6 ms·

If we were to get to a single-payer healthcare system, it seems like we would have to tackle the issue of medical school debt. $360K of debt would be a massive

by aantix 3y ago

If we were to get to a single-payer healthcare system, it seems like we would have to tackle the issue of medical school debt. $360K of debt would be a massive burden if the system had fixed costs.

echelon 3y ago
It's not just tuition. There are so many issues with the workforce and their education: - We cap the number of residency students per year, creating an artificial limited supply. - We don't allow immigrant doctors to transfer their credentials, creating an artificial limited supply. - Med school is expensive, limiting the pool of applicants. - Nurses and nurse practitioners are extremely close to the action on a daily basis. There should be a path for them to graduate into doctors, perhaps by attending night school and then some form of on-the-job residency.
- dmoy 3y ago
  plus the other 85% of medical expenses (since what only 15% is doctor & nurse & tech pay?) Even if doctors and nurses worked for $0, we'd still have the most expensive healthcare system due to admin, drug, etc costs.
- HEmanZ 3y ago
  Yes, it is similar skill and effort for an np who got a one year online degree that took 15th/wk of studying and a doctor who spent 80hrs per week of studying for 4 years to complete med school, then did 4-7 years of 80-100hrs per week of intense residency. Do you really believe this when a loved one’s life is on the line?
  - echelon 3y ago
    There's no path they could take to become a doctor? Even if they spend a decade in the field, fully hands on?
    - HEmanZ 3y ago
      I actually do like the idea there should be more ladder and less silo. Im not sure how it could be implemented tho. I’m just reacting to the idea that mid levels are anywhere near as skilled (meaning training) as most physicians. The hurdles I see are: There’s a reason doctors have really intense study time before residency, and you’d have to replicate that. There’s also a reason residency is so intense, you’re not going to get anything like resident experience doing ordinary mid level work. You’d need to hybrid model, but who is going to agree to something like: instead of working as a nurse 40 hours per week, you’re going to work 40hrs/wk and study 40hrs/wk, for 8 years, and if you pass the tests you’ll move on to the next level. This could work but basically sounds like part-time med school. Part time residency would be even less appealing, it would take you like 10+ years to get the amount of cases a resident has if you were only doing it part time
      - echelon 3y ago
        These are fair points. It does sound like a difficult bridge to build. I don't think it would be impossible, but there's clearly a big gap.
        devilbunny 3y ago
        The bridge is "apply to, be accepted at, and graduate from medical school". Offhand, I personally know at least four physicians who were nurses first, and they certainly worked occasional shifts as nurses during med school for extra money, but it's hard to describe just how big of a torrent of information medical students are expected to absorb. There's very little overlap in the education, although former nurses usually have better simple-procedure skills (IV's, catheters, etc.) and superior skills at dealing with difficult patients early on in clinical education.
    - ejb999 3y ago
      The problem I see with that is, a typical medical student is going to have to do study and clinical rotations across all disciplines - even ones they don't end up practicing - i.e. pysch, derm, emergency medicine, surgery, ortho etc - i.e., they will get training in all those areas. Compare that to an NP that went from their 18 month NP class, to work in primary medicine/family practice office - and lets say they work there for 10 years, so great, now they are an experienced NP in family medicine (and someone I for one would be perfectly happy to see as a patient for most routine things) - but what they don't have is the experience in all those other areas that matter - even if they are not practicing it. There is just no shortcut without putting in the time - thousands and thousands of hours of study and patient facing experience under the supervision of an experienced MD. There is nothing wrong with being an experienced NP seeing patients (and that is mostly who I end up seeing) - but there is simply no reason to somehow 'promote' those people to doctors - they don't have the same skills or the same experience, and doing so doesn't solve any problem.
- ejb999 3y ago
  I for one am glad we don't just let foreign doctors transfer their credentials - the education and standards are not always the same, and not really sure I want to go see a doctor that moved here after taking a accelerated/minimal set of courses at whatever country happens to have the easiest/cheapest graduation requirements. Certainly there are some countries that probably have similar course of study and requirements as the USA, but I think you would need to approve transfer's very carefully after serious review of the sending countries education and training requirements. NP vs MD education is not even close to being similar - that is why their is no easy path from one to the other - a typical NP will graduate having done ~600 to 700 hours of patient care hours. A typical MD will have had 12,000 to 16,000 hours of patient care experience before they start practicing - there are plenty of things were seeing an NP is more than enough - but you can't just give a few months of extra training to bump an NP to an MD - their education and knowledge is not even close to comparable. There is a place for both in our health care system - but they are not the same job.
  - ilc 3y ago
    Personally, I'll take the 60 year old NP over the 30 year old doctor 95%+ of the time. The NP has seen more and been around the block. The doctor still is a baby in medicine.
    - FireBeyond 3y ago
