4 ms·

For some time my read on this situation has been that the "doctor shortage" that produces 7-minute diagnoses stems from a restricted number of residency slots,

by majos 9y ago

For some time my read on this situation has been that the "doctor shortage" that produces 7-minute diagnoses stems from a restricted number of residency slots, which is set (I believe?) by the federal government. I had thought the AMA was influential in lobbying to keep the number of such slots low to prop up doctors' salaries, but with some research it's unclear how true this is. Anyone know? How strong a lobbying force is the AMA, anyway?

arkades 9y ago
The AMA has actually been lobbying quite strongly to expand the number of residency spots. Doctors salaries are generally pushed from the top down by Medicare and not by general supply-and-demand principles. So these shortages don’t lead to salary bumps, they lead to inferior substitutions (expansion of mid-level practice privileges), which actually puts a downward pressure on salary while also providing worse care for the public. The problem with residency slots is that they’re funded as part of the larger Medicare legislation, and no one wants to push for the bump in funding/taxes for Medicare needed to expand it. The reason visits are seven minutes long is because part of a trend that started with the HMOs in the 80s. The hypothesis on the part of insurers was that docs have a general target income - that they don’t work at maximum capacity (in general - obviously wonky things happen at the extremes.) If you reduce per-service billing, docs would maintain constant output to hit their personal target income goal. And... that’s exactly what happened. Since then, insurers have continued to hit against per-service fees, and docs and facilities have continued to shrink the time they alot to each service in order to keep afloat. In fairness, docs don’t have an awful lot of flex on this - they have to meet overhead costs which are fixed regardless of how small their reimbursement gets, and even with pitifully short visits doc real earning power has gone down quite a lot in the last 30 years. Docs work about 3x as hard as they used to, for about one third of the real income. It’s actually a bit scary: there’s not a lot of leeway left in this, and medical education is more expensive than its ever been. Docs carry the financial risk and massive increase in burnout, patients bear the risk of the reduction in time and quality of care, and everyone else is squeezing the juice out of the grapes. Something’s gonna give.
- majos 9y ago
  Interesting. It seems like I was wrong about the AMA then. Is there a reason that a standalone bill cannot secure federal funding for addition residency slots, or is the stumbling block that increasing the number of residency slots will be expensive (even in federal money terms) regardless of how it's enacted?
  - kenesom1 9y ago
    Your comment wasn't wrong. In 1997, The AMA along with five other medical groups lobbied congress to limit the number of medicare-funded residency slots [1, 2]. This limit was enacted in the Balanced Budget Act of 1997 and hasn't changed since then [3]. Hospitals were paid hundreds of millions of dollars to voluntarily reduce the size of their resident training programs [4]. [1] http://articles.baltimoresun.com/1997-03-01/news/1997060012_1_foreign-medical-schools-new-doctors-american-medical http://articles.baltimoresun.com/1997-03-01/news/1997060012_... [2] http://www.nytimes.com/1997/03/01/us/doctors-assert-there-are-too-many-of-them.html http://www.nytimes.com/1997/03/01/us/doctors-assert-there-ar... [3] https://www.cnn.com/2017/03/13/health/train-more-doctors-residency/index.html https://www.cnn.com/2017/03/13/health/train-more-doctors-res... [4] http://www.cnn.com/HEALTH/9708/24/doctor.glut/ http://www.cnn.com/HEALTH/9708/24/doctor.glut/
    - arkades 9y ago
      You posted this two hours after I replied with a list of google results showing you’re two decades out of date. Now it’s -clear- you’re being disingenuous, but for the life of me I cannot fathom why.
      - kenesom1 9y ago
        None of this is outdated. You're trying hard to to rewrite history with downvotes. The 1997 cap on medicare-funded residency slots has remained in place since that time, unchanged despite population growth and an aging population. The current crisis and physician shortage is in large part a result of that two-decades-old legislation which was engineered by the AMA and other major medical groups. Based on your comment history, you trained as a doctor, which is great and absolutely commendable [1]. However, do you feel compelled to troll and post obviously slanted information due to your personal association with the AMA? For the record, I think doctors should get paid well and more than they currently do. Clinics should be run by physicians. But allowing guilds like the AMA to artificially restrict the availability of critical healthcare has resulted in millions of avoidable deaths and serious suffering across the entire population. "The predicted physician shortages will result in decreased access to care for millions of individuals. [...] [A]dding one PCP per 10,000 people would reduce predicted all-cause mortality [...] by 5.31 percent. Translated nationally, this would avert 127,617 deaths." [2] [1] https://news.ycombinator.com/item?id=16337410 https://news.ycombinator.com/item?id=16337410 [2] https://web.stanford.edu/group/sjph/cgi-bin/sjphsite/the-looming-primary-care-physician-shortage-why-it-isnt-just-about-the-physicians/ https://web.stanford.edu/group/sjph/cgi-bin/sjphsite/the-loo...
kenesom1 9y ago
"In 1997, a consortium that included the AAMC, the AMA, and other major organizations declared that [...] 'the United States is on the verge of a serious oversupply of physicians'. The consortium recommended limiting the number of residency positions funded by Medicare, a goal that was partially achieved in the Balanced Budget Act of 1997" [1] See also the 1997 senate finance committee hearings on graduate medical education [2]. [1] http://annals.org/aim/fullarticle/717927 http://annals.org/aim/fullarticle/717927 [2] https://www.finance.senate.gov/imo/media/doc/hrg105-901.pdf https://www.finance.senate.gov/imo/media/doc/hrg105-901.pdf
- arkades 9y ago
  That’s more than twenty years out of date. I can’t help but feel it’s purposely disingenuous, considering all the top google results on the topic point to their efforts to expand residency funding: http://lmgtfy.com/?q=ama+position+on+residency+funding http://lmgtfy.com/?q=ama+position+on+residency+funding

