6 ms·

When we ask ourselves why healthcare is so expensive in the US, we never seem to point out that it's the health care that's so expensive. As many others have al

When we ask ourselves why healthcare is so expensive in the US, we never seem to point out that it's the health care that's so expensive. As many others have already said, the AMA puts an artificial cap on the number of medical school graduates each year at around 20,000. Anecdotally, I know several bright minds who either pursued a DO or dropped out of medicine entirely because they couldn't pass the med schools' opaque admissions procedures. I'm cynical, but there's something disturbing about the fact that GPs and family doctors have to invest so much time and undertake so much debt just to become professional symptom Googlers. I'm glad this article has the chutzpah to call the AMA what it really is-- a protectionist guild. These doctors make me sick.

hhs 6y ago
According to the AAMC, it seems like residency slots have also been an issue: https://www.aamc.org/news-insights/medical-school-enrollments-grow-residency-slots-haven-t-kept-pace https://www.aamc.org/news-insights/medical-school-enrollment...
- mimikatz 6y ago
  Do all doctors need residency or is it another barrier to having enough cheap doctors?
  - Spivak 6y ago
    I’m not sure most people would be comfortable with doctors that have zero on-the-job training. There are some places that don’t require it or only require it for a short period but I think most people are in the camp that residency programs are a good thing and not an artificial barrier.
    - walshemj 6y ago
      There's a joke in the NHS that when the new batch of doctors join in September - the risk on mistakes increases. I had a major operation just before 2017's intake it was interesting having a new doctor trying to cannulate me - I suspect the nurses where round the corner trying do to laugh.
  - phaedrus441 6y ago
    Medical license rules differ by state, but doctors need at least 1 year of postgraduate training to apply for a license (though without completing a residency, which is 3 years at a minimum, career options are severely limited).
  - tonyhb 6y ago
    It's a way of forcing ungraduated docs to pay to work. No joke - you have to pay to attend residency and work. And this isn't covered by student debt/government assistance programs. I know of several doctors who are in _significant_ debt despite working for the public sector for years. Their loans are forgiven, but the residency sits and accumulates interest that they can't quickly pay off because that same public sector work doesn't pay as well. It's not-quite slave labour.
    - phaedrus441 6y ago
      What are you talking about? Residents earn a salary (just google "XYZ university resident salary" to find it...). Medical school (which is prior to residency) is where the debt gets heaped on.
      - tonyhb 6y ago
        I suppose it depends on where you study. If you're at a school (a school based hospital), you pay to go. You might get a stipend, but I know people from NYU who have had to pay to attend residency. I don't know the most about this field and you're right, a bunch of hospitals do pay. That's cool.
eej71 6y ago
Is it the AMA that puts that cap on? I was always under the impression that was really a consequence of the 1997 Balanced Budget Act (?).
- EvanAnderson 6y ago
  The AMA lobbied for that cap. https://usatoday30.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm https://usatoday30.usatoday.com/news/health/2005-03-02-docto...
wutbrodo 6y ago
I have a lot of doctors in my family, and while it's not surprising that they've fully swallowed the bizarre fetishization of doctors we have in this country[0], it's really shocking to me the degree to which almost _everyone_ I know has, including those with no ties to the medical field whatsoever. To be extremely clear, I don't think there's anything wrong with appreciating doctors for the hard work they do, nor the special feelings that people have historically always had towards healers[1]. If someone said they respected a person more for choosing medicine as a career, I can't say I'd disagree. But for some reason, most people seem to model doctors as incorruptible angels, incapable of making decisions that are suboptimal for others or for society. This makes it uniquely difficult to have a conversation about the problems of the devilishly complex healthcare system, since it's impossible to talk about one of the most important groups of stakeholders and their role in healthcare economics. I remember talking to my sister shortly after her med school graduation about a topic that involved influences , and she said with a straight face "doctors don't do things that aren't in the patient's best interest". My (Ivy-League educated, MD-holding) sister isn't the sharpest tool in the shed, but even for her, the idea that an entire industry full of people are immune to incentives is an especially pants-on-head stupid model of the world. She's since unlearned much of the creepy indoctrination that med school drilled into her (and that her much-smarter doctor husband was never fully taken by), but the same messages have trickled down to many of the friends and family I have that are unconnected with the medical field, without any of the ego-protective incentives that my doctor acquaintances have. [0] And most countries; if anything, it's way worse in the other countries I'm familiar with, as the US tends to be (on average) more dynamic and less worshiping of formal credentials than the average country [1] Though I do think it's irrational; I distinctly remember my mom trying to communicate this feeling to me when trying to get me to be a doctor, and my high-decoupling teenage self telling her that she should also be appreciating the engineers whose work powers the hospital and the economists whose work was critical to building the hospital and paying doctor's salaries.
