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> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools They do not. You may be confus

> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools They do not. You may be confusing the AMA (which less than 25% of doctors even belong to) with the AAMC. The latter does cap the number of medical school positions nationwide, but they've also made a concerted effort over the last ten years to increase that number steadily. But even if they eliminated that cap entirely, it wouldn't matter, because the number of medical school slots isn't a bottleneck for the number of practicing physicians. The number of residency slots is, and the funding gap for that comes from Medicare, which is responsible for funding them. Unless more residency programs are funded, increasing the number of medical school positions would simply increase the number of people who have medical school debt and aren't licensed or trained to practice medicine, which would be even worse, > which also allows the existing schools to crank costs to astronomical levels (“don’t worry, you’ll make enough to pay it back”). Hardly - in fact, there's already been significant downward pressure on these, because the debt level is already at the tipping point. Today, the typical person who enters medical school can expect to pay off their medical school debt in their 40s. That level of debt load is already having a negative impact on qualifications for medical school applicants (who wants to be past child-bearing age by the time they've paid off their debt, when they can just go into another better-paying field without any of that)?

zellyn 9y ago
Is this part of the article incorrect? > In recent years, the number of medical residents has become so restricted that even the American Medical Association is pushing to have the number of slots increased. The major obstacle at this point is funding. It costs a teaching hospital roughly $150,000 a year for a residency slot. Most of the money comes from Medicare, with a lesser amount from Medicaid and other government sources. The number of slots supported by Medicare has been frozen for two decades after Congress lowered it in 1997 at the request of the American Medical Association and other doctors’ organizations.
- jjoonathan 9y ago
  Does it cost $150k/yr of actual concrete costs or does it cost $150k/yr because that's what they're used to receiving and they want the gravy train to continue?
  - chimeracoder 9y ago
    > Does it cost $150k/yr of actual concrete costs or does it cost $150k/yr because that's what they're used to receiving and they want the gravy train to continue? There's no "gravy train" - residency programs are not self-sufficient without this money from Medicare. It costs a lot to train a doctor, and that's even paying doctors less than minimum wage in many areas[0]. If they were, hospitals would be free to open as many residency programs as they wanted without Medicare's subsidies, except they generally don't. There are very few non-Medicare funded residency positions, and they tend to be very special cases in obscure regions. [0] The average resident salary comes out to $12.25/hour, which is literally less than minimum wage in some areas.
    - Symmetry 9y ago
      The fact that residents aren't paid much by the hospitals doesn't mean that the hospitals aren't making a net profit, it would normally be evidence that it is profitable for the hospitals. Even working 100 hour weeks all year that salary would only come to $65k leaving another $85k to be accounted for. Some of that is benefits and some is the time used by doctors to train the residents and by hospital administrators to oversee them. But the residents also do work for the hospital that would otherwise have to be done by doctors or nurses. So I'd expect that they are profit centers for the hospital but I'm willing to be convinced otherwise if someone can come up with numbers.
      - chimeracoder 9y ago
        > The fact that residents aren't paid much by the hospitals doesn't mean that the hospitals aren't making a net profit, No, the fact that hospitals don't just hire more residents is what demonstrates that it's not profitable for hospitals to simply hire more residents.
- jacobrobbins 9y ago
  I was confused by that part too because the article goes on to say teaching colleges "have an incentive to offer residencies in specialties from which they can get the most revenue per resident." My guess is the 150K number ignores the revenue contribution of the residents (which must be significant because they carry out a significant amount of the work that requires a doctor at a hospital) I did a google search and found one article that seems to confirm this: "Whether the programs are ultimately costs or moneymakers for hospitals is mostly unknown. Expenses tied directly to the programs are tracked, but overall cost-benefit accounting that would take into account such things as savings or lower medical bills for patients from the use of lower-paid residents instead of practicing physicians isn't done." http://www.modernhealthcare.com/article/20150719/news/307199999 http://www.modernhealthcare.com/article/20150719/news/307199... The argument that federal funding is the only way to create more educational "seats" for doctors seems strange since the article claims they are paid much more than other fields, and is not really laid out well in the article.
  - chimeracoder 9y ago
    > but overall cost-benefit accounting that would take into account such things as savings or lower medical bills for patients from the use of lower-paid residents instead of practicing physicians isn't done This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital. From an accounting or business perspective, it's pretty clear that residency programs don't make money for hospitals. An easy way to reason about this is to remember that nothing's stopping hospitals from opening up residency slots that they self-fund. If residency programs predictably broke even, you'd expect them to do that. Except, almost no hospital does this, because the programs don't predictably break even - in fact, they pretty predictably lose money.