by majos 9y ago

arkades 9y ago

The AMA has actually been lobbying quite strongly to expand the number of residency spots. Doctors salaries are generally pushed from the top down by Medicare and not by general supply-and-demand principles. So these shortages don’t lead to salary bumps, they lead to inferior substitutions (expansion of mid-level practice privileges), which actually puts a downward pressure on salary while also providing worse care for the public. The problem with residency slots is that they’re funded as part of the larger Medicare legislation, and no one wants to push for the bump in funding/taxes for Medicare needed to expand it. The reason visits are seven minutes long is because part of a trend that started with the HMOs in the 80s. The hypothesis on the part of insurers was that docs have a general target income - that they don’t work at maximum capacity (in general - obviously wonky things happen at the extremes.) If you reduce per-service billing, docs would maintain constant output to hit their personal target income goal. And... that’s exactly what happened. Since then, insurers have continued to hit against per-service fees, and docs and facilities have continued to shrink the time they alot to each service in order to keep afloat. In fairness, docs don’t have an awful lot of flex on this - they have to meet overhead costs which are fixed regardless of how small their reimbursement gets, and even with pitifully short visits doc real earning power has gone down quite a lot in the last 30 years. Docs work about 3x as hard as they used to, for about one third of the real income. It’s actually a bit scary: there’s not a lot of leeway left in this, and medical education is more expensive than its ever been. Docs carry the financial risk and massive increase in burnout, patients bear the risk of the reduction in time and quality of care, and everyone else is squeezing the juice out of the grapes. Something’s gonna give.

majos 9y ago
Interesting. It seems like I was wrong about the AMA then. Is there a reason that a standalone bill cannot secure federal funding for addition residency slots, or is the stumbling block that increasing the number of residency slots will be expensive (even in federal money terms) regardless of how it's enacted?
- kenesom1 9y ago
  Your comment wasn't wrong. In 1997, The AMA along with five other medical groups lobbied congress to limit the number of medicare-funded residency slots [1, 2]. This limit was enacted in the Balanced Budget Act of 1997 and hasn't changed since then [3]. Hospitals were paid hundreds of millions of dollars to voluntarily reduce the size of their resident training programs [4]. [1] http://articles.baltimoresun.com/1997-03-01/news/1997060012_1_foreign-medical-schools-new-doctors-american-medical http://articles.baltimoresun.com/1997-03-01/news/1997060012_... [2] http://www.nytimes.com/1997/03/01/us/doctors-assert-there-are-too-many-of-them.html http://www.nytimes.com/1997/03/01/us/doctors-assert-there-ar... [3] https://www.cnn.com/2017/03/13/health/train-more-doctors-residency/index.html https://www.cnn.com/2017/03/13/health/train-more-doctors-res... [4] http://www.cnn.com/HEALTH/9708/24/doctor.glut/ http://www.cnn.com/HEALTH/9708/24/doctor.glut/
  - arkades 9y ago
    You posted this two hours after I replied with a list of google results showing you’re two decades out of date. Now it’s -clear- you’re being disingenuous, but for the life of me I cannot fathom why.
    - kenesom1 9y ago
      None of this is outdated. You're trying hard to to rewrite history with downvotes. The 1997 cap on medicare-funded residency slots has remained in place since that time, unchanged despite population growth and an aging population. The current crisis and physician shortage is in large part a result of that two-decades-old legislation which was engineered by the AMA and other major medical groups. Based on your comment history, you trained as a doctor, which is great and absolutely commendable [1]. However, do you feel compelled to troll and post obviously slanted information due to your personal association with the AMA? For the record, I think doctors should get paid well and more than they currently do. Clinics should be run by physicians. But allowing guilds like the AMA to artificially restrict the availability of critical healthcare has resulted in millions of avoidable deaths and serious suffering across the entire population. "The predicted physician shortages will result in decreased access to care for millions of individuals. [...] [A]dding one PCP per 10,000 people would reduce predicted all-cause mortality [...] by 5.31 percent. Translated nationally, this would avert 127,617 deaths." [2] [1] https://news.ycombinator.com/item?id=16337410 https://news.ycombinator.com/item?id=16337410 [2] https://web.stanford.edu/group/sjph/cgi-bin/sjphsite/the-looming-primary-care-physician-shortage-why-it-isnt-just-about-the-physicians/ https://web.stanford.edu/group/sjph/cgi-bin/sjphsite/the-loo...

kenesom1 9y ago

"In 1997, a consortium that included the AAMC, the AMA, and other major organizations declared that [...] 'the United States is on the verge of a serious oversupply of physicians'. The consortium recommended limiting the number of residency positions funded by Medicare, a goal that was partially achieved in the Balanced Budget Act of 1997" [1] See also the 1997 senate finance committee hearings on graduate medical education [2]. [1] http://annals.org/aim/fullarticle/717927 http://annals.org/aim/fullarticle/717927 [2] https://www.finance.senate.gov/imo/media/doc/hrg105-901.pdf https://www.finance.senate.gov/imo/media/doc/hrg105-901.pdf

arkades 9y ago
That’s more than twenty years out of date. I can’t help but feel it’s purposely disingenuous, considering all the top google results on the topic point to their efforts to expand residency funding: http://lmgtfy.com/?q=ama+position+on+residency+funding http://lmgtfy.com/?q=ama+position+on+residency+funding