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Why does nobody look at the medical profession as the racket it is? You don't need to be an MD to handle %80 of hospital visits, and you can train trades people

Why does nobody look at the medical profession as the racket it is? You don't need to be an MD to handle %80 of hospital visits, and you can train trades people to handle most emergencies. Insurance companies are awful, but seriously, we can train field medics to do stitches and set bones, why should it cost $3000 to have an MD do it? Listening the hand wringing about it is infuriating when you realize that the reason you have to wait for simple procedures that barbers used to do is because there is a med school bottleneck.

gowld 7y ago
The US has nurses and PAs for this stuff. A doctor is only needed as a staff supervisor, much like an engineering project only needs one licensed engineer to sign off. It costs <$300 of an MD's time to set a bone, even if you get MD service. GP doctors aren't very expensive. The costs are elsewhere.
arkades 7y ago
Everyone with absolutely no knowledge of our healthcare system "look(s) at the medical profession as the racket it is." They then proceed to point at things as the root cause that every health policy expert in the country can tell you is not the root cause, and that doesn't hold up to even slight scrutiny by comparison with other, similar, countries.
- asveikau 7y ago
  Could that just be a way of saying that health policy experts are attached to the status quo? Do they have a consensus on how to fix commonly cited problems, and agreement that we ought to?
  - arkades 7y ago
    Yes to both of the latter, but no authority to do so. Academics ain't legislators.
    - motohagiography 7y ago
      So, I've spent over a decade consulting to public sector health agencies in charge of delivering everything from electronic health records to cancer research to chronic disease management, long terms care, mental health, and privacy, among many other areas. Before you call someone ignorant and say that the bureaucracy disagrees and so what possible standing could I have, consider a little bit of charitable reasoning would add some much needed credibility to the objection.
      - arkades 7y ago
        Oh, I didn't judge you on your professional history. I judged you on the content of your comment - that is to say, on the merit of your statement rather than an appeal to authority. That you've done consulting to the healthcare sector doesn't mean much of anything to me, one way or another. Heck, the IT consultant for our CTO in my health chain can say the same, and all he does is EMR rollouts. He has about 0% understanding of healthcare policy, or how the system actually works. He understands EMR implementations. The financial analyst consulting to our COO has been in the hc sector for about a year and his knowledge of actual hc policy outstrips the EMR guy by at least an order of magnitude. As a physician and healthcare policy expert, I don't much need any credibility, outside of that provided by the contents of my posts. I'm happy to let them speak for themselves, rather than appeal to authority - the latter of which is essentially non-existent in this pseudonymous context.
        motohagiography 7y ago
        The #1 job of policy analysts is to preserve their ability to make policy. While you have spent a respectable amount of time working in bureaucracies, a criticism of the legitimacy of those institutions' ability to improve outcomes is not something people encounter on the inside. Meaningful endogenous change isn't going to happen. As the job of physician is being reduced to that of a health care service project manager who assembles and directs specialists using technology tools, it's becoming vulnerable to the same technology changes that sidelined project managers. Skill is pareto distributed, and there is a long tail of medical services that could be done by apprenticed tradespeople, and the only thing preventing that is medical associations - and as you say, holding litigation risk.
- pasquinelli 7y ago
  So what's up then? Or if you can't say what's up -- fair enough, you're not an oracle -- what slight scrutiny in particular topples this particular root cause hypothesis?
  - solveit 7y ago
    It doesn't cost 3k to have an MD do stitches. That money's going somewhere else (Actual experts may or may not know where).
    - arkades 7y ago
      Cost of ER, as has been said on a million posts like this throughout HN's history, are due to the fact that you're taking up one of the highest-overhead spaces in the hospital, a lot of which is malpractice-insurance-related. The criticism almost inevitably goes like this, "I went to (the absolute most expensive service center for service X) and it cost a shit-ton!" And it's almost inevitably quoting the price for an uninsured patient - because at insured, contracted rates, your OOP responsibility for ER visits is rarely >1K. Then people complain about itemization (which is why it's so rarely done)("$50 band-aids?! I could have bought my own!"), even though the itemization is nonsense. Overhead has to be allocated, and that's the itemization price - the "band-aids" item includes everything from their storage, the staff member deploying them, etc. It's not $50 band-aids. It's $50 of going to a hospital, seeing an ER doc, and having a nurse put on a band-aid for you. Don't want $50 band-aids? Go to the pharmacy and put on a band-aid for 30 cents. People pretend price transparency will make things better, but it's not obfuscation that gives rise to this - itemization is price transparency, and people who don't understand the idea of allocating overhead just get more inflamed by it. By the way, actual cost transparency has winners