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Hospitals are 40% of the NH spending so I would even not look at doctors that way. The market structure is such that there are very few doctors, so you need to

Hospitals are 40% of the NH spending so I would even not look at doctors that way. The market structure is such that there are very few doctors, so you need to do your operations in a way that doctors spend as little as possible with patients, and you delegate as much to assistants and administrative chores. With a massive supply shock on doctors you would not only lower wages for doctors, you would also lower admin costs. One caveat, even though doctors wages are very high, they are also rent-captured by universities that charge mid six-digits for an education and medical insurance, and certifications that are burdensome and expensive. I remember medical malpractice insurance going to several thousand a month for OBGYN. There is a reason why clinical doctors have an abnormally high suicide rate in the US. Then hospitals get massive fed spending and money, plus often local protections that mean you cant open competing hospitals. In the book " The Social Transformation of American Medicine" they talk a lot about how hospitals rent-seeking behavior is to turn themselves as a non-profit, and then ask for federal funding and getting that denied to for-profit hospitals, effectively capping the amount of hospitals you can open. The WHOLE market structure needs a detonation. And this is my desire/wish/prediction: at some point we will get an Uber for medicine. Americans will do most their telemedicine with doctors outside the united states, where education is free, there are not legal requirements or certifications or licenses, etc. This is what immigrants like myself do. A psychiatrist in argentina, for example, charges 5U$S for a visit, while one in Palo Alto, CA charges 1000U$S with a 3 month wait list.

huitzitziltzin 5y ago
Lots of stuff here… >> Hospitals are 40% of the NH spending so I would even not look at doctors that way. Hospitals are 30% and physicians are 20% >> The market structure is such that there are very few doctors, Agree. Add more medical schools and residency spots. >> With a massive supply shock on doctors you would not only lower wages for doctors, Yes, this is a good idea. >> you would also lower admin costs. Not clear that this is true or why it would happen. >>One caveat, even though doctors wages are very high, they are also rent-captured by universities that charge mid six-digits for an education and medical insurance, and certifications that are burdensome and expensive. Medical school debt may be high, but salaries are higher. Certifications are not likely a large obstacle to more entry, IMO. >> I remember medical malpractice insurance going to several thousand a month for OBGYN. There are plenty of “tort reform” states that cap malpractice payouts. Medical services are not cheaper there. >> There is a reason why clinical doctors have an abnormally high suicide rate in the US. Source needed on this claim. Might be true. I’m skeptical though. High relative to what? >> Then hospitals get massive fed spending and money, They do and certainly in the COVID stimulus bill that was a HUGE waste of public money. >> plus often local protections that mean you cant open competing hospitals. This is called “certificate of need.” These laws are dumb but don’t exist in 15-20 states at this point. More entry would be great, but you need more doctors, more competition and more price transparency too. >> In the book " The Social Transformation of American Medicine" they talk a lot about how hospitals rent-seeking behavior is to turn themselves as a non-profit, and then ask for federal funding and getting that denied to for-profit hospitals, effectively capping the amount of hospitals you can open. Certificate of need laws are state, not federal. >> The WHOLE market structure needs a detonation. I’m on board. But by detonation I really mean: - more medical schools, - more doctors, including permitting foreign doctors to practice here - price transparency - meaningful competition among hospitals on price. >> And this is my desire/wish/prediction: at some point we will get an Uber for medicine. Amazon is starting an Amazon Care product. Looks like urgent care for the time being. My hope is that they open hospitals eventually. >> Americans will do most their telemedicine with doctors outside the united states, where education is free, there are not legal requirements or certifications or licenses, etc. This is what immigrants like myself do. A psychiatrist in argentina, for example, charges 5U$S for a visit, while one in Palo Alto, CA charges 1000U$S with a 3 month wait list. Great idea and this is what my (foreign born) wife does too. A great way to save money. For anyone else reading this far down, you can do it too. There are English speaking doctors everywhere.
- GabrielBen 5y ago
  Excited to read this! > >> you would also lower admin costs. > Not clear that this is true or why it would happen. There is an operational tax whenever you involve more people into the operation. You need to communicate, add paper trails, set up structure, etc. If say, you had one person collecting payments instead of a secretary, a doctor writing a paper, an insurance biller, an insurance agent, etc for the same ops, it would be a lot easier. You would have doctors perform many of these tasks. For example, give vaccinations, take vitals, etc. > Medical school debt may be high, but salaries are higher. Certifications are not likely a large obstacle to more entry, IMO. Thats the survivorship bias. Salaries cant be lower because people would go bankrupt. Certifications reduce competition, and make it harder to practice. There's even a startup that Raised a series A of multiple millions just to make this process faster (medallion). Evidence this affects the market is that most doctors are only licensed in a couple of states at most. > There are plenty of “tort reform” states that cap malpractice payouts. Medical services are not cheaper there. I'd like to see some data about this if you have it. Conceptually malpractice insurance is a fix cost that puts downward pressure on supply. IT is particularly salient for physicians that would like to work part-time. > Source needed on this claim. Might be true. I’m skeptical though. High relative to what? https://www.webmd.com/mental-health/news/20180508/doctors-suicide-rate-highest-of-any-profession https://www.webmd.com/mental-health/news/20180508/doctors-su.... This is a well known fact in the profession. >> In the book " The Social Transformation of American Medicine" they talk a lot about how hospitals rent-seeking behavior is to turn themselves as a non-profit, and then ask for federal funding and getting that denied to for-profit hospitals, effectively capping the amount of hospitals you can open. > Certificate of need laws are state, not federal. The point above is that by making it impossible for for-profit hospitals to compete due to lack of subsidies, the supply is deliberately constrained. Cheers!
- DanBC 5y ago
  >> There is a reason why clinical doctors have an abnormally high suicide rate in the US. > Source needed on this claim. Might be true. I’m skeptical though. High relative to what? It's a persistent misunderstanding of the data, pushed mostly by doctors or people who don't know where to find the data but also by the complexity of understanding suicide. Firstly, every death is a tragedy and we should be looking at suicide as mostly preventable. Doctors are highly educated, well paid, and tied into local healthcare systems. These should be protective factors. So we should see lower rates of death by suicide in this group. Both of these mean that the rate of death in doctors is too high, and should be reduced. The "relative to what?" part should be "to other professionals, such as lawyers or architects". And sure, compared to those groups we see doctors have a higher rate of death, and that's worrying because of the protective factors that should be present. (This is mostly because female doctors have a higher rate of death by suicide than women in general.) In healthcare we see nurses and other female care givers have higher rates than doctors. https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a1-H.pdf https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a1-H.pdf > In 2017, nearly 38,000 persons of working age (16–64 years) in the United States died by suicide, which represents a 40% rate increase (12.9 per 100,000 population in 2000 to 18.0 in 2017) in less than 2 decades.* To inform suicide prevention, CDC analyzed suicide data by industry and occupation among working-age decedents presumed to be employed at the time of death from the 32 states participating in the 2016 National Violent Death Reporting System (NVDRS). †,§ > Compared with rates in the total study population, suicide rates were significantly higher in five major industry groups: 1) Mining, Quarrying, and Oil and Gas Extraction (males); 2) Construction (males); 3) Other Services (e.g., automotive repair) (males); 4) Agriculture, Forestry, Fishing, and Hunting (males); and 5) Transportation and Warehousing (males and females). Rates were also significantly higher in six major occupational groups: 1) Construction and Extraction (males and females); 2) Installation, Maintenance, and Repair (males); 3) Arts, Design, Entertainment, Sports, and Media (males); 4) Transportation and Material Moving (males and females); 5) Protective Service (females); and 6) Healthcare Support (females).

