably, no one has stepped up to replace the federal government gravy train. Since the AAMC is predominantly responsible for Graduate Medical Education (the formal name of residency) it is absolutely the appropriate scapegoat for the residency bottleneck (since their only answer is to make the FGGT bigger), as is the AMA for pushing increasingly long residency requirements for medical licensure.
- chimeracoder 11y ago
  > The law that created Medicare specifically stated it was to subsidize residencies “until the community undertakes to bear such education costs in some other way.” Understandably, no one has stepped up to replace the federal government gravy train. It seems like you don't want Medicare to be responsible for the funding of residency programs, and you'll get no disagreement from me on that point. In an ideal world, this would not come Medicare, because Medicare is the least efficient funding source for - well, pretty much anything. But the fact remains that residency programs are not a profit center for hospitals, and hospitals cannot absorb an extra $9.8 billion/year just to train residents. And there's no other funding source for these programs at most hospitals that doesn't ultimately make its way back to the patient in some form. It's also worth mentioning that the Balanced Budget Act capped Medicare's funding for residency programs specifically to reduce the number of residency slots available and avoid an "oversupply" of doctors. It's not that the AAMC is looking for free money so that they can keep the number of physicians artificially low, as you're implying; the external funding is what drove the increase in the number of physicians in the first place. If you want residency programs to be funded by someone other than Medicare, that's fine, but just realize that the free-market would reach equilibrium at even fewer residency slots than we have today.

jessaustin 11y ago

Does this mean there is an ever-growing population of "post-doc" physicians, stuck in labs or other non-patient-facing situations? What numbers are we talking about?

chimeracoder 11y ago
> What numbers are we talking about? In 2015 there were 41,000+ applicants for ~30,000 residency positions[0]. I don't have the 2015 numbers for medical schools, but in 2014, there were 18,000 graduates in the US[1]. Increasing the number of medical school graduates in the US would mean that a larger percentage of residency slots are taken by people who went to school in the US but not the total number of residents. Ironically, this would actually be a bad thing cost-wise, since foreign medical schools are usually cheaper and students carry a lower debt load[2]. > Does this mean there is an ever-growing population of "post-doc" physicians, stuck in labs or other non-patient-facing situations? Yes. You are likely to see them take jobs in industry - e.g. at a pharmaceutical or insurance company, but on the business side, since they're not licensed to practice. (Nor are they even qualified - medical school teaches essential knowledge for doctors, but they receive basically no training on actual clinical practice. All of that happens during residency). It's worth noting that not all doctors want to practice medicine - for example, people in an MD/PhD program often go into research, and that's a good thing. But if we're talking about increasing the supply of practicing physicians, increasing the number of medical school applicants in the US makes literally zero difference. [0] http://www.nrmp.org/press-release-2015-residency-match-largest-on-record-with-more-than-41000-applicants-vying-for-over-30000-residency-positions-in-4756-programs/ http://www.nrmp.org/press-release-2015-residency-match-large... [1] https://www.aamc.org/download/321532/data/factstable27-2.pdf https://www.aamc.org/download/321532/data/factstable27-2.pdf [2] These aren't necessarily "foreign" students either; it's quite common for people in the US to go to medical school in the Caribbean and then come back for their residency.

maxerickson 11y ago

Why can't some other entity fund residency programs? What if the Gates Foundation decided it wanted to fund 1 residency position? Is there some structural roadblock in the way of its money?

chimeracoder 11y ago
I am not aware of any legal roadblock to this, though there may be one. (I wouldn't be surprised if there were - there are already plenty of laws restricting providers from taking money for the same kinds of services that Medicare funds, even if Medicare isn't actually funding that service, which is terrible for Medicare patients who want to pay out-of-pocket certain care above the limit for what their plan covers and discover that they literally cannot.) But besides that, the Gates Foundation has decided that the most effective way to spend its money, dollar-for-dollar, is on efforts like polio eradication and malaria research. You'd have to convince them that this would be the most worthwhile use of their money - and quite frankly, if I were in their shoes, I wouldn't. Even if lowering the costs of healthcare in the US were their explicit goal (it's not), it would be a rather inefficient way to go about it. And eradicating infectious diseases that largely affect the poor is a much bigger win for humanity than an ongoing subsidy[0] for medical care in the developed world. [0] This would require perpetual funding for it to be effective; as soon as they decided to stop funding residency programs, we'd go back to the status quo.
- maxerickson 11y ago
  I knew labeling the pile of money was risky, I realize it is unlikely to do such a thing. But the point of using a concrete example was that it clearly could afford it, not to speculate about whether it would do it.

vonmoltke 11y ago

> Increasing the number of residency slots is up to Medicare, because Medicare funds residency programs nationwide. No, it isn't. Congress limited the number of residency slots Medicare could underwrite, but medical residency is not controlled by Medicare. Additionally, Medicare only pays for about 25% to the total costs incurred by residency programs. In fact, the law that created Medicare specifically stated it was to subsidize residencies “until the community undertakes to bear such education costs in some other way.” Understandably, no one has stepped up to replace the federal government gravy train. Since the AAMC is predominantly responsible for Graduate Medical Education (the formal name of residency) it is absolutely the appropriate scapegoat for the residency bottleneck (since their only answer is to make the FGGT bigger), as is the AMA for pushing increasingly long residency requirements for medical licensure.

chimeracoder 11y ago
> The law that created Medicare specifically stated it was to subsidize residencies “until the community undertakes to bear such education costs in some other way.” Understandably, no one has stepped up to replace the federal government gravy train. It seems like you don't want Medicare to be responsible for the funding of residency programs, and you'll get no disagreement from me on that point. In an ideal world, this would not come Medicare, because Medicare is the least efficient funding source for - well, pretty much anything. But the fact remains that residency programs are not a profit center for hospitals, and hospitals cannot absorb an extra $9.8 billion/year just to train residents. And there's no other funding source for these programs at most hospitals that doesn't ultimately make its way back to the patient in some form. It's also worth mentioning that the Balanced Budget Act capped Medicare's funding for residency programs specifically to reduce the number of residency slots available and avoid an "oversupply" of doctors. It's not that the AAMC is looking for free money so that they can keep the number of physicians artificially low, as you're implying; the external funding is what drove the increase in the number of physicians in the first place. If you want residency programs to be funded by someone other than Medicare, that's fine, but just realize that the free-market would reach equilibrium at even fewer residency slots than we have today.