and losers too. The winner is generally private insurers, who can use it to negotiate reimbursement further downward. The losers are everyone else. It's pretty much never the patient, regardless of what advocates of "patient consumerism" cry. When you're a grain of sand between two massive gears, you don't ever win the game of policy arbitrage. If all you need is stitches, you can go to your PCP ($20-$60), surgeon's private office ($50-$100) or Urgent Care ($50-$200). Instead you go to the highest overhead center, occupy the attention of at least 2 nurses, a mid-level, and a doc, and... yes, pay for all of the above. In a space whose allocated overhead includes the weighted average of "stitches that shouldn't have come in" to "diabetic ketoacidosis with multiple organ failure." Part of our systemic problems is, due to how we're structured, it's borderline impossible for an ER to say (a polite version of) "You're fucking kidding me. We have an urgent care center across the street - go there." [1] We have many, many, many systemic problems. People using the ED as a primary care office and complaining about the disparity in prices is the least egregious of them. [1] In part because hospitals used to try to bounce indigent patients. So now they can't do anything that smacks of bouncing anyone. So even if you try to divert patients from the ED to an in-house Urgent-ish Care, they still have to go through the ED pathway to determine that they're stable (meaning a doc has to evaluate them), before they can be shunted over. And now you're in a hospital, so the overhead of the Urgent-ish Care is already way higher than just having gone to UC to begin with. The hospital has no incentive to establish a spot for providing the same level of care, at high overhead, for lower reimbursement.
amiga_500 7y ago
Other countries have fully trained doctors yet they don't have this problem. Therefore fully trained doctors setting bones is not the problem. It's another problem or set of problems that occurs in the USA.
- new_time 7y ago
  In the 19th and early 20th centuries there was in the US a proliferation of medical schools - many unaffiliated with Universities - with very few entrance requirements, extremely uneven quality of education and little standardization in curriculum. In fact many people became doctors through apprenticeship right up through the turn of the 20th century. Many states had extremely lax or nonexistent licensing requirements. It was quite chaotic and unregulated. In light of this, Abraham Flexner was commissioned by the Carnegie Foundation to produce a report on the state of medical education and to make recommendations. The Flexner Report was published in book form in 1910 and set forth a programme of reform for medical education and the broader healthcare system in America. The structure envisioned by Flexner largely remains with us to this day. The crux of the problem is that in response to a very chaotic system, order was imposed in the form of strict licensing and educational requirements which made sense given the problems of the time but have contributed to new problems in our time. Outdated regulations, standard practices and conventions have artificially restricted supply of qualified medical personnel in America and it's time we address these structural issues. Targeted reform of the system is the best solution for American healthcare.
  - wahern 7y ago
    The number of physicians per capita in the U.S. is greater than Canada or Japan, both of which have cheaper healthcare. Yes, apparently most European countries have a significantly higher ratio. But, interestingly, all the Anglo countries (UK/GB, US, AU, IE) seem to cluster together. The issue seems more complex than something simple like number of physicians. A high ratio is unnecessary for cheaper, quality healthcare (e.g. Canada, Japan), and whatever dynamics control the ratio in the U.S. (schooling, licensing) probably also exist in other countries with similar legal systems, but with different outcomes. Data: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=US-FR-DE-JP-IT-AU-GB-IE-CA https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?location... EDIT: Looking at the ratio of GP to specialists for Canada (~1:1) and California (~1:2), it's more likely that the problem (such as it relates to numbers of physicians) is that we have too many specialists in the U.S. See https://www.cma.ca/sites/default/files/pdf/Physician%20Data/02-physicians-by-specialty-age-e.pdf https://www.cma.ca/sites/default/files/pdf/Physician%20Data/... and https://www.chcf.org/wp-content/uploads/2018/06/CAPhysicianSupply2018.pdf https://www.chcf.org/wp-content/uploads/2018/06/CAPhysicianS... And that probably has to do with 1) how we consume healthcare in this country and 2) the career expectations of medical students. And arguably this is a typical pattern of American culture more generally and in all our industries. Everybody wants to push the envelope and everybody expects the products and services they consume to be bleeding edge, both as a cultural expectation and in pursuit of higher profits--as consumers we tend to assume more costly services are more advanced.
deleted 7y ago
[deleted]
abakker 7y ago
My sister is a veterinarian. Honestly, I think I’d rather have her give me stitches than most doctors. She’s had to give so many more than most doctors.
- chrisco255 7y ago
  After seeing a vet work on a horse that had its leg stripped of all of its skin, I would agree.
- stormdennis 7y ago
  Most doctors aren't surgeons though.
- hycaria 7y ago
