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Everyone complains about the cost of healthcare and nobody asks why the AMA operates like a cartel. The number of doctors allowed to graduate hasn't changed in

Everyone complains about the cost of healthcare and nobody asks why the AMA operates like a cartel. The number of doctors allowed to graduate hasn't changed in 40 years.

fragmede 6y ago
Which is why Nurse Practitioners are the best thing to happen for patients in decades. Better access to healthcare means better treatment.
- prostoalex 6y ago
  It's a tough road for NPs in California at least https://www.usnews.com/news/health-news/articles/2019-07-03/california-doctors-oppose-expanding-nurse-practitioner-authorities https://www.usnews.com/news/health-news/articles/2019-07-03/...
whatshisface 6y ago
A lot of people talk about that, actually. I've heard it several times and it comes up in most of these discussions. However, doctor's pay is not enough on its own to explain even a small fraction of the cost problem. In reality it's an issue permeating every single component of the system, each one making a small contribution to the overall pile. I've heard of this situation being called "cost disease."
- stocknoob 6y ago
  Perhaps in small, private forums, but in public physicians are a protected class. Not many op-eds criticizing the AMA vs the big, evil pharma companies. That said, it's not a panacea, but not great when a 15-min visit to get a $.10 pill costs $200.
  - whatshisface 6y ago
    Oh, of course, it just hadn't occurred to me to consider op-eds a meaningful participant or representative of the public discourse.
    - stocknoob 6y ago
      They set the Overton window of allowed policies.
  - matthewdgreen 6y ago
    Not great, but also: people above this asked why the system doesn't get reformed, and the answer is that doctors are popular with the voting population, and tackling their salaries will only have a modest impact in reducing costs. This is not to say that doctor's pay shouldn't be addressed, but the system doesn't get reformed because every discussion on fixing it gets derailed into a discussion of doctor's pay, which is literally the highest-effort lowest-payoff part of the problem. And the situation stays bad because of this dynamic.
  - teorema 6y ago
    A $.10 pill that the person has been taking for years and is maybe even safer than many things sitting on the shelves of the hardware or grocery store.
- lostapathy 6y ago
  > doctor's pay is not enough on its own to explain even a small fraction of the cost problem Not on it's own, but doctor shortage can still contribute to medical costs. Do doctors make more mistakes due to high patient loads? Are preventable items missed because doctors can't spend enough time with patients? Would people be less likely to abuse the ER and/or wait to address conditions if they could get a primary care appointment more easily? If doctors had a little more slack in their schedules, might they innovate in other ways? If we had more doctors, would it be harder for mega-hospital chains to gobble up the supply of doctors in your area, leaving more independent practices to innovate in other ways?
  - teorema 6y ago
    Also: What if your pharmacist could do most of the practical things that matter to you about your medication, rather than requiring prescriber permission? What if you could do X by going to a psychologist or optometrist, or some other profession that doesn't currently exist, instead of going to an MD or PA or LPN? What if you could just buy certain things directly without a middleman? US healthcare is over regulated in general (in many areas, even as it's arguably underregulated in others).
- teorema 6y ago
  It's not doctor pay, it's economic repurcussions of monopolies. It's also not just limiting the numbers of physicians, it's locking out alternate providers of care and other models. Right now US healthcare is very hierarchical, with physicians at the top, nurses close by. Other professions and services are subsidiary to them. You don't get to choose a provider based on skillset per se, you are forced to abide by this hierarchy. That's the real economic cost, the restrictions in provider and service choice.
ardy42 6y ago
> Everyone complains about the cost of healthcare and nobody asks why the AMA operates like a cartel. That's not entirely a bad thing. It would be bad for Medicine to turn out like Law, with a huge glut of unemployable graduates after a long, expensive training program (IIRC, an intense 7 years post-college, minimum). There's a need to balance demand with the need for all (or nearly all) the graduates to be able to find a job. Also, you're neglecting Osteopathic schools, which aren't controlled by the AMA but graduate students with the same practice rights. > The number of doctors allowed to graduate hasn't changed in 40 years. Do you have any data to back that claim up? The Association of American Medical Colleges says enrollment rates are increasing: > In response to concerns that a projected doctor shortage could impact patient care, the AAMC in 2006 called on medical schools to increase first-year enrollment by 30%. That target was reached in 2018-19, when first-year matriculation reached 21,622 students. Osteopathic schools increased their enrollment by 164% during this same time period, with 8,124 first-year students enrolled. (https://www.aamc.org/news-insights/us-medical-school-enrollment-rises-30 https://www.aamc.org/news-insights/us-medical-school-enrollm...)
- salawat 6y ago
  Enrollment != graduation and licensure. More people may be interested but nobody can practice until after residency, and you have a large pool of hopefuls basically in a lottery for residency slots. You can get all the theory, but not be able to get the requisite practicum. Even if you do get a slot, you also get treated like a stevedore from what I have heard.
  - ardy42 6y ago
    > Enrollment != graduation and licensure. > More people may be interested but nobody can practice until after residency, and you have a large pool of hopefuls basically in a lottery for residency slots. But my understanding is that residency capacity is matched to graduating class sizes, at least in the US. The selectivity is intentionally placed up front (at med school admission) so the path is clear to residency and licensure as long as the student doesn't totally fall apart (which the selectivity is supposed to guard against). IIRC, it's foreign medical school graduates may have trouble getting a US residency.
jxramos 6y ago
what is this "allowed to graduate" business? What authority do they have to dictate such a thing and is it in writing anywhere what said quota is?
- aaomidi 6y ago
  The number of residency spots is an artificial barrier to being able to properly practice medicine. That number is controlled by doctors.
  - jxramos 6y ago
    Is this the organization where the barrier to entry is enforced? https://en.wikipedia.org/wiki/National_Resident_Matching_Program https://en.wikipedia.org/wiki/National_Resident_Matching_Pro.... What does it look like precisely to the aspiring physicians who don't make the cut? Where exactly do they get communicated to that you didn't meet, get selected, etc for stage XYZ.
sangnoir 6y ago
> The number of doctors allowed to graduate hasn't changed in 40 years. In stark contrast, the number of hospital administrators, along with their salaries has ballooned over the same time period - even at non-profit systems.
- teorema 6y ago
  Does anyone know of any general literature on this administratively top-heavy structure? It shows up in higher education as well, and I'm sure in other places too. I'm curious about patterns across domains and links to economic issues. Seems too coincidental that this type of structure is emerging in two of the most economically controversial areas of society.
- prostoalex 6y ago
  How much of medical care is distributed through hospitals vs private practices? Seems like a healthy person would go to hospital only for emergencies or major projects like birth. On the other hand, I know there are entire hospital systems in southern states that cater to elderly and are basically Medicare billing factories.