huitzitziltzin 5y ago

Lots of stuff here… >> Hospitals are 40% of the NH spending so I would even not look at doctors that way. Hospitals are 30% and physicians are 20% >> The market structure is such that there are very few doctors, Agree. Add more medical schools and residency spots. >> With a massive supply shock on doctors you would not only lower wages for doctors, Yes, this is a good idea. >> you would also lower admin costs. Not clear that this is true or why it would happen. >>One caveat, even though doctors wages are very high, they are also rent-captured by universities that charge mid six-digits for an education and medical insurance, and certifications that are burdensome and expensive. Medical school debt may be high, but salaries are higher. Certifications are not likely a large obstacle to more entry, IMO. >> I remember medical malpractice insurance going to several thousand a month for OBGYN. There are plenty of “tort reform” states that cap malpractice payouts. Medical services are not cheaper there. >> There is a reason why clinical doctors have an abnormally high suicide rate in the US. Source needed on this claim. Might be true. I’m skeptical though. High relative to what? >> Then hospitals get massive fed spending and money, They do and certainly in the COVID stimulus bill that was a HUGE waste of public money. >> plus often local protections that mean you cant open competing hospitals. This is called “certificate of need.” These laws are dumb but don’t exist in 15-20 states at this point. More entry would be great, but you need more doctors, more competition and more price transparency too. >> In the book " The Social Transformation of American Medicine" they talk a lot about how hospitals rent-seeking behavior is to turn themselves as a non-profit, and then ask for federal funding and getting that denied to for-profit hospitals, effectively capping the amount of hospitals you can open. Certificate of need laws are state, not federal. >> The WHOLE market structure needs a detonation. I’m on board. But by detonation I really mean: - more medical schools, - more doctors, including permitting foreign doctors to practice here - price transparency - meaningful competition among hospitals on price. >> And this is my desire/wish/prediction: at some point we will get an Uber for medicine. Amazon is starting an Amazon Care product. Looks like urgent care for the time being. My hope is that they open hospitals eventually. >> Americans will do most their telemedicine with doctors outside the united states, where education is free, there are not legal requirements or certifications or licenses, etc. This is what immigrants like myself do. A psychiatrist in argentina, for example, charges 5U$S for a visit, while one in Palo Alto, CA charges 1000U$S with a 3 month wait list. Great idea and this is what my (foreign born) wife does too. A great way to save money. For anyone else reading this far down, you can do it too. There are English speaking doctors everywhere.