    - canes123456 9y ago
      Not if the government already pays for it. Why open up self-funded slots and show that the government doesn't need to pay for it? If you make a small profit, you are just putting the other pure profit slots at risk...
- sjg007 9y ago
  Or you know, hospitals with residency programs could just use of the massive insurance money they make to fund residency positions. It's not like the residents aren't employees or something.. Even the medicaid/medicare procedures are reimbursable.
  - chimeracoder 9y ago
    > Even the medicaid/medicare procedures are reimbursable. Medicare reimburses rates below-cost. About 7% below COGS, which means they lose money per-patient, even before they have to pay doctors, nurses, janitorial staff, etc. > Or you know, hospitals with residency programs could just use of the massive insurance money they make to fund residency positions. The "massive insurance money" is used to subsidize the losses that hospitals make on Medicare patients. > It's not like the residents aren't employees or something Great point. And that's why companies generally don't hire employees unless they work they do is profitable for the company. As it turns out, residents are not profitable for hospitals, which is why hospitals don't "just hire more of them".
    - sanderjd 9y ago
      You keep giving me the sense (like with your "7% below COGS" statistic) that you do actually know why residencies aren't profitable, but you keep making an indirect economic argument instead of talking about that directly. All anyone in this thread is trying to figure out is why folks getting paid poorly to do work that we know costs tons of money (because we see the bills) would incur net negative profit.
      - chimeracoder 9y ago
        > All anyone in this thread is trying to figure out is why folks getting paid poorly to do work that we know costs tons of money (because we see the bills) would incur net negative profit. Because hospitals have to pay: - residents' salaries - attendings' salaries - health insurance - residents' insurance (for practicing) - licensing fees - taxes It turns out, that all comes out to a lot of money. And hiring additional residents doesn't really save them much money, or bring in much additional revenue. The costs are greater than the revenue or savings. So, it's not profitable. > to do work that we know costs tons of money (because we see the bills) That's a question of medical billing, which is a whole other separate topic. In short: hospitals don't receive anywhere near the sticker amount for those bills, and a massive chunk of reimbursements from privately-insured patients goes towards recouping the losses that Medicare and Medicaid patients incur (as explained elsewhere, hospitals lose money on a per-patient basis for publicly-insured patients).
- mattmcknight 9y ago
  I think it is correct. They pushed for a cap, but are now pushing for an increase. ...the AAMC is now calling for an annual increase of 3000 Medicare-funded slots. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978854/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978854/ According to the above article, new programs are not capped. However, the bureaucracy hurdles you are required to jump to establish such a residency program is huge.
hkmurakami 9y ago
Iirc residents are a profit center for hospitals, meaning that if they really wanted to, residency slots could be self funded by the host institution without federal funding. That line of reasoning sounds like an attempt at obfuscation (not necessarily by you, but by the hospitals and medical profession in general).
- chimeracoder 9y ago
  > Iirc residents are a profit center for hospitals, meaning that if they really wanted to, residency slots could be self funded by the host institution without federal funding. That line of reasoning sounds like an attempt at obfuscation (not necessarily by you, but by the hospitals and medical profession in general). They're not. If they were a profit center, there would be more of them, unless you think that hospitals would willingly refuse to do something that's clearly profitable for them.
  - sjg007 9y ago
    Well the alternate is capacity. They only have so many doctors on staff to supervise which limits the slots. Think of it as a management problem.
    - chimeracoder 9y ago
      > Well the alternate is capacity. They only have so many doctors on staff to supervise which limits the slots. Think of it as a management problem. First: residents are doctors. Second: Yes, they ratio of residents to attendings is fixed, by law, as is the number of hours that they're allowed to work per week. Both of those were fixed because we found that working residents 100-120 hours/week and without enough attendings resulted in mistakes and people dying. Since this ratio is fixed, it means that hiring 4 more residents also means hiring an additional attending, and you only get an additional 320 resident-hours/week from them. It turns out that this isn't profitable, because if it were, more hospitals would do it.
      - 9y ago
chii 9y ago
why aren't there more residency spots? Why can't people who need to do residency be forced to go to a (more) far away city that has a lack of doctors and be trained there?
- sndean 9y ago
  > city that has a lack of doctors and be trained there? Residents need lots of close attention by experienced doctors. The current attending:resident ratio is already suboptimal, from what I've seen.
- priam 9y ago
  Residents have a limited ability to choose where they attend residency. The following shows the percentage of residency positions filled by speciality: http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Re...
- SkyPuncher 9y ago
  Because residency programs are very difficult to operate and require a level of staff that not all hospitals have access to. The issue isn't with the supply of graduating students, it's with the number of residency spots. This year 95.3%[0] of graduating students matched to a residency program. Out of 18.5k applicants, only 17.5k matched to an available residency program. 0: http://www.nrmp.org/wp-content/uploads/2017/03/2017-Match-by-the-Numbers.pdf http://www.nrmp.org/wp-content/uploads/2017/03/2017-Match-by...