  I am a veterinarian too. It's ridiculous how stitches are so impossible to have access to (at least where I live). Last time I had a coworker fix me up after a bicycle fall (was on the elbow sadly, could hardly do it solo), not because of cost where I live, gladly, but because a MD can't stitch me, so it's either the emergency department, or MD and then only referal (so yet another appointment and all the trouble that is) to a surgeon. I mean I get it, wounds can turn (really) bad, but other people than MDs (like nurses, or pharmacists were even discussed for this in France) should be able to do them, and give a follow up appointment to some MD / nurse a few days later to check if recovery is going well. Only time tells how the healing goes anyways.
unsrsly 7y ago
LOL. I agree with you- healthcare should be way more accessible and affordable. But I suspect that if you looked at what it costs to train and deploy a field medic in today's military, you would find that it is a lot. And the many reasons for that very high expense probably echo some of the issues that also exist in healthcare. Hint: the MD isn't getting anywhere near $3000 to do your stitches.
- armenarmen 7y ago
  If you were to drop the arms training and all that stuff from a “civilian field medic’s” training surely the cost would come down. Not to mention that the Airfoce purchasing $10k toilet seats and related financially irresponsible decisions would probably be less likely to happen in any non governmental org
hannasanarion 7y ago
Yeah, it's definitely not the insurance companies that extort everyone for outrageous fees under threat of death thus creating most profitable industry in the world, yet producing nothing of value whatsoever who are the problem, it's all the doctors fault.
- armenarmen 7y ago
  This. Insurance companies want medical procedures to cost more so that they can charge higher fees and punish those who don’t choose to participate in their industry.
  - HPsquared 7y ago
    Exactly, it's the same for car insurance where (industry-wide) high repair costs mean the insurance industry has more turnover from which to extract a percentage profit margin. Exactly the same forces apply for medical insurance.
mundo 7y ago
There's a parallel here, between the medical field requiring 8+ years of schooling to put in stitches, and the days (not so distant) when most software companies wouldn't hire you to write an online mortgage interest calculator unless you had passed classes in compiler design and calculus. edit: that said though, your opening question is kind of odd - doesn't pretty much everyone view the medical field as a racket?
stormdennis 7y ago
A sibling of mine is a very highly paid medical specialist. She studied, worked and studied more doing exams into her early thirties. Combined with having to travel a lot to get experience meant she wasn't able to settle till her mid thirties. Prior to that she earned good money but worked insane hours not including study time. I know because I stayed with her sometimes. I work in a pretty stressful job but I couldn't handle the stress her job entails on a daily basis where she sees extremely ill people in theatre and whose lives are literally in her hands both there and later in the ICU. She's well into her fifties now but still one week a month had to be available to work in the middle of the night if called on a rota. She earns a good multiple of what I do but I think she earns every penny.
- HPsquared 7y ago
  The current system restricts the supply of medics and results in overwork, often sleep-deprived stressed people in a rush to make decisions. It would be better to allow more people in who can take more time and consideration of each case.
lukifer 7y ago
"Do no harm" sounds suspiciously like "don't be evil": https://en.wikipedia.org/wiki/Iatrogenesis https://en.wikipedia.org/wiki/Iatrogenesis Just as with politics, it's mostly well-intentioned, "good people in a bad system"; nonetheless, each individual is perversely-incentivized to normalize the moral hazard.
mrtksn 7y ago
So does the developers. Anyone can code and do %90 of what a developer can do with a very little training. Yet, these are highly paid jobs because It’s not about being able to do it, it’s about understanding what they are doing. This way, they don’t just know how to do it but why to do it and what are the implications of doings it and how to debug it when the outcome is not the expected one. Any junior can probably do %99 of what their seniors can do, yet when you look for a highly paid senior you don’t take a cheap junior as an option. US health system might be a racket but not the health profession. No where else visiting a hospital is a financial decision(yet the med staff is still well paid), you only worry about the medical issue and it’s impact on your life and the lives of your loved ones, except maybe when you need some very novel treatment for your rare condition. I have to add that this way of thinking, in general, is a very blue collar mental model on how world works. Nurses claim that they can do what doctors do, mechanics claim that they can do what engineers do all the time.
- drdeca 7y ago
  There isn’t a legal requirement to have gone to programming school before one can practice software development. (And a good thing too!) If someone wants to hire someone who can kinda program a little, because they charge less, and are likely able to accomplish the task the person has in mind, then they should be free to do that. (Of course, if the task is one where failure causes a big problem, then one should get someone more qualified.)
  - mrtksn 7y ago
    That’s only because of the size if the impact if things go wrong. You need a license too to build a house or drive a truck because it’s actually very easy to do it %99 of the time well but you can’t afford that %1. Low affordance causes spilled blood, blood causes regulations.
    - ggreer 7y ago