      The problem is the Zero-to-NP programs that have an "Accelerated RN" component. One (not all) aspects of the NP program was similar to your comment, building off career and professional experience, and using that as one basis for knowledge. These programs are not even giving you the RN -student- nursing experience (let alone post graduation), they're skipping that entirely. Looking online: "Become an NP in 20 months". "NP in 27 months". From HIGH SCHOOL. In EMS, there is a push to make paramedicine at least an associates, if not a bachelors degree (there are programs with all three, certificate, associate, bachelors). Paramedics are the advanced version of when you call 911. The invasive side (versus EMT which is - largely - non-invasive). Cardiac arrest and dysrhythmia management (ECG interpretation, manual defib and pacing, approximately a dozen cardiac drugs), airway management and intubation (including sedatives, paralytics and analgesia), childbirth, trauma, burns. In my area we can give approximately 60 different meds IM, IV, IN, IO from fairly benign to quite acute (adenosine, atropine, etomidate, rocuronium, etc.) The push for this is for at least two years of school, if not four. But yet you have schools pumping out NPs in as little as a year and eight months? With zero field supervision (for better or worse, and with varying degrees of intensity, PAs ostensibly operate under physician supervision/direction). This is going to cause a huge problem, I expect. Not the concept as a whole, but our YOLO attitude to these things, and schools seeing dollar signs.
- fasthands9 3y ago
  I agree. The donation is a pretty great thing - but without increasing the number of residency slots per year it seems like it may just shift people that would go to another school to go to this one.
Scoundreller 3y ago
Canada has managed to undertrain its own people domestically for med school for a while with many going to the US/caribbean/europe for training at full rates. We’ve had to change our terminology from “international medical graduates” to “foreign medical graduates” because a lot of those trying to get foreign credentials recognized are locals. Probably a tough slog upon return to pay back the debts but net-positive in the long-run (unless interest rates go up, uh oh).
abeppu 3y ago
Is it necessarily the case that median physician pay must go down for a single-payer system? I would hope that we could have savings if the total payments to actual care providers was similar, but billing, and insurance parts of the system were dropped out of the picture.
- Scoundreller 3y ago
  The numbers I can quickly Google for US are ~15-30% spent on administration, not that those zero out under single-payer. It's not just the physician/surgeon aspect of US healthcare that's expensive, it's all of it. I'm on the Canadian side, and drugs have never been single-payer outside of a hospital, but that leg of the system is still much cheaper (on average) in Canada.
HEmanZ 3y ago
Medical school debt and physician insurance. Some specialties have just wildly high insurance. My wife is an OB and has to pay $140,000/yr per year for tail insurance in my state. So she literally needs to make, after all other costs of the practice, $140k just to break an even $0/yr. And people wonder why it costs so much to have a baby.
- Scoundreller 3y ago
  Why is insurance just a flat rate? Shouldn’t it be per procedure or something else better correlated to risk? (Sure, charging precisely for risk would just result in some patients/scenarios being avoided, but per case or a percentage of billing would make much more sense).
  - HEmanZ 3y ago
    It isn’t flat, that’s the average of the last two years. It does adjust for a lot of things, like any insurance. It is higher than avg in the state for my wife right now because she is only a few years out of residency. Mid career, she should only expect to pay about $120k/yr…
  - devilbunny 3y ago
    Doing more procedures exposes a physician to more risk, but those who do a lot of procedures generally are better at them. I'm an anesthesiologist, but I don't do infants or cardiac cases, and I haven't done them in long enough that I wouldn't want to do them without someone around to get me back in the groove. Someone who does one vaginal delivery a month is not going to be as good at doing them as someone who does two or three a day. And they certainly won't be as good at cesarean sections. Delivering just one baby costs a hell of a lot of money in insurance, which is a major part of why family doctors in rural areas don't do that anymore. By contrast, people who drive more miles - even if they are excellent drivers - are at higher risk of being in a collision because they have to deal with other people on the road, who may be terrible drivers.
- FireBeyond 3y ago
  If she is still working as an OB, what would be the difference in premium to renew her claims-made policy with prior acts coverage? I can't imagine (but do not know) that it is more efficient to pay claims-made AND tail, versus claims-made with prior acts (unless of course your employer is paying the claims-made). For those not in the medical field, tail or ERP (extended reporting period) coverage is liability coverage for when the original policy has ended - i.e. you were insured for 2024, but in 2025 a malpractice suit comes to you for an incident in 2024. In the auto/general world, this is fairly well accommodated, but in the medical liability world, insurers say it is because of the preponderance of claims that may arrive significantly later than coverage. However, many insurers absolutely ream providers on it. Tail insurance is typically double the actual claim premium, i.e. insurers are saying that your insurance premium is only covering 1/3 of the claims they expect to pay on your behalf. I ... have doubts ... on that number. And I also suspect that there is a bell curve happening where certainly, complex malpractice claims may take time to be built out and filed, and that may extend beyond coverage, but then at a certain point, you can relatively confidently assume that the incoming claims are asymptotically approaching zero. Additionally, I cannot exactly remember if malpractice insurers are required to abide by MLR - profit restrictions - like the 80/20 rule, but in your wife's case, the insurers as a whole (claims-made and tail) are implying that they expect to pay out $168,000 a year for her liability.