- bsanr2 6y ago
  Ask marginalized people - generally a subset of, but not limited to, people subject to generational poverty, people with prominent genetic ancestry in the Global South, LGBT/queer folk (especially the T), and those with visible, chronic physical (weight, height, mobility, etc.) or mental (developmental disorders, mental illness, etc.) "deviances" - and you'll learn just how effective and esteemed doctors really are. (Of course, people generally don't ask us, so...) While I imagine that some people have already had a certain particular rage switch thrown in their brain wrt the preceding list, stay with me here. We're not just talking about intersectional pile-ups; go ask your fat friend about his last check-up.
jbob2000 6y ago
This reminds me of a debate I had in high school, where the topic was (and I quote verbatim) "A country that does not provide universal healthcare to its residents is evil". I was assigned the side that argued that it's not evil. The problem our opponents had was that they could not could not argue for a definition of evil that was strict enough to capture universal healthcare but not so strict that a doctor who makes a mistake and kills someone is also evil.
tobmlt 6y ago
Well said. If anyone would care to read further on the history from a similar point of view: https://mises.org/library/100-years-medical-robbery https://mises.org/library/100-years-medical-robbery
phaedrus441 6y ago
The biggest issue isn't domestic medical school slots, it's a lack of residency training slots (for which federal funding was capped in 1996). If more residency slots were available with adequate funding, these positions could easily be filled with foreign medical graduates that have passed the US's medical boards (USMLE steps 1 & 2, with 3 taken during or after intern year).
- killjoywashere 6y ago
  There were more US residency spots (23,339) than US allopathic medical school graduates (17,789) in 2016. https://pubmed.ncbi.nlm.nih.gov/28919221/ https://pubmed.ncbi.nlm.nih.gov/28919221/
  - phaedrus441 6y ago
    Don’t neglect osteopathic graduates as well (though I’d imagine that is only several thousand more)
pc86 6y ago
> I know several bright minds who either pursued a DO or dropped out of medicine entirely because they couldn't pass the med schools' opaque admissions procedures. I... what? A DO is a doctor, full stop. Aside from there being different organizations, there is no difference between what an MD can do and a DO. In fact, a DO is trained in OMM while an MD is not. DOs have more training than MDs, not less. A lot (I think most, but I'm not 100% sure) of residency programs are combined and will accept either credentials. Many are still DO-only. Med schools conferring a DO degree have identical admissions processes to those conferring MDs. It may be unintentional but the wording of the quoted phrase makes it seem like if you can't get into an MD program you will either go "down" and apply to a DO program, or not go into medicine. > there's something disturbing about the fact that GPs and family doctors have to invest so much time and undertake so much debt just to become professional symptom Googlers I'm not defending the ludicrous price of medical school (which is due in large part to the AMA's physician cap that you mentioned), but even mediocre GPs are much more than "professional symptom Googlers."
jjav 6y ago
> it's the health care that's so expensive Doctors earn well but not particularly different from FAANG-style software salaries. I don't know how good these numbers are but here's some: https://blog.nomadhealth.com/complete-list-of-average-doctor-salaries-by-specialty-locum-tenens/ https://blog.nomadhealth.com/complete-list-of-average-doctor... For example emergency medicine doctor is listed at 366K average (~$162/hr). So when I've had to go to the emergency room and end up seeing the doctor for about 20 minutes, that's about $54 worth of doctor-time (as an order-of-magnitude approximation, ignoring fully-loaded employee costs since I don't have that number). And yet the bill that arrives is on the order of ~$6000. Sure there's also nurse salary to pay for my visit and other legitimate overhead that's part of the actual "care". So from that bill I got, over $5000 are inefficiencies and non-care-providing rentiers inflating the cost. Nearly all the bill goes to entities other than the actual medical care providers! So no, it's the the actual doctor+nurse salaries that makes the USA health care so exceptionally expensive.
- nn3 6y ago
  For the emergency room bills most of it is paying for other people who didn't pay. It's kind of socialized medicine.
  - jjav 6y ago
    That would suggest only something on the order of one in every 50 emergency room visits actually pay. I don't have the numbers to confirm or refute that, but that ratio seems highly unlikely. Or take a general family medicine doctor visit. 242K average salary = ~$116/hr. On a typical appointment I'll see him 15 minutes or $29 of doctor-time. Yet the bill is $450.
- MagnumOpus 6y ago
  > Doctors earn well but not particularly different from FAANG-style software salaries. Yes, but ALL doctors earn that much ALL the time, whereas the FAANG salaries you read are the lucky/skilled top 5% of the industry and only during a once-in-a-generation share price boom where stock grants exceed salaries. And yes, doctor/nurse salaries are a big part of US healthcare excess cost (as is over-prescription, obesity,insurance profits, insurance admin overhead)

hhs 6y ago

According to the AAMC, it seems like residency slots have also been an issue: https://www.aamc.org/news-insights/medical-school-enrollments-grow-residency-slots-haven-t-kept-pace https://www.aamc.org/news-insights/medical-school-enrollment...