      I would argue that bus drivers have a much larger impact in terms of lives lost if things go wrong, yet they have significantly lower wages and require less training. The same goes for pilots and air traffic controllers.
HeadsUpHigh 7y ago
Because it's not. If you actually look at the numbers doctors only get about 1/3 of the money. Furthermore with the kind of money you have to loan it would make no financial sense to become a doctor. Noone is having a good time with this system. Doctors want the insane amounts of work and stress coming from the lack of personnel that justify the salaries just so they can pay the student loans.
robomartin 7y ago
> why should it cost $3000 to have an MD do it? Let me suggest you fire-up a spreadsheet and start to calculate the cost structures surrounding healthcare in the US. I don't think you have enough information yet to fully understand the subject enough to answer the question you posed. I'll suggest you model something like a team conducting surgery at a mid size hospital. You have to model the cost structure each person in that room is subjected to. Three simple items are the cost of their education, malpractice insurance and taxes. The next step is to estimate the number of people who support that team within that hospital. From administration to nurses and janitors. Add to that external services such as labs. Now calculate the equipment costs. You could dig deeper and understand the regulatory costs, taxation and liability equipment manufacturers are subjected to. Interesting point to note: The Trump administration had to guarantee protection from liability before anyone was willing to make even something as simple as an N95 mask for use in hospitals. Now calculate the cost structure for the hospital. Again, regulatory, liability/malpractice, taxation, etc. If the ambulance service is independent, add them to the exercise. If you run through the above exercise you will actually be surprised that it only costs $3,000 for an MD to perform a procedure. Notice insurance isn't anywhere in these calculation. Health insurance is an easy to point to evil, yet it is perhaps the most insignificant portion of the cost matrix that drives the cost of healthcare in the US. In fact, health insurance is NOT a driver, it's a symptom. You cannot fix our medical system by manipulating insurance. If the costs are high, care will be expensive. If the costs are lower, care will become more affordable. And this will drive insurance costs down as a result. Insurance isn't the cause, it's the effect. Remember that next time you hear a politician claim that they can improve things by screwing with insurance. They are lying to you. Don't allow that to happen. Be informed.
- fzeroracer 7y ago
  Logically this may make sense, but in reality it does not. Other countries with more sane healthcare systems have costs that are fractional compared to ours despite having the exact same costs you mention. If the equipment is the same, the admin overhead is the same and the education is the same, then that leaves only one real difference between us and other countries. And that's our Byzantine insurance system.
sacred_numbers 7y ago
I think that there are certainly some issues with an artificial scarcity of doctors as well as overly restrictive regulations requiring MDs for certain procedures that don't require MD training, but the evidence shows that this is not the main driver of high costs. Physician salaries are only about 8% of healthcare spending[1] and according to my own research, only about 20% is due to all healthcare worker salaries (including physicians, nurses, physician assistants, etc. The remaining 80% is medicine, medical supplies, capital costs (MRI machines, hospitals) and administrative costs. Unfortunately there's no single cost that could instantly solve everything if eliminated; there's just a lot of middlemen each taking a tiny portion that add up to a huge total cost. [1]https://www.npr.org/sections/money/2019/03/12/702500408/are-doctors-overpaid https://www.npr.org/sections/money/2019/03/12/702500408/are-...
- HPsquared 7y ago
  There are plenty of ways it could be made cheaper, hugely cheaper, but the regulatory system protects the established players / methods and prevents competition.
wozniacki 7y ago
This. This gets so rarely uttered if ever I'm having a hard time believing it hasn't been down voted by hyper-credentialists on HN. I fully believe the number of doctors allowed to start practicing medicine is heavily controlled using arbitrary rationales and spurious education / training thresholds. There's no need for so much garbage bureaucracy in medical pedagogy especially when so many doctors are paid insanely lofty salaries. The whole enterprise of medicine and the way its practiced in the U.S. ( including HIPAA ), needs some heavy de-bloating.
LatteLazy 7y ago
"Do you want the best medical care?" "Of course" says everyone because it seems like an easy answer. "Then you're sprained ancle will need a team of 20 super MDs, an MRI, CAT scan, sterile isolation ward and a helicopter to get you there. That will be 100 million dollars please!" says the greedy fuck maximising profit, and he's giving you what you said you wanted... This is basically the US system in a nutshell. Other nations have an approach with more focus on affordability, but the US system (from hospitals, to doctors themselves, to insurers, to drug makers, to the courts) is entirely focused on maximum quality. That's what makes it unaffordable. That's also why you don't have teired treatment like you say: an MD is 0.5% better than a trained nurse at setting a bone. They cost 100 times more. But you decide purely based on the 0.5%
brazzy 7y ago
> You don't need to be an MD to handle %80 of hospital visits You do, however, need to be an MD to recognize some of the other 20% as not being part of the 80%.