Everyone complains about the cost of healthcare and nobody asks why the AMA operates like a cartel. The number of doctors allowed to graduate hasn't changed in 40 years.

fragmede 6y ago

Which is why Nurse Practitioners are the best thing to happen for patients in decades. Better access to healthcare means better treatment.

prostoalex 6y ago
It's a tough road for NPs in California at least https://www.usnews.com/news/health-news/articles/2019-07-03/california-doctors-oppose-expanding-nurse-practitioner-authorities https://www.usnews.com/news/health-news/articles/2019-07-03/...

whatshisface 6y ago

A lot of people talk about that, actually. I've heard it several times and it comes up in most of these discussions. However, doctor's pay is not enough on its own to explain even a small fraction of the cost problem. In reality it's an issue permeating every single component of the system, each one making a small contribution to the overall pile. I've heard of this situation being called "cost disease."

stocknoob 6y ago
Perhaps in small, private forums, but in public physicians are a protected class. Not many op-eds criticizing the AMA vs the big, evil pharma companies. That said, it's not a panacea, but not great when a 15-min visit to get a $.10 pill costs $200.
- whatshisface 6y ago
  Oh, of course, it just hadn't occurred to me to consider op-eds a meaningful participant or representative of the public discourse.
  - stocknoob 6y ago
    They set the Overton window of allowed policies.
- matthewdgreen 6y ago
  Not great, but also: people above this asked why the system doesn't get reformed, and the answer is that doctors are popular with the voting population, and tackling their salaries will only have a modest impact in reducing costs. This is not to say that doctor's pay shouldn't be addressed, but the system doesn't get reformed because every discussion on fixing it gets derailed into a discussion of doctor's pay, which is literally the highest-effort lowest-payoff part of the problem. And the situation stays bad because of this dynamic.
- teorema 6y ago
  A $.10 pill that the person has been taking for years and is maybe even safer than many things sitting on the shelves of the hardware or grocery store.
lostapathy 6y ago
> doctor's pay is not enough on its own to explain even a small fraction of the cost problem Not on it's own, but doctor shortage can still contribute to medical costs. Do doctors make more mistakes due to high patient loads? Are preventable items missed because doctors can't spend enough time with patients? Would people be less likely to abuse the ER and/or wait to address conditions if they could get a primary care appointment more easily? If doctors had a little more slack in their schedules, might they innovate in other ways? If we had more doctors, would it be harder for mega-hospital chains to gobble up the supply of doctors in your area, leaving more independent practices to innovate in other ways?
- teorema 6y ago
  Also: What if your pharmacist could do most of the practical things that matter to you about your medication, rather than requiring prescriber permission? What if you could do X by going to a psychologist or optometrist, or some other profession that doesn't currently exist, instead of going to an MD or PA or LPN? What if you could just buy certain things directly without a middleman? US healthcare is over regulated in general (in many areas, even as it's arguably underregulated in others).
teorema 6y ago
It's not doctor pay, it's economic repurcussions of monopolies. It's also not just limiting the numbers of physicians, it's locking out alternate providers of care and other models. Right now US healthcare is very hierarchical, with physicians at the top, nurses close by. Other professions and services are subsidiary to them. You don't get to choose a provider based on skillset per se, you are forced to abide by this hierarchy. That's the real economic cost, the restrictions in provider and service choice.