mimikatz 6y ago
Do all doctors need residency or is it another barrier to having enough cheap doctors?
- Spivak 6y ago
  I’m not sure most people would be comfortable with doctors that have zero on-the-job training. There are some places that don’t require it or only require it for a short period but I think most people are in the camp that residency programs are a good thing and not an artificial barrier.
  - walshemj 6y ago
    There's a joke in the NHS that when the new batch of doctors join in September - the risk on mistakes increases. I had a major operation just before 2017's intake it was interesting having a new doctor trying to cannulate me - I suspect the nurses where round the corner trying do to laugh.
- phaedrus441 6y ago
  Medical license rules differ by state, but doctors need at least 1 year of postgraduate training to apply for a license (though without completing a residency, which is 3 years at a minimum, career options are severely limited).
- tonyhb 6y ago
  It's a way of forcing ungraduated docs to pay to work. No joke - you have to pay to attend residency and work. And this isn't covered by student debt/government assistance programs. I know of several doctors who are in _significant_ debt despite working for the public sector for years. Their loans are forgiven, but the residency sits and accumulates interest that they can't quickly pay off because that same public sector work doesn't pay as well. It's not-quite slave labour.
  - phaedrus441 6y ago
    What are you talking about? Residents earn a salary (just google "XYZ university resident salary" to find it...). Medical school (which is prior to residency) is where the debt gets heaped on.
    - tonyhb 6y ago
      I suppose it depends on where you study. If you're at a school (a school based hospital), you pay to go. You might get a stipend, but I know people from NYU who have had to pay to attend residency. I don't know the most about this field and you're right, a bunch of hospitals do pay. That's cool.

eej71 6y ago

Is it the AMA that puts that cap on? I was always under the impression that was really a consequence of the 1997 Balanced Budget Act (?).

EvanAnderson 6y ago
The AMA lobbied for that cap. https://usatoday30.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm https://usatoday30.usatoday.com/news/health/2005-03-02-docto...

wutbrodo 6y ago

I have a lot of doctors in my family, and while it's not surprising that they've fully swallowed the bizarre fetishization of doctors we have in this country[0], it's really shocking to me the degree to which almost _everyone_ I know has, including those with no ties to the medical field whatsoever. To be extremely clear, I don't think there's anything wrong with appreciating doctors for the hard work they do, nor the special feelings that people have historically always had towards healers[1]. If someone said they respected a person more for choosing medicine as a career, I can't say I'd disagree. But for some reason, most people seem to model doctors as incorruptible angels, incapable of making decisions that are suboptimal for others or for society. This makes it uniquely difficult to have a conversation about the problems of the devilishly complex healthcare system, since it's impossible to talk about one of the most important groups of stakeholders and their role in healthcare economics. I remember talking to my sister shortly after her med school graduation about a topic that involved influences , and she said with a straight face "doctors don't do things that aren't in the patient's best interest". My (Ivy-League educated, MD-holding) sister isn't the sharpest tool in the shed, but even for her, the idea that an entire industry full of people are immune to incentives is an especially pants-on-head stupid model of the world. She's since unlearned much of the creepy indoctrination that med school drilled into her (and that her much-smarter doctor husband was never fully taken by), but the same messages have trickled down to many of the friends and family I have that are unconnected with the medical field, without any of the ego-protective incentives that my doctor acquaintances have. [0] And most countries; if anything, it's way worse in the other countries I'm familiar with, as the US tends to be (on average) more dynamic and less worshiping of formal credentials than the average country [1] Though I do think it's irrational; I distinctly remember my mom trying to communicate this feeling to me when trying to get me to be a doctor, and my high-decoupling teenage self telling her that she should also be appreciating the engineers whose work powers the hospital and the economists whose work was critical to building the hospital and paying doctor's salaries.