by aantix 3y ago

If we were to get to a single-payer healthcare system, it seems like we would have to tackle the issue of medical school debt. $360K of debt would be a massive burden if the system had fixed costs.

echelon 3y ago

It's not just tuition. There are so many issues with the workforce and their education: - We cap the number of residency students per year, creating an artificial limited supply. - We don't allow immigrant doctors to transfer their credentials, creating an artificial limited supply. - Med school is expensive, limiting the pool of applicants. - Nurses and nurse practitioners are extremely close to the action on a daily basis. There should be a path for them to graduate into doctors, perhaps by attending night school and then some form of on-the-job residency.

dmoy 3y ago
plus the other 85% of medical expenses (since what only 15% is doctor & nurse & tech pay?) Even if doctors and nurses worked for $0, we'd still have the most expensive healthcare system due to admin, drug, etc costs.
HEmanZ 3y ago
Yes, it is similar skill and effort for an np who got a one year online degree that took 15th/wk of studying and a doctor who spent 80hrs per week of studying for 4 years to complete med school, then did 4-7 years of 80-100hrs per week of intense residency. Do you really believe this when a loved one’s life is on the line?
- echelon 3y ago
  There's no path they could take to become a doctor? Even if they spend a decade in the field, fully hands on?
  - HEmanZ 3y ago
    I actually do like the idea there should be more ladder and less silo. Im not sure how it could be implemented tho. I’m just reacting to the idea that mid levels are anywhere near as skilled (meaning training) as most physicians. The hurdles I see are: There’s a reason doctors have really intense study time before residency, and you’d have to replicate that. There’s also a reason residency is so intense, you’re not going to get anything like resident experience doing ordinary mid level work. You’d need to hybrid model, but who is going to agree to something like: instead of working as a nurse 40 hours per week, you’re going to work 40hrs/wk and study 40hrs/wk, for 8 years, and if you pass the tests you’ll move on to the next level. This could work but basically sounds like part-time med school. Part time residency would be even less appealing, it would take you like 10+ years to get the amount of cases a resident has if you were only doing it part time
    - echelon 3y ago
      These are fair points. It does sound like a difficult bridge to build. I don't think it would be impossible, but there's clearly a big gap.
      - devilbunny 3y ago
        The bridge is "apply to, be accepted at, and graduate from medical school". Offhand, I personally know at least four physicians who were nurses first, and they certainly worked occasional shifts as nurses during med school for extra money, but it's hard to describe just how big of a torrent of information medical students are expected to absorb. There's very little overlap in the education, although former nurses usually have better simple-procedure skills (IV's, catheters, etc.) and superior skills at dealing with difficult patients early on in clinical education.
  - ejb999 3y ago
    The problem I see with that is, a typical medical student is going to have to do study and clinical rotations across all disciplines - even ones they don't end up practicing - i.e. pysch, derm, emergency medicine, surgery, ortho etc - i.e., they will get training in all those areas. Compare that to an NP that went from their 18 month NP class, to work in primary medicine/family practice office - and lets say they work there for 10 years, so great, now they are an experienced NP in family medicine (and someone I for one would be perfectly happy to see as a patient for most routine things) - but what they don't have is the experience in all those other areas that matter - even if they are not practicing it. There is just no shortcut without putting in the time - thousands and thousands of hours of study and patient facing experience under the supervision of an experienced MD. There is nothing wrong with being an experienced NP seeing patients (and that is mostly who I end up seeing) - but there is simply no reason to somehow 'promote' those people to doctors - they don't have the same skills or the same experience, and doing so doesn't solve any problem.