sndean 9y ago
> Hardly - in fact, there's already been significant downward pressure on these, because the debt level is already at the tipping point. Yeah, by my calculations, my SO is currently taking home around $-1 per hour in residency. Some reasons: ~50k/year, expensive area, ~400k in loans, 8% interest rate. I took a slightly more comfy route, career-wise (Ph.D.). Her bank account will likely surpass mine when she's ready to retire (around 55-60).
- distances 9y ago
  A bit offtopic, but 8% interest rate on a loan you can't default on sounds bonkers. I'd rather expect something like 0.5 percentage points over the current interbank offered rate.
  - sndean 9y ago
    We really need to refinance, but the best we can find is ~7%, I think? Most of the residents I've been around either seem to be in denial about how terrible their debt situation is or quickly change the subject.
    - distances 9y ago
      Yeah, I didn't mean that you could find a much better deal. Just that the loan market itself is seriously broken with these kind of interest rates.
- SkyPuncher 9y ago
  I did a similar calculation with my S.O. At the time she's licensed, she'll be over a million dollars behind where she would have been if she went straight into industry. Break even is something like 25 years down the road - even with "high doctor salaries"
  - mac01021 9y ago
    a million dollars behind where she would have been if she went straight into what industry?
deleted 9y ago
[deleted]
danblick 9y ago
Restricting access to medical education (certification) is only one way to restrict supply. Another way is to require certification for more kinds of activities in the first place. If Americans want access to less expensive healthcare, why not make it so that some kinds of medical treatment are available from people with ~2 years of education instead of 10? (Yes, the treatment would be inferior, but also much less expensive.) Also, when IBM's Watson becomes the world's best diagnostician (Any Day Now), what will its legal status be? Probably IBM would be happy with a special exception to the law that makes it hard for other computer companies to enter the market?
- chimeracoder 9y ago
  > If Americans want access to less expensive healthcare, why not make it so that some kinds of medical treatment are available from people with ~2 years of education instead of 10? (Yes, the treatment would be inferior, but also much less expensive.) We already have. It turns out that patients generally don't want this. When given the choice, they generally opt for the practitioner with more training (the physician) over the one with less (an NP or PA). Sure, we can (and do) pass these costs on to the patient, or (in some cases) force them to use the cheaper option, but at that point, you're literally talking about either: (A) forcing patients to assume the costs of their care directly, either entirely or in proportion; or (B) forcing patients to use the lower-cost, lower-quality option Politically, people don't like (A) because it means patients' access to quality medicine is restricted by their ability to pay. And people don't like (B) because nobody likes to be told that they can't have access to the top level of quality (whether or not they're expected to pay for it themselves).
  - warcher 9y ago
    Man, pro tip- always go with a PA over an actual doctor for most general purpose visits. Doctors are waaaaaaaaay harried and checked out of the process. PA all the way. Honestly, even for hard problems I'm half inclined to go with a PA first, just because getting through to a doctor is so difficult, and there's always an easier solution they're going to try to make you prove won't work (to save themselves a little trouble).
rayiner 9y ago
That's an interesting theory. It seems to parallel the situation in the legal field. Unlike in medicine, there's no shortage of JD graduates--there are about twice as many graduates as there are legal jobs for them. But the bottleneck for the supply of trained lawyers is the number of opportunities to get real-world experience, which is limited by the underlying economy (the number of trials, the number of mergers, etc.).
chrisseaton 9y ago
> the typical person who enters medical school can expect to pay off their medical school debt in their 40s. That level of debt load Does how long it takes someone to pay a debt off say anything at all about how big the debt load was? You've juxtaposed these sentences as if it does. Many people pay off their student loans last, as they're usually very low interest. You could have a student debt into your 40s but not because you can't pay it off - rather because it's cheaper than your mortgage. Why pay off a cheap debt to buy a new expensive one? People probably pay off their student debts in their 40s as they part of pay off the last of the mortgages and look to finally get rid of other debts.
- jcadam 9y ago
  Yea, I'm 37 and have about $2,500 of student loan debt left. I could pretty much pay off the balance whenever, but the interest is low, the monthly payment is low, so meh.
- chimeracoder 9y ago
  > Many people pay off their student loans last, as they're usually very low interest. You could have a student debt into your 40s but not because you can't pay it off - rather because it's cheaper than your mortgage. As explained below, no, the debt load that doctors hold is not very low interest. It's in the line of 8-10%. For contrast, I have credit cards that have APRs within striking distance of those rates, and that's consumer debt. You seem to be thinking of undergraduate student loan debt, which is heavily subsidized.
siculars 9y ago
This. Residency is the bottleneck and is funded mostly by the Govt. I'm not a doctor but have worked in healthcare the majority of my career and have family members who are doctors. Doctors deserve what they are paid. Period. https://www.texastribune.org/2017/11/16/regents-vote-create-medical-school-university-houston/ https://www.texastribune.org/2017/11/16/regents-vote-create-...
- tptacek 9y ago