bsanr2 6y ago
Ask marginalized people - generally a subset of, but not limited to, people subject to generational poverty, people with prominent genetic ancestry in the Global South, LGBT/queer folk (especially the T), and those with visible, chronic physical (weight, height, mobility, etc.) or mental (developmental disorders, mental illness, etc.) "deviances" - and you'll learn just how effective and esteemed doctors really are. (Of course, people generally don't ask us, so...) While I imagine that some people have already had a certain particular rage switch thrown in their brain wrt the preceding list, stay with me here. We're not just talking about intersectional pile-ups; go ask your fat friend about his last check-up.

jbob2000 6y ago

This reminds me of a debate I had in high school, where the topic was (and I quote verbatim) "A country that does not provide universal healthcare to its residents is evil". I was assigned the side that argued that it's not evil. The problem our opponents had was that they could not could not argue for a definition of evil that was strict enough to capture universal healthcare but not so strict that a doctor who makes a mistake and kills someone is also evil.

tobmlt 6y ago

Well said. If anyone would care to read further on the history from a similar point of view: https://mises.org/library/100-years-medical-robbery https://mises.org/library/100-years-medical-robbery

phaedrus441 6y ago

The biggest issue isn't domestic medical school slots, it's a lack of residency training slots (for which federal funding was capped in 1996). If more residency slots were available with adequate funding, these positions could easily be filled with foreign medical graduates that have passed the US's medical boards (USMLE steps 1 & 2, with 3 taken during or after intern year).

killjoywashere 6y ago
There were more US residency spots (23,339) than US allopathic medical school graduates (17,789) in 2016. https://pubmed.ncbi.nlm.nih.gov/28919221/ https://pubmed.ncbi.nlm.nih.gov/28919221/
- phaedrus441 6y ago
  Don’t neglect osteopathic graduates as well (though I’d imagine that is only several thousand more)

pc86 6y ago

> I know several bright minds who either pursued a DO or dropped out of medicine entirely because they couldn't pass the med schools' opaque admissions procedures. I... what? A DO is a doctor, full stop. Aside from there being different organizations, there is no difference between what an MD can do and a DO. In fact, a DO is trained in OMM while an MD is not. DOs have more training than MDs, not less. A lot (I think most, but I'm not 100% sure) of residency programs are combined and will accept either credentials. Many are still DO-only. Med schools conferring a DO degree have identical admissions processes to those conferring MDs. It may be unintentional but the wording of the quoted phrase makes it seem like if you can't get into an MD program you will either go "down" and apply to a DO program, or not go into medicine. > there's something disturbing about the fact that GPs and family doctors have to invest so much time and undertake so much debt just to become professional symptom Googlers I'm not defending the ludicrous price of medical school (which is due in large part to the AMA's physician cap that you mentioned), but even mediocre GPs are much more than "professional symptom Googlers."

jjav 6y ago

> it's the health care that's so expensive Doctors earn well but not particularly different from FAANG-style software salaries. I don't know how good these numbers are but here's some: https://blog.nomadhealth.com/complete-list-of-average-doctor-salaries-by-specialty-locum-tenens/ https://blog.nomadhealth.com/complete-list-of-average-doctor... For example emergency medicine doctor is listed at 366K average (~$162/hr). So when I've had to go to the emergency room and end up seeing the doctor for about 20 minutes, that's about $54 worth of doctor-time (as an order-of-magnitude approximation, ignoring fully-loaded employee costs since I don't have that number). And yet the bill that arrives is on the order of ~$6000. Sure there's also nurse salary to pay for my visit and other legitimate overhead that's part of the actual "care". So from that bill I got, over $5000 are inefficiencies and non-care-providing rentiers inflating the cost. Nearly all the bill goes to entities other than the actual medical care providers! So no, it's the the actual doctor+nurse salaries that makes the USA health care so exceptionally expensive.

nn3 6y ago
For the emergency room bills most of it is paying for other people who didn't pay. It's kind of socialized medicine.
- jjav 6y ago
  That would suggest only something on the order of one in every 50 emergency room visits actually pay. I don't have the numbers to confirm or refute that, but that ratio seems highly unlikely. Or take a general family medicine doctor visit. 242K average salary = ~$116/hr. On a typical appointment I'll see him 15 minutes or $29 of doctor-time. Yet the bill is $450.
MagnumOpus 6y ago
> Doctors earn well but not particularly different from FAANG-style software salaries. Yes, but ALL doctors earn that much ALL the time, whereas the FAANG salaries you read are the lucky/skilled top 5% of the industry and only during a once-in-a-generation share price boom where stock grants exceed salaries. And yes, doctor/nurse salaries are a big part of US healthcare excess cost (as is over-prescription, obesity,insurance profits, insurance admin overhead)