gowld 7y ago

The US has nurses and PAs for this stuff. A doctor is only needed as a staff supervisor, much like an engineering project only needs one licensed engineer to sign off. It costs <$300 of an MD's time to set a bone, even if you get MD service. GP doctors aren't very expensive. The costs are elsewhere.

arkades 7y ago

Everyone with absolutely no knowledge of our healthcare system "look(s) at the medical profession as the racket it is." They then proceed to point at things as the root cause that every health policy expert in the country can tell you is not the root cause, and that doesn't hold up to even slight scrutiny by comparison with other, similar, countries.

asveikau 7y ago
Could that just be a way of saying that health policy experts are attached to the status quo? Do they have a consensus on how to fix commonly cited problems, and agreement that we ought to?
- arkades 7y ago
  Yes to both of the latter, but no authority to do so. Academics ain't legislators.
  - motohagiography 7y ago
    So, I've spent over a decade consulting to public sector health agencies in charge of delivering everything from electronic health records to cancer research to chronic disease management, long terms care, mental health, and privacy, among many other areas. Before you call someone ignorant and say that the bureaucracy disagrees and so what possible standing could I have, consider a little bit of charitable reasoning would add some much needed credibility to the objection.
    - arkades 7y ago
      Oh, I didn't judge you on your professional history. I judged you on the content of your comment - that is to say, on the merit of your statement rather than an appeal to authority. That you've done consulting to the healthcare sector doesn't mean much of anything to me, one way or another. Heck, the IT consultant for our CTO in my health chain can say the same, and all he does is EMR rollouts. He has about 0% understanding of healthcare policy, or how the system actually works. He understands EMR implementations. The financial analyst consulting to our COO has been in the hc sector for about a year and his knowledge of actual hc policy outstrips the EMR guy by at least an order of magnitude. As a physician and healthcare policy expert, I don't much need any credibility, outside of that provided by the contents of my posts. I'm happy to let them speak for themselves, rather than appeal to authority - the latter of which is essentially non-existent in this pseudonymous context.
      - motohagiography 7y ago
        The #1 job of policy analysts is to preserve their ability to make policy. While you have spent a respectable amount of time working in bureaucracies, a criticism of the legitimacy of those institutions' ability to improve outcomes is not something people encounter on the inside. Meaningful endogenous change isn't going to happen. As the job of physician is being reduced to that of a health care service project manager who assembles and directs specialists using technology tools, it's becoming vulnerable to the same technology changes that sidelined project managers. Skill is pareto distributed, and there is a long tail of medical services that could be done by apprenticed tradespeople, and the only thing preventing that is medical associations - and as you say, holding litigation risk.
pasquinelli 7y ago
So what's up then? Or if you can't say what's up -- fair enough, you're not an oracle -- what slight scrutiny in particular topples this particular root cause hypothesis?
- solveit 7y ago
  It doesn't cost 3k to have an MD do stitches. That money's going somewhere else (Actual experts may or may not know where).
  - arkades 7y ago
    Cost of ER, as has been said on a million posts like this throughout HN's history, are due to the fact that you're taking up one of the highest-overhead spaces in the hospital, a lot of which is malpractice-insurance-related. The criticism almost inevitably goes like this, "I went to (the absolute most expensive service center for service X) and it cost a shit-ton!" And it's almost inevitably quoting the price for an uninsured patient - because at insured, contracted rates, your OOP responsibility for ER visits is rarely >1K. Then people complain about itemization (which is why it's so rarely done)("$50 band-aids?! I could have bought my own!"), even though the itemization is nonsense. Overhead has to be allocated, and that's the itemization price - the "band-aids" item includes everything from their storage, the staff member deploying them, etc. It's not $50 band-aids. It's $50 of going to a hospital, seeing an ER doc, and having a nurse put on a band-aid for you. Don't want $50 band-aids? Go to the pharmacy and put on a band-aid for 30 cents. People pretend price transparency will make things better, but it's not obfuscation that gives rise to this - itemization is price transparency, and people who don't understand the idea of allocating overhead just get more inflamed by it. By the way, actual cost transparency has winners and losers too. The winner is generally private insurers, who can use it to negotiate reimbursement further downward. The losers are everyone else. It's pretty much never the patient, regardless of what advocates of "patient consumerism" cry. When you're a grain of sand between two massive gears, you don't ever win the game of policy arbitrage. If all you need is stitches, you can go to your PCP ($20-$60), surgeon's private office ($50-$100) or Urgent Care ($50-$200). Instead you go to the highest overhead center, occupy the attention of at least 2 nurses, a mid-level, and a doc, and... yes, pay for all of the above. In a space whose allocated overhead includes the weighted average of "stitches that shouldn't have come in" to "diabetic ketoacidosis with multiple organ failure." Part of our systemic problems is, due to how we're structured, it's borderline impossible for an ER to say (a polite version of) "You're fucking kidding me. We have an urgent care center across the street - go there." [1] We have many, many, many systemic problems. People using the ED as a primary care office and complaining about the disparity in prices is the least egregious of them. [1] In part because hospitals used to try to bounce indigent patients. So now they can't do anything that smacks of bouncing anyone. So even if you try to divert patients from the ED to an in-house Urgent-ish Care, they still have to go through the ED pathway to determine that they're stable (meaning a doc has to evaluate them), before they can be shunted over. And now you're in a hospital, so the overhead of the Urgent-ish Care is already way higher than just having gone to UC to begin with. The hospital has no incentive to establish a spot for providing the same level of care, at high overhead, for lower reimbursement.