  What does "deserve" have to do with it? People who work at Walmart deserve a living wage and a financially secure retirement, too. If there's an artificial restriction in the supply of doctors (because the government sets an arbitrary limit on the number of residency slots it will fund), then doctor salaries are inflated by government fiat. If we increase the number of residency slots to reduce the price of medical care --- which everyone seems to agree we badly need to do --- then doctor compensation will decrease. You seem to believe that's a bad thing.
  - siculars 9y ago
    Everyone deserves to be paid fairly. There is a difference between a doctor and someone who works at Walmart. You seem to discount the fact that there is infinite demand for doctors in specific and healthcare in general.
cat199 9y ago
> who wants to be past child-bearing age by the time they've paid off their debt, when they can just go into another better-paying field without any of that)? doesn't matter if the non-debt income is substantially higher.. most would rather take 500k a year with 100k of debt repayment over 100k a year with none..
SilasX 9y ago
Every time the topic comes up, you bring up the Medicare funding issue. Every time I explain why that doesn't seem to make sense: If there are more aspiring doctors than can fill the subsidized slots (there are), you can balance demand and supply by passing some of the costs on to the resident[1]; many will still gladly accept this because of the extreme returns to becoming a doctor. The fact that they don't allow that happen is not a funding issue. You can further massively increase the supply at little cost to doctor quality by getting rid of the pointless four-year degree pre-requisite. (vindicating the blame placed on the AMA) More generally, if demand vastly exceeds supply (as it does here), subsidies can't be the bottleneck. To reiterate the analogy (from the past copies of this exchange), it would be like saying the musical Hamilton can't come to LA because the TSA won't pay for the plane tickets to get the cast down there. No: there is enough demand to cover the cost of airfare. And there is enough demand to cover the shortfalls in resident subsides. [1] Concretely: instead of funding 100,000 slots at 100%, fund 120,000 at 80% or something like that.
- chimeracoder 9y ago
  > Every time the topic comes up, you bring up the Medicare funding issue. Every time I explain why that doesn't seem to make sense: you can balance demand and supply by passing some of the costs on to the resident[1]; many will still gladly accept this because of the extreme returns to becoming a doctor. And every time, I've explained that there aren't "extreme returns" to becoming a doctor. After accounting for all the expenses that physicians are required to pay out-of-pocket (which are not tax-deductible, due to AMT), the expected take-home pay is lower than what a mid-career engineer at Google or Microsoft makes, And the debt load is already high enough that it's discouraging people from entering the field[0][1][2], due to both the size and the risk.. Making medicine an even riskier bet (by taking on an even larger debt load with a longer time horizon) isn't going to solve any of that; it'll just lower the overall quality. At that point, it's more efficient to talk about NPs and PAs than piling on more debt to physicians. [0] https://news.ycombinator.com/item?id=15758833 https://news.ycombinator.com/item?id=15758833 [1] https://news.ycombinator.com/item?id=15757466 https://news.ycombinator.com/item?id=15757466 [2] https://news.ycombinator.com/item?id=15758984 https://news.ycombinator.com/item?id=15758984
sol_remmy 9y ago
> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools >> They do not. You may be confusing the AMA (which less than 25% of doctors even belong to) with the AAMC. Actually the AMA is the problem. They lobby to uphold the incredibly strict licensing requirements that doctors use to maintain the exclusivity of their job. Doctor licensure requirements are stricter in America than most of Europe. For instance, why do doctors NEED to do a 4-year undergrad degree before medical school? Why do they NEED to go to a 2+ year residency after medical school? In Europe, students can go straight to medical school from high school. Each additional licensure requirement to become a doctor decreases the supply of new doctors, increases the salary of current doctors, and increases the cost to consumers. https://mises.org/library/how-government-helped-create-coming-doctor-shortage https://mises.org/library/how-government-helped-create-comin...
- chimeracoder 9y ago
  > For instance, why do doctors NEED to do a 4-year undergrad degree before medical school? They don't. Medical schools can accept students straight out of high school, as long as they've completed the required pre-medical coursework. They don't, however, because those students drastically underperform their peers who received an undergraduate degree in a different field. > Why do they NEED to go to a 2+ year residency after medical school? Because without it, they literally have never been trained to practice medicine. Where do you get the idea that Europe is somehow different? Residency is required (and comparably long) in the UK, Germany, etc.
  - FireBeyond 9y ago
    > Medical schools can accept students straight out of high school, as long as they've completed the required pre-medical coursework. They don't, however, because those students drastically underperform their peers who received an undergraduate degree in a different field. I guess all those Australian medical schools will be interested in hearing how their graduates "drastically underperform" all these American doctors who did a postgraduate medical school. http://www.med.monash.edu.au/medicine/admissions/direct-entry/course-outline.html http://www.med.monash.edu.au/medicine/admissions/direct-entr... - Bachelor of Medicine, a 5 year undergraduate degree with direct entry from school, and the 5th year being clinical rotations. Seems to work well enough, to me, as someone who has used physicians extensively in both countries, and worked in healthcare in both. "drastically underperforming" doesn't really fit that picture.