ardy42 6y ago

> Everyone complains about the cost of healthcare and nobody asks why the AMA operates like a cartel. That's not entirely a bad thing. It would be bad for Medicine to turn out like Law, with a huge glut of unemployable graduates after a long, expensive training program (IIRC, an intense 7 years post-college, minimum). There's a need to balance demand with the need for all (or nearly all) the graduates to be able to find a job. Also, you're neglecting Osteopathic schools, which aren't controlled by the AMA but graduate students with the same practice rights. > The number of doctors allowed to graduate hasn't changed in 40 years. Do you have any data to back that claim up? The Association of American Medical Colleges says enrollment rates are increasing: > In response to concerns that a projected doctor shortage could impact patient care, the AAMC in 2006 called on medical schools to increase first-year enrollment by 30%. That target was reached in 2018-19, when first-year matriculation reached 21,622 students. Osteopathic schools increased their enrollment by 164% during this same time period, with 8,124 first-year students enrolled. (https://www.aamc.org/news-insights/us-medical-school-enrollment-rises-30 https://www.aamc.org/news-insights/us-medical-school-enrollm...)

salawat 6y ago
Enrollment != graduation and licensure. More people may be interested but nobody can practice until after residency, and you have a large pool of hopefuls basically in a lottery for residency slots. You can get all the theory, but not be able to get the requisite practicum. Even if you do get a slot, you also get treated like a stevedore from what I have heard.
- ardy42 6y ago
  > Enrollment != graduation and licensure. > More people may be interested but nobody can practice until after residency, and you have a large pool of hopefuls basically in a lottery for residency slots. But my understanding is that residency capacity is matched to graduating class sizes, at least in the US. The selectivity is intentionally placed up front (at med school admission) so the path is clear to residency and licensure as long as the student doesn't totally fall apart (which the selectivity is supposed to guard against). IIRC, it's foreign medical school graduates may have trouble getting a US residency.

jxramos 6y ago

what is this "allowed to graduate" business? What authority do they have to dictate such a thing and is it in writing anywhere what said quota is?

aaomidi 6y ago
The number of residency spots is an artificial barrier to being able to properly practice medicine. That number is controlled by doctors.
- jxramos 6y ago
  Is this the organization where the barrier to entry is enforced? https://en.wikipedia.org/wiki/National_Resident_Matching_Program https://en.wikipedia.org/wiki/National_Resident_Matching_Pro.... What does it look like precisely to the aspiring physicians who don't make the cut? Where exactly do they get communicated to that you didn't meet, get selected, etc for stage XYZ.

sangnoir 6y ago

> The number of doctors allowed to graduate hasn't changed in 40 years. In stark contrast, the number of hospital administrators, along with their salaries has ballooned over the same time period - even at non-profit systems.

teorema 6y ago
Does anyone know of any general literature on this administratively top-heavy structure? It shows up in higher education as well, and I'm sure in other places too. I'm curious about patterns across domains and links to economic issues. Seems too coincidental that this type of structure is emerging in two of the most economically controversial areas of society.
prostoalex 6y ago
How much of medical care is distributed through hospitals vs private practices? Seems like a healthy person would go to hospital only for emergencies or major projects like birth. On the other hand, I know there are entire hospital systems in southern states that cater to elderly and are basically Medicare billing factories.