amiga_500 7y ago

Other countries have fully trained doctors yet they don't have this problem. Therefore fully trained doctors setting bones is not the problem. It's another problem or set of problems that occurs in the USA.

new_time 7y ago
In the 19th and early 20th centuries there was in the US a proliferation of medical schools - many unaffiliated with Universities - with very few entrance requirements, extremely uneven quality of education and little standardization in curriculum. In fact many people became doctors through apprenticeship right up through the turn of the 20th century. Many states had extremely lax or nonexistent licensing requirements. It was quite chaotic and unregulated. In light of this, Abraham Flexner was commissioned by the Carnegie Foundation to produce a report on the state of medical education and to make recommendations. The Flexner Report was published in book form in 1910 and set forth a programme of reform for medical education and the broader healthcare system in America. The structure envisioned by Flexner largely remains with us to this day. The crux of the problem is that in response to a very chaotic system, order was imposed in the form of strict licensing and educational requirements which made sense given the problems of the time but have contributed to new problems in our time. Outdated regulations, standard practices and conventions have artificially restricted supply of qualified medical personnel in America and it's time we address these structural issues. Targeted reform of the system is the best solution for American healthcare.
- wahern 7y ago
  The number of physicians per capita in the U.S. is greater than Canada or Japan, both of which have cheaper healthcare. Yes, apparently most European countries have a significantly higher ratio. But, interestingly, all the Anglo countries (UK/GB, US, AU, IE) seem to cluster together. The issue seems more complex than something simple like number of physicians. A high ratio is unnecessary for cheaper, quality healthcare (e.g. Canada, Japan), and whatever dynamics control the ratio in the U.S. (schooling, licensing) probably also exist in other countries with similar legal systems, but with different outcomes. Data: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=US-FR-DE-JP-IT-AU-GB-IE-CA https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?location... EDIT: Looking at the ratio of GP to specialists for Canada (~1:1) and California (~1:2), it's more likely that the problem (such as it relates to numbers of physicians) is that we have too many specialists in the U.S. See https://www.cma.ca/sites/default/files/pdf/Physician%20Data/02-physicians-by-specialty-age-e.pdf https://www.cma.ca/sites/default/files/pdf/Physician%20Data/... and https://www.chcf.org/wp-content/uploads/2018/06/CAPhysicianSupply2018.pdf https://www.chcf.org/wp-content/uploads/2018/06/CAPhysicianS... And that probably has to do with 1) how we consume healthcare in this country and 2) the career expectations of medical students. And arguably this is a typical pattern of American culture more generally and in all our industries. Everybody wants to push the envelope and everybody expects the products and services they consume to be bleeding edge, both as a cultural expectation and in pursuit of higher profits--as consumers we tend to assume more costly services are more advanced.

deleted 7y ago

[deleted]

abakker 7y ago

My sister is a veterinarian. Honestly, I think I’d rather have her give me stitches than most doctors. She’s had to give so many more than most doctors.

chrisco255 7y ago
After seeing a vet work on a horse that had its leg stripped of all of its skin, I would agree.
stormdennis 7y ago
Most doctors aren't surgeons though.
hycaria 7y ago
I am a veterinarian too. It's ridiculous how stitches are so impossible to have access to (at least where I live). Last time I had a coworker fix me up after a bicycle fall (was on the elbow sadly, could hardly do it solo), not because of cost where I live, gladly, but because a MD can't stitch me, so it's either the emergency department, or MD and then only referal (so yet another appointment and all the trouble that is) to a surgeon. I mean I get it, wounds can turn (really) bad, but other people than MDs (like nurses, or pharmacists were even discussed for this in France) should be able to do them, and give a follow up appointment to some MD / nurse a few days later to check if recovery is going well. Only time tells how the healing goes anyways.

