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> I suspect therefore that changing the credentialling process is unlikely to have much impact on these issues and/or is not the most effective way to impact t

> I suspect therefore that changing the credentialling process is unlikely to have much impact on these issues and/or is not the most effective way to impact these issues. The easiest way to expand medicine access would probably just be to remove government restrictions on the number of medical schools, the number of hospitals, and the number of physicians. I don’t think we need to dismantle the credential system. > I'm 57 years old. I've never, ever met anyone who isn't a libertarian nerd (I have friends ...) that checks to see what medical school a physician attended. This why we have to be careful about generalizing from our own experience conclusively :) > If they are "checking" at something approximating that level, they do so via clinical affiliation (e.g. "anyone at the Mayo has to be great"). There’s how things are, and how things should be. People ought to take more responsibility for their healthcare and that includes who provides it. > Not really. The "watchers" in our current system are government agencies, not private (potentially for-profit, or at least for-big-salary) corporations. The incentives align in significantly different ways. Perhaps you haven’t noticed but the watchers in government agencies and the for-profit, big salary corporations they are supposed to be watching are the same people. its called “regulatory capture” and “revolving door”.

PaulDavisThe1st 6y ago
> The easiest way to expand medicine access ... This seems to suppose one (or both) of two things: 1) access to medicine is limited because of the supply of health care providers, so more providers would help 2) access to medicine is limited due to cost, and more providers would force the cost down, as per "supply and demand", "the market" etc. I'm not aware of much evidence for (1), though I don't deny that it is possible. For (2) to be true, it would have to be the case there can actually be a competitive marketplace for all kinds of health care, and we know that this is not true for (at least) emergency care. Many volumes have been written by people much smarter than me that explain the many reasons why health care is not really susceptible to what are supposedly "normal market" behaviors and benefits. Just increasing the number of doctors will (a) not necessarily drive down the cost of health care nor (b) expand access to health care. > This why we have to be careful about generalizing from our own experience conclusively :) Certainly in general, this is true. But when the claim is that "anyone who wants a good physician" would do this, not so much. Falsifiability, and all that. > People ought to take more responsibility ... This is a moral statement, not some sort of fundamental statement about the nature of reality. Not only is the level of personal responsibility up for the debate, but so is the form such responsibility should take. Citizens in many other countries have chosen to "take more responsibility" for their healthcare in different ways than you are proposing (by taking aggregate action to create socialized health care systems that delegate many things to the system, intentionally). > Perhaps you haven’t noticed but the watchers in government agencies and the for-profit, big salary corporations they are supposed to be watching are the same people. its called “regulatory capture” and “revolving door”. Speaking of over-generalizing ... also, "There’s how things are, and how things should be." I do not believe that regulatory capture is an inevitable outcome of a democratic-ish governmental structure.
- chordalkeyboard 6y ago
  > For (2) to be true, it would have to be the case there can actually be a competitive marketplace for all kinds of health care, and we know that this is not true for (at least) emergency care. I’m really not sure what to make of this, there is already a market for things such as emergency care. Even with all the regulation, when you get in an ambulance you can tell them to take you to a specific hospital. When people are treating non-emergency conditions, the same regulated market offers them even more options. Ikm not really sure what you mean here. > Many volumes have been written by people much smarter than me that explain the many reasons why health care is not really susceptible to what are supposedly "normal market" behaviors and benefits. Many volumes have been written on how the four humours can be used to diagnose and treat disease. However modern medicine no longer uses the four humours model. Perhaps it is also time for modern medicine to embrace the scarcity management aspects of markets rather than looking for answers in musty old volumes. > I'm not aware of much evidence for (1), though I don't deny that it is possible. It is not only possible, it is the case. The bottleneck is at schools, at residencies, and at licenses. Possibly elsewhere. In a basic simple mathematical way, fewer providers means less access to care. > Certainly in general, this is true. But when the claim is that "anyone who wants a good physician" would do this, not so much. Falsifiability, and all that. Certain values of “want” may not be sufficient, as with anything else. Anyone who wants a good physician enough to look for one would perform the due diligence required to obtain one. Kind of like now, actually. > This is a moral statement, not some sort of fundamental statement about the nature of reality. Not only is the level of personal responsibility up for the debate, but so is the form such responsibility should take. Citizens in many other countries have chosen to "take more responsibility" for their healthcare in different ways than you are proposing (by taking aggregate action to create socialized health care systems that delegate many things to the system, intentionally). Yes, its a moral statement. And its an interesting question whether people who entrust bureaucrats with healthcare have taken reaponsibility or shirked it. > Speaking of over-generalizing ... also, "There’s how things are, and how things should be." I do not believe that regulatory capture is an inevitable outcome of a democratic-ish governmental structure. The problem is that things like social planning of healthcare provision are evidently flawed in every respect due to the belief that they can’t be trusted to markets. We don’t want to believe we are getting competent care because the government says so, we want to have confidence we are getting competent care because the incentive structure is aligned witn the outcome from the patient’s perspective. We don’t want to believe we are getting the best price for drugs because a bureaucrat claims to negotiate on our behalf with his cronies, we want to know that we get the best price in drugs because they are sold in a competitive market where companies are rivals for the business of patients.