zellyn 9y ago

Is this part of the article incorrect? > In recent years, the number of medical residents has become so restricted that even the American Medical Association is pushing to have the number of slots increased. The major obstacle at this point is funding. It costs a teaching hospital roughly $150,000 a year for a residency slot. Most of the money comes from Medicare, with a lesser amount from Medicaid and other government sources. The number of slots supported by Medicare has been frozen for two decades after Congress lowered it in 1997 at the request of the American Medical Association and other doctors’ organizations.

jjoonathan 9y ago
Does it cost $150k/yr of actual concrete costs or does it cost $150k/yr because that's what they're used to receiving and they want the gravy train to continue?
- chimeracoder 9y ago
  > Does it cost $150k/yr of actual concrete costs or does it cost $150k/yr because that's what they're used to receiving and they want the gravy train to continue? There's no "gravy train" - residency programs are not self-sufficient without this money from Medicare. It costs a lot to train a doctor, and that's even paying doctors less than minimum wage in many areas[0]. If they were, hospitals would be free to open as many residency programs as they wanted without Medicare's subsidies, except they generally don't. There are very few non-Medicare funded residency positions, and they tend to be very special cases in obscure regions. [0] The average resident salary comes out to $12.25/hour, which is literally less than minimum wage in some areas.
  - Symmetry 9y ago
    The fact that residents aren't paid much by the hospitals doesn't mean that the hospitals aren't making a net profit, it would normally be evidence that it is profitable for the hospitals. Even working 100 hour weeks all year that salary would only come to $65k leaving another $85k to be accounted for. Some of that is benefits and some is the time used by doctors to train the residents and by hospital administrators to oversee them. But the residents also do work for the hospital that would otherwise have to be done by doctors or nurses. So I'd expect that they are profit centers for the hospital but I'm willing to be convinced otherwise if someone can come up with numbers.
    - chimeracoder 9y ago
      > The fact that residents aren't paid much by the hospitals doesn't mean that the hospitals aren't making a net profit, No, the fact that hospitals don't just hire more residents is what demonstrates that it's not profitable for hospitals to simply hire more residents.
jacobrobbins 9y ago
I was confused by that part too because the article goes on to say teaching colleges "have an incentive to offer residencies in specialties from which they can get the most revenue per resident." My guess is the 150K number ignores the revenue contribution of the residents (which must be significant because they carry out a significant amount of the work that requires a doctor at a hospital) I did a google search and found one article that seems to confirm this: "Whether the programs are ultimately costs or moneymakers for hospitals is mostly unknown. Expenses tied directly to the programs are tracked, but overall cost-benefit accounting that would take into account such things as savings or lower medical bills for patients from the use of lower-paid residents instead of practicing physicians isn't done." http://www.modernhealthcare.com/article/20150719/news/307199999 http://www.modernhealthcare.com/article/20150719/news/307199... The argument that federal funding is the only way to create more educational "seats" for doctors seems strange since the article claims they are paid much more than other fields, and is not really laid out well in the article.
- chimeracoder 9y ago
  > but overall cost-benefit accounting that would take into account such things as savings or lower medical bills for patients from the use of lower-paid residents instead of practicing physicians isn't done This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital. From an accounting or business perspective, it's pretty clear that residency programs don't make money for hospitals. An easy way to reason about this is to remember that nothing's stopping hospitals from opening up residency slots that they self-fund. If residency programs predictably broke even, you'd expect them to do that. Except, almost no hospital does this, because the programs don't predictably break even - in fact, they pretty predictably lose money.
  - canes123456 9y ago
    Not if the government already pays for it. Why open up self-funded slots and show that the government doesn't need to pay for it? If you make a small profit, you are just putting the other pure profit slots at risk...
sjg007 9y ago
Or you know, hospitals with residency programs could just use of the massive insurance money they make to fund residency positions. It's not like the residents aren't employees or something.. Even the medicaid/medicare procedures are reimbursable.
- chimeracoder 9y ago
  > Even the medicaid/medicare procedures are reimbursable. Medicare reimburses rates below-cost. About 7% below COGS, which means they lose money per-patient, even before they have to pay doctors, nurses, janitorial staff, etc. > Or you know, hospitals with residency programs could just use of the massive insurance money they make to fund residency positions. The "massive insurance money" is used to subsidize the losses that hospitals make on Medicare patients. > It's not like the residents aren't employees or something Great point. And that's why companies generally don't hire employees unless they work they do is profitable for the company. As it turns out, residents are not profitable for hospitals, which is why hospitals don't "just hire more of them".
  - sanderjd 9y ago
    You keep giving me the sense (like with your "7% below COGS" statistic) that you do actually know why residencies aren't profitable, but you keep making an indirect economic argument instead of talking about that directly. All anyone in this thread is trying to figure out is why folks getting paid poorly to do work that we know costs tons of money (because we see the bills) would incur net negative profit.
    - chimeracoder 9y ago
      > All anyone in this thread is trying to figure out is why folks getting paid poorly to do work that we know costs tons of money (because we see the bills) would incur net negative profit. Because hospitals have to pay: - residents' salaries - attendings' salaries - health insurance - residents' insurance (for practicing) - licensing fees - taxes It turns out, that all comes out to a lot of money. And hiring additional residents doesn't really save them much money, or bring in much additional revenue. The costs are greater than the revenue or savings. So, it's not profitable. > to do work that we know costs tons of money (because we see the bills) That's a question of medical billing, which is a whole other separate topic. In short: hospitals don't receive anywhere near the sticker amount for those bills, and a massive chunk of reimbursements from privately-insured patients goes towards recouping the losses that Medicare and Medicaid patients incur (as explained elsewhere, hospitals lose money on a per-patient basis for publicly-insured patients).
mattmcknight 9y ago
I think it is correct. They pushed for a cap, but are now pushing for an increase. ...the AAMC is now calling for an annual increase of 3000 Medicare-funded slots. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978854/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978854/ According to the above article, new programs are not capped. However, the bureaucracy hurdles you are required to jump to establish such a residency program is huge.