unsrsly 7y ago

LOL. I agree with you- healthcare should be way more accessible and affordable. But I suspect that if you looked at what it costs to train and deploy a field medic in today's military, you would find that it is a lot. And the many reasons for that very high expense probably echo some of the issues that also exist in healthcare. Hint: the MD isn't getting anywhere near $3000 to do your stitches.

armenarmen 7y ago
If you were to drop the arms training and all that stuff from a “civilian field medic’s” training surely the cost would come down. Not to mention that the Airfoce purchasing $10k toilet seats and related financially irresponsible decisions would probably be less likely to happen in any non governmental org

hannasanarion 7y ago

Yeah, it's definitely not the insurance companies that extort everyone for outrageous fees under threat of death thus creating most profitable industry in the world, yet producing nothing of value whatsoever who are the problem, it's all the doctors fault.

armenarmen 7y ago
This. Insurance companies want medical procedures to cost more so that they can charge higher fees and punish those who don’t choose to participate in their industry.
- HPsquared 7y ago
  Exactly, it's the same for car insurance where (industry-wide) high repair costs mean the insurance industry has more turnover from which to extract a percentage profit margin. Exactly the same forces apply for medical insurance.

mundo 7y ago

There's a parallel here, between the medical field requiring 8+ years of schooling to put in stitches, and the days (not so distant) when most software companies wouldn't hire you to write an online mortgage interest calculator unless you had passed classes in compiler design and calculus. edit: that said though, your opening question is kind of odd - doesn't pretty much everyone view the medical field as a racket?

stormdennis 7y ago

A sibling of mine is a very highly paid medical specialist. She studied, worked and studied more doing exams into her early thirties. Combined with having to travel a lot to get experience meant she wasn't able to settle till her mid thirties. Prior to that she earned good money but worked insane hours not including study time. I know because I stayed with her sometimes. I work in a pretty stressful job but I couldn't handle the stress her job entails on a daily basis where she sees extremely ill people in theatre and whose lives are literally in her hands both there and later in the ICU. She's well into her fifties now but still one week a month had to be available to work in the middle of the night if called on a rota. She earns a good multiple of what I do but I think she earns every penny.

HPsquared 7y ago
The current system restricts the supply of medics and results in overwork, often sleep-deprived stressed people in a rush to make decisions. It would be better to allow more people in who can take more time and consideration of each case.

lukifer 7y ago

"Do no harm" sounds suspiciously like "don't be evil": https://en.wikipedia.org/wiki/Iatrogenesis https://en.wikipedia.org/wiki/Iatrogenesis Just as with politics, it's mostly well-intentioned, "good people in a bad system"; nonetheless, each individual is perversely-incentivized to normalize the moral hazard.

mrtksn 7y ago

So does the developers. Anyone can code and do %90 of what a developer can do with a very little training. Yet, these are highly paid jobs because It’s not about being able to do it, it’s about understanding what they are doing. This way, they don’t just know how to do it but why to do it and what are the implications of doings it and how to debug it when the outcome is not the expected one. Any junior can probably do %99 of what their seniors can do, yet when you look for a highly paid senior you don’t take a cheap junior as an option. US health system might be a racket but not the health profession. No where else visiting a hospital is a financial decision(yet the med staff is still well paid), you only worry about the medical issue and it’s impact on your life and the lives of your loved ones, except maybe when you need some very novel treatment for your rare condition. I have to add that this way of thinking, in general, is a very blue collar mental model on how world works. Nurses claim that they can do what doctors do, mechanics claim that they can do what engineers do all the time.

drdeca 7y ago
There isn’t a legal requirement to have gone to programming school before one can practice software development. (And a good thing too!) If someone wants to hire someone who can kinda program a little, because they charge less, and are likely able to accomplish the task the person has in mind, then they should be free to do that. (Of course, if the task is one where failure causes a big problem, then one should get someone more qualified.)
- mrtksn 7y ago
  That’s only because of the size if the impact if things go wrong. You need a license too to build a house or drive a truck because it’s actually very easy to do it %99 of the time well but you can’t afford that %1. Low affordance causes spilled blood, blood causes regulations.
  - ggreer 7y ago
    I would argue that bus drivers have a much larger impact in terms of lives lost if things go wrong, yet they have significantly lower wages and require less training. The same goes for pilots and air traffic controllers.