ejb999 3y ago
I for one am glad we don't just let foreign doctors transfer their credentials - the education and standards are not always the same, and not really sure I want to go see a doctor that moved here after taking a accelerated/minimal set of courses at whatever country happens to have the easiest/cheapest graduation requirements. Certainly there are some countries that probably have similar course of study and requirements as the USA, but I think you would need to approve transfer's very carefully after serious review of the sending countries education and training requirements. NP vs MD education is not even close to being similar - that is why their is no easy path from one to the other - a typical NP will graduate having done ~600 to 700 hours of patient care hours. A typical MD will have had 12,000 to 16,000 hours of patient care experience before they start practicing - there are plenty of things were seeing an NP is more than enough - but you can't just give a few months of extra training to bump an NP to an MD - their education and knowledge is not even close to comparable. There is a place for both in our health care system - but they are not the same job.
- ilc 3y ago
  Personally, I'll take the 60 year old NP over the 30 year old doctor 95%+ of the time. The NP has seen more and been around the block. The doctor still is a baby in medicine.
  - FireBeyond 3y ago
    The problem is the Zero-to-NP programs that have an "Accelerated RN" component. One (not all) aspects of the NP program was similar to your comment, building off career and professional experience, and using that as one basis for knowledge. These programs are not even giving you the RN -student- nursing experience (let alone post graduation), they're skipping that entirely. Looking online: "Become an NP in 20 months". "NP in 27 months". From HIGH SCHOOL. In EMS, there is a push to make paramedicine at least an associates, if not a bachelors degree (there are programs with all three, certificate, associate, bachelors). Paramedics are the advanced version of when you call 911. The invasive side (versus EMT which is - largely - non-invasive). Cardiac arrest and dysrhythmia management (ECG interpretation, manual defib and pacing, approximately a dozen cardiac drugs), airway management and intubation (including sedatives, paralytics and analgesia), childbirth, trauma, burns. In my area we can give approximately 60 different meds IM, IV, IN, IO from fairly benign to quite acute (adenosine, atropine, etomidate, rocuronium, etc.) The push for this is for at least two years of school, if not four. But yet you have schools pumping out NPs in as little as a year and eight months? With zero field supervision (for better or worse, and with varying degrees of intensity, PAs ostensibly operate under physician supervision/direction). This is going to cause a huge problem, I expect. Not the concept as a whole, but our YOLO attitude to these things, and schools seeing dollar signs.
fasthands9 3y ago
I agree. The donation is a pretty great thing - but without increasing the number of residency slots per year it seems like it may just shift people that would go to another school to go to this one.

Scoundreller 3y ago

Canada has managed to undertrain its own people domestically for med school for a while with many going to the US/caribbean/europe for training at full rates. We’ve had to change our terminology from “international medical graduates” to “foreign medical graduates” because a lot of those trying to get foreign credentials recognized are locals. Probably a tough slog upon return to pay back the debts but net-positive in the long-run (unless interest rates go up, uh oh).

abeppu 3y ago

Is it necessarily the case that median physician pay must go down for a single-payer system? I would hope that we could have savings if the total payments to actual care providers was similar, but billing, and insurance parts of the system were dropped out of the picture.

Scoundreller 3y ago
The numbers I can quickly