hkmurakami 9y ago

Iirc residents are a profit center for hospitals, meaning that if they really wanted to, residency slots could be self funded by the host institution without federal funding. That line of reasoning sounds like an attempt at obfuscation (not necessarily by you, but by the hospitals and medical profession in general).

chimeracoder 9y ago
> Iirc residents are a profit center for hospitals, meaning that if they really wanted to, residency slots could be self funded by the host institution without federal funding. That line of reasoning sounds like an attempt at obfuscation (not necessarily by you, but by the hospitals and medical profession in general). They're not. If they were a profit center, there would be more of them, unless you think that hospitals would willingly refuse to do something that's clearly profitable for them.
- sjg007 9y ago
  Well the alternate is capacity. They only have so many doctors on staff to supervise which limits the slots. Think of it as a management problem.
  - chimeracoder 9y ago
    > Well the alternate is capacity. They only have so many doctors on staff to supervise which limits the slots. Think of it as a management problem. First: residents are doctors. Second: Yes, they ratio of residents to attendings is fixed, by law, as is the number of hours that they're allowed to work per week. Both of those were fixed because we found that working residents 100-120 hours/week and without enough attendings resulted in mistakes and people dying. Since this ratio is fixed, it means that hiring 4 more residents also means hiring an additional attending, and you only get an additional 320 resident-hours/week from them. It turns out that this isn't profitable, because if it were, more hospitals would do it.
    - 9y ago

chii 9y ago

why aren't there more residency spots? Why can't people who need to do residency be forced to go to a (more) far away city that has a lack of doctors and be trained there?

sndean 9y ago
> city that has a lack of doctors and be trained there? Residents need lots of close attention by experienced doctors. The current attending:resident ratio is already suboptimal, from what I've seen.
priam 9y ago
Residents have a limited ability to choose where they attend residency. The following shows the percentage of residency positions filled by speciality: http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Re...
SkyPuncher 9y ago
Because residency programs are very difficult to operate and require a level of staff that not all hospitals have access to. The issue isn't with the supply of graduating students, it's with the number of residency spots. This year 95.3%[0] of graduating students matched to a residency program. Out of 18.5k applicants, only 17.5k matched to an available residency program. 0: http://www.nrmp.org/wp-content/uploads/2017/03/2017-Match-by-the-Numbers.pdf http://www.nrmp.org/wp-content/uploads/2017/03/2017-Match-by...

sndean 9y ago

> Hardly - in fact, there's already been significant downward pressure on these, because the debt level is already at the tipping point. Yeah, by my calculations, my SO is currently taking home around $-1 per hour in residency. Some reasons: ~50k/year, expensive area, ~400k in loans, 8% interest rate. I took a slightly more comfy route, career-wise (Ph.D.). Her bank account will likely surpass mine when she's ready to retire (around 55-60).