PaulDavisThe1st 6y ago

> The easiest way to expand medicine access ... This seems to suppose one (or both) of two things: 1) access to medicine is limited because of the supply of health care providers, so more providers would help 2) access to medicine is limited due to cost, and more providers would force the cost down, as per "supply and demand", "the market" etc. I'm not aware of much evidence for (1), though I don't deny that it is possible. For (2) to be true, it would have to be the case there can actually be a competitive marketplace for all kinds of health care, and we know that this is not true for (at least) emergency care. Many volumes have been written by people much smarter than me that explain the many reasons why health care is not really susceptible to what are supposedly "normal market" behaviors and benefits. Just increasing the number of doctors will (a) not necessarily drive down the cost of health care nor (b) expand access to health care. > This why we have to be careful about generalizing from our own experience conclusively :) Certainly in general, this is true. But when the claim is that "anyone who wants a good physician" would do this, not so much. Falsifiability, and all that. > People ought to take more responsibility ... This is a moral statement, not some sort of fundamental statement about the nature of reality. Not only is the level of personal responsibility up for the debate, but so is the form such responsibility should take. Citizens in many other countries have chosen to "take more responsibility" for their healthcare in different ways than you are proposing (by taking aggregate action to create socialized health care systems that delegate many things to the system, intentionally). > Perhaps you haven’t noticed but the watchers in government agencies and the for-profit, big salary corporations they are supposed to be watching are the same people. its called “regulatory capture” and “revolving door”. Speaking of over-generalizing ... also, "There’s how things are, and how things should be." I do not believe that regulatory capture is an inevitable outcome of a democratic-ish governmental structure.

chordalkeyboard 6y ago
> For (2) to be true, it would have to be the case there can actually be a competitive marketplace for all kinds of health care, and we know that this is not true for (at least) emergency care. I’m really not sure what to make of this, there is already a market for things such as emergency care. Even with all the regulation, when you get in an ambulance you can tell them to take you to a specific hospital. When people are treating non-emergency conditions, the same regulated market offers them even more options. Ikm not really sure what you mean here. > Many volumes have been written by people much smarter than me that explain the many reasons why health care is not really susceptible to what are supposedly "normal market" behaviors and benefits. Many volumes have been written on how the four humours can be used to diagnose and treat disease. However modern medicine no longer uses the four humours model. Perhaps it is also time for modern medicine to embrace the scarcity management aspects of markets rather than looking for answers in musty old volumes. > I'm not aware of much evidence for (1), though I don't deny that it is possible. It is not only possible, it is the case. The bottleneck is at schools, at residencies, and at licenses. Possibly elsewhere. In a basic simple mathematical way, fewer providers means less access to care. > Certainly in general, this is true. But when the claim is that "anyone who wants a good physician" would do this, not so much. Falsifiability, and all that. Certain values of “want” may not be sufficient, as with anything else. Anyone who wants a good physician enough to look for one would perform the due diligence required to obtain one. Kind of like now, actually. > This is a moral statement, not some sort of fundamental statement about the nature of reality. Not only is the level of personal responsibility up for the debate, but so is the form such responsibility should take. Citizens in many other countries have chosen to "take more responsibility" for their healthcare in different ways than you are proposing (by taking aggregate action to create socialized health care systems that delegate many things to the system, intentionally). Yes, its a moral statement. And its an interesting question whether people who entrust bureaucrats with healthcare have taken reaponsibility or shirked it. > Speaking of over-generalizing ... also, "There’s how things are, and how things should be." I do not believe that regulatory capture is an inevitable outcome of a democratic-ish governmental structure. The problem is that things like social planning of healthcare provision are evidently flawed in every respect due to the belief that they can’t be trusted to markets. We don’t want to believe we are getting competent care because the government says so, we want to have confidence we are getting competent care because the incentive structure is aligned witn the outcome from the patient’s perspective. We don’t want to believe we are getting the best price for drugs because a bureaucrat claims to negotiate on our behalf with his cronies, we want to know that we get the best price in drugs because they are sold in a competitive market where companies are rivals for the business of patients.