GabrielBen 5y ago
Excited to read this! > >> you would also lower admin costs. > Not clear that this is true or why it would happen. There is an operational tax whenever you involve more people into the operation. You need to communicate, add paper trails, set up structure, etc. If say, you had one person collecting payments instead of a secretary, a doctor writing a paper, an insurance biller, an insurance agent, etc for the same ops, it would be a lot easier. You would have doctors perform many of these tasks. For example, give vaccinations, take vitals, etc. > Medical school debt may be high, but salaries are higher. Certifications are not likely a large obstacle to more entry, IMO. Thats the survivorship bias. Salaries cant be lower because people would go bankrupt. Certifications reduce competition, and make it harder to practice. There's even a startup that Raised a series A of multiple millions just to make this process faster (medallion). Evidence this affects the market is that most doctors are only licensed in a couple of states at most. > There are plenty of “tort reform” states that cap malpractice payouts. Medical services are not cheaper there. I'd like to see some data about this if you have it. Conceptually malpractice insurance is a fix cost that puts downward pressure on supply. IT is particularly salient for physicians that would like to work part-time. > Source needed on this claim. Might be true. I’m skeptical though. High relative to what? https://www.webmd.com/mental-health/news/20180508/doctors-suicide-rate-highest-of-any-profession https://www.webmd.com/mental-health/news/20180508/doctors-su.... This is a well known fact in the profession. >> In the book " The Social Transformation of American Medicine" they talk a lot about how hospitals rent-seeking behavior is to turn themselves as a non-profit, and then ask for federal funding and getting that denied to for-profit hospitals, effectively capping the amount of hospitals you can open. > Certificate of need laws are state, not federal. The point above is that by making it impossible for for-profit hospitals to compete due to lack of subsidies, the supply is deliberately constrained. Cheers!
DanBC 5y ago
>> There is a reason why clinical doctors have an abnormally high suicide rate in the US. > Source needed on this claim. Might be true. I’m skeptical though. High relative to what? It's a persistent misunderstanding of the data, pushed mostly by doctors or people who don't know where to find the data but also by the complexity of understanding suicide. Firstly, every death is a tragedy and we should be looking at suicide as mostly preventable. Doctors are highly educated, well paid, and tied into local healthcare systems. These should be protective factors. So we should see lower rates of death by suicide in this group. Both of these mean that the rate of death in doctors is too high, and should be reduced. The "relative to what?" part should be "to other professionals, such as lawyers or architects". And sure, compared to those groups we see doctors have a higher rate of death, and that's worrying because of the protective factors that should be present. (This is mostly because female doctors have a higher rate of death by suicide than women in general.) In healthcare we see nurses and other female care givers have higher rates than doctors. https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a1-H.pdf https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6903a1-H.pdf > In 2017, nearly 38,000 persons of working age (16–64 years) in the United States died by suicide, which represents a 40% rate increase (12.9 per 100,000 population in 2000 to 18.0 in 2017) in less than 2 decades.* To inform suicide prevention, CDC analyzed suicide data by industry and occupation among working-age decedents presumed to be employed at the time of death from the 32 states participating in the 2016 National Violent Death Reporting System (NVDRS). †,§ > Compared with rates in the total study population, suicide rates were significantly higher in five major industry groups: 1) Mining, Quarrying, and Oil and Gas Extraction (males); 2) Construction (males); 3) Other Services (e.g., automotive repair) (males); 4) Agriculture, Forestry, Fishing, and Hunting (males); and 5) Transportation and Warehousing (males and females). Rates were also significantly higher in six major occupational groups: 1) Construction and Extraction (males and females); 2) Installation, Maintenance, and Repair (males); 3) Arts, Design, Entertainment, Sports, and Media (males); 4) Transportation and Material Moving (males and females); 5) Protective Service (females); and 6) Healthcare Support (females).