distances 9y ago
A bit offtopic, but 8% interest rate on a loan you can't default on sounds bonkers. I'd rather expect something like 0.5 percentage points over the current interbank offered rate.
- sndean 9y ago
  We really need to refinance, but the best we can find is ~7%, I think? Most of the residents I've been around either seem to be in denial about how terrible their debt situation is or quickly change the subject.
  - distances 9y ago
    Yeah, I didn't mean that you could find a much better deal. Just that the loan market itself is seriously broken with these kind of interest rates.
SkyPuncher 9y ago
I did a similar calculation with my S.O. At the time she's licensed, she'll be over a million dollars behind where she would have been if she went straight into industry. Break even is something like 25 years down the road - even with "high doctor salaries"
- mac01021 9y ago
  a million dollars behind where she would have been if she went straight into what industry?

deleted 9y ago

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danblick 9y ago

Restricting access to medical education (certification) is only one way to restrict supply. Another way is to require certification for more kinds of activities in the first place. If Americans want access to less expensive healthcare, why not make it so that some kinds of medical treatment are available from people with ~2 years of education instead of 10? (Yes, the treatment would be inferior, but also much less expensive.) Also, when IBM's Watson becomes the world's best diagnostician (Any Day Now), what will its legal status be? Probably IBM would be happy with a special exception to the law that makes it hard for other computer companies to enter the market?

chimeracoder 9y ago
> If Americans want access to less expensive healthcare, why not make it so that some kinds of medical treatment are available from people with ~2 years of education instead of 10? (Yes, the treatment would be inferior, but also much less expensive.) We already have. It turns out that patients generally don't want this. When given the choice, they generally opt for the practitioner with more training (the physician) over the one with less (an NP or PA). Sure, we can (and do) pass these costs on to the patient, or (in some cases) force them to use the cheaper option, but at that point, you're literally talking about either: (A) forcing patients to assume the costs of their care directly, either entirely or in proportion; or (B) forcing patients to use the lower-cost, lower-quality option Politically, people don't like (A) because it means patients' access to quality medicine is restricted by their ability to pay. And people don't like (B) because nobody likes to be told that they can't have access to the top level of quality (whether or not they're expected to pay for it themselves).
- warcher 9y ago
  Man, pro tip- always go with a PA over an actual doctor for most general purpose visits. Doctors are waaaaaaaaay harried and checked out of the process. PA all the way. Honestly, even for hard problems I'm half inclined to go with a PA first, just because getting through to a doctor is so difficult, and there's always an easier solution they're going to try to make you prove won't work (to save themselves a little trouble).

rayiner 9y ago

That's an interesting theory. It seems to parallel the situation in the legal field. Unlike in medicine, there's no shortage of JD graduates--there are about twice as many graduates as there are legal jobs for them. But the bottleneck for the supply of trained lawyers is the number of opportunities to get real-world experience, which is limited by the underlying economy (the number of trials, the number of mergers, etc.).

chrisseaton 9y ago

> the typical person who enters medical school can expect to pay off their medical school debt in their 40s. That level of debt load Does how long it takes someone to pay a debt off say anything at all about how big the debt load was? You've juxtaposed these sentences as if it does. Many people pay off their student loans last, as they're usually very low interest. You could have a student debt into your 40s but not because you can't pay it off - rather because it's cheaper than your mortgage. Why pay off a cheap debt to buy a new expensive one? People probably pay off their student debts in their 40s as they part of pay off the last of the mortgages and look to finally get rid of other debts.

jcadam 9y ago
Yea, I'm 37 and have about $2,500 of student loan debt left. I could pretty much pay off the balance whenever, but the interest is low, the monthly payment is low, so meh.
chimeracoder 9y ago
> Many people pay off their student loans last, as they're usually very low interest. You could have a student debt into your 40s but not because you can't pay it off - rather because it's cheaper than your mortgage. As explained below, no, the debt load that doctors hold is not very low interest. It's in the line of 8-10%. For contrast, I have credit cards that have APRs within striking distance of those rates, and that's consumer debt. You seem to be thinking of undergraduate student loan debt, which is heavily subsidized.

siculars 9y ago

This. Residency is the bottleneck and is funded mostly by the Govt. I'm not a doctor but have worked in healthcare the majority of my career and have family members who are doctors. Doctors deserve what they are paid. Period. https://www.texastribune.org/2017/11/16/regents-vote-create-medical-school-university-houston/ https://www.texastribune.org/2017/11/16/regents-vote-create-...

tptacek 9y ago
What does "deserve" have to do with it? People who work at Walmart deserve a living wage and a financially secure retirement, too. If there's an artificial restriction in the supply of doctors (because the government sets an arbitrary limit on the number of residency slots it will fund), then doctor salaries are inflated by government fiat. If we increase the number of residency slots to reduce the price of medical care --- which everyone seems to agree we badly need to do --- then doctor compensation will decrease. You seem to believe that's a bad thing.
- siculars 9y ago
  Everyone deserves to be paid fairly. There is a difference between a doctor and someone who works at Walmart. You seem to discount the fact that there is infinite demand for doctors in specific and healthcare in general.

cat199 9y ago

> who wants to be past child-bearing age by the time they've paid off their debt, when they can just go into another better-paying field without any of that)? doesn't matter if the non-debt income is substantially higher.. most would rather take 500k a year with 100k of debt repayment over 100k a year with none..