HeadsUpHigh 7y ago

Because it's not. If you actually look at the numbers doctors only get about 1/3 of the money. Furthermore with the kind of money you have to loan it would make no financial sense to become a doctor. Noone is having a good time with this system. Doctors want the insane amounts of work and stress coming from the lack of personnel that justify the salaries just so they can pay the student loans.

robomartin 7y ago

> why should it cost $3000 to have an MD do it? Let me suggest you fire-up a spreadsheet and start to calculate the cost structures surrounding healthcare in the US. I don't think you have enough information yet to fully understand the subject enough to answer the question you posed. I'll suggest you model something like a team conducting surgery at a mid size hospital. You have to model the cost structure each person in that room is subjected to. Three simple items are the cost of their education, malpractice insurance and taxes. The next step is to estimate the number of people who support that team within that hospital. From administration to nurses and janitors. Add to that external services such as labs. Now calculate the equipment costs. You could dig deeper and understand the regulatory costs, taxation and liability equipment manufacturers are subjected to. Interesting point to note: The Trump administration had to guarantee protection from liability before anyone was willing to make even something as simple as an N95 mask for use in hospitals. Now calculate the cost structure for the hospital. Again, regulatory, liability/malpractice, taxation, etc. If the ambulance service is independent, add them to the exercise. If you run through the above exercise you will actually be surprised that it only costs $3,000 for an MD to perform a procedure. Notice insurance isn't anywhere in these calculation. Health insurance is an easy to point to evil, yet it is perhaps the most insignificant portion of the cost matrix that drives the cost of healthcare in the US. In fact, health insurance is NOT a driver, it's a symptom. You cannot fix our medical system by manipulating insurance. If the costs are high, care will be expensive. If the costs are lower, care will become more affordable. And this will drive insurance costs down as a result. Insurance isn't the cause, it's the effect. Remember that next time you hear a politician claim that they can improve things by screwing with insurance. They are lying to you. Don't allow that to happen. Be informed.

fzeroracer 7y ago
Logically this may make sense, but in reality it does not. Other countries with more sane healthcare systems have costs that are fractional compared to ours despite having the exact same costs you mention. If the equipment is the same, the admin overhead is the same and the education is the same, then that leaves only one real difference between us and other countries. And that's our Byzantine insurance system.

sacred_numbers 7y ago

I think that there are certainly some issues with an artificial scarcity of doctors as well as overly restrictive regulations requiring MDs for certain procedures that don't require MD training, but the evidence shows that this is not the main driver of high costs. Physician salaries are only about 8% of healthcare spending[1] and according to my own research, only about 20% is due to all healthcare worker salaries (including physicians, nurses, physician assistants, etc. The remaining 80% is medicine, medical supplies, capital costs (MRI machines, hospitals) and administrative costs. Unfortunately there's no single cost that could instantly solve everything if eliminated; there's just a lot of middlemen each taking a tiny portion that add up to a huge total cost. [1]https://www.npr.org/sections/money/2019/03/12/702500408/are-doctors-overpaid https://www.npr.org/sections/money/2019/03/12/702500408/are-...

HPsquared 7y ago
There are plenty of ways it could be made cheaper, hugely cheaper, but the regulatory system protects the established players / methods and prevents competition.

wozniacki 7y ago

This. This gets so rarely uttered if ever I'm having a hard time believing it hasn't been down voted by hyper-credentialists on HN. I fully believe the number of doctors allowed to start practicing medicine is heavily controlled using arbitrary rationales and spurious education / training thresholds. There's no need for so much garbage bureaucracy in medical pedagogy especially when so many doctors are paid insanely lofty salaries. The whole enterprise of medicine and the way its practiced in the U.S. ( including HIPAA ), needs some heavy de-bloating.

LatteLazy 7y ago

"Do you want the best medical care?" "Of course" says everyone because it seems like an easy answer. "Then you're sprained ancle will need a team of 20 super MDs, an MRI, CAT scan, sterile isolation ward and a helicopter to get you there. That will be 100 million dollars please!" says the greedy fuck maximising profit, and he's giving you what you said you wanted... This is basically the US system in a nutshell. Other nations have an approach with more focus on affordability, but the US system (from hospitals, to doctors themselves, to insurers, to drug makers, to the courts) is entirely focused on maximum quality. That's what makes it unaffordable. That's also why you don't have teired treatment like you say: an MD is 0.5% better than a trained nurse at setting a bone. They cost 100 times more. But you decide purely based on the 0.5%

brazzy 7y ago

> You don't need to be an MD to handle %80 of hospital visits You do, however, need to be an MD to recognize some of the other 20% as not being part of the 80%.