SilasX 9y ago

Every time the topic comes up, you bring up the Medicare funding issue. Every time I explain why that doesn't seem to make sense: If there are more aspiring doctors than can fill the subsidized slots (there are), you can balance demand and supply by passing some of the costs on to the resident[1]; many will still gladly accept this because of the extreme returns to becoming a doctor. The fact that they don't allow that happen is not a funding issue. You can further massively increase the supply at little cost to doctor quality by getting rid of the pointless four-year degree pre-requisite. (vindicating the blame placed on the AMA) More generally, if demand vastly exceeds supply (as it does here), subsidies can't be the bottleneck. To reiterate the analogy (from the past copies of this exchange), it would be like saying the musical Hamilton can't come to LA because the TSA won't pay for the plane tickets to get the cast down there. No: there is enough demand to cover the cost of airfare. And there is enough demand to cover the shortfalls in resident subsides. [1] Concretely: instead of funding 100,000 slots at 100%, fund 120,000 at 80% or something like that.

chimeracoder 9y ago
> Every time the topic comes up, you bring up the Medicare funding issue. Every time I explain why that doesn't seem to make sense: you can balance demand and supply by passing some of the costs on to the resident[1]; many will still gladly accept this because of the extreme returns to becoming a doctor. And every time, I've explained that there aren't "extreme returns" to becoming a doctor. After accounting for all the expenses that physicians are required to pay out-of-pocket (which are not tax-deductible, due to AMT), the expected take-home pay is lower than what a mid-career engineer at Google or Microsoft makes, And the debt load is already high enough that it's discouraging people from entering the field[0][1][2], due to both the size and the risk.. Making medicine an even riskier bet (by taking on an even larger debt load with a longer time horizon) isn't going to solve any of that; it'll just lower the overall quality. At that point, it's more efficient to talk about NPs and PAs than piling on more debt to physicians. [0] https://news.ycombinator.com/item?id=15758833 https://news.ycombinator.com/item?id=15758833 [1] https://news.ycombinator.com/item?id=15757466 https://news.ycombinator.com/item?id=15757466 [2] https://news.ycombinator.com/item?id=15758984 https://news.ycombinator.com/item?id=15758984

sol_remmy 9y ago

> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools >> They do not. You may be confusing the AMA (which less than 25% of doctors even belong to) with the AAMC. Actually the AMA is the problem. They lobby to uphold the incredibly strict licensing requirements that doctors use to maintain the exclusivity of their job. Doctor licensure requirements are stricter in America than most of Europe. For instance, why do doctors NEED to do a 4-year undergrad degree before medical school? Why do they NEED to go to a 2+ year residency after medical school? In Europe, students can go straight to medical school from high school. Each additional licensure requirement to become a doctor decreases the supply of new doctors, increases the salary of current doctors, and increases the cost to consumers. https://mises.org/library/how-government-helped-create-coming-doctor-shortage https://mises.org/library/how-government-helped-create-comin...

chimeracoder 9y ago
> For instance, why do doctors NEED to do a 4-year undergrad degree before medical school? They don't. Medical schools can accept students straight out of high school, as long as they've completed the required pre-medical coursework. They don't, however, because those students drastically underperform their peers who received an undergraduate degree in a different field. > Why do they NEED to go to a 2+ year residency after medical school? Because without it, they literally have never been trained to practice medicine. Where do you get the idea that Europe is somehow different? Residency is required (and comparably long) in the UK, Germany, etc.
- FireBeyond 9y ago
  > Medical schools can accept students straight out of high school, as long as they've completed the required pre-medical coursework. They don't, however, because those students drastically underperform their peers who received an undergraduate degree in a different field. I guess all those Australian medical schools will be interested in hearing how their graduates "drastically underperform" all these American doctors who did a postgraduate medical school. http://www.med.monash.edu.au/medicine/admissions/direct-entry/course-outline.html http://www.med.monash.edu.au/medicine/admissions/direct-entr... - Bachelor of Medicine, a 5 year undergraduate degree with direct entry from school, and the 5th year being clinical rotations. Seems to work well enough, to me, as someone who has used physicians extensively in both countries, and worked in healthcare in both. "drastically underperforming" doesn't really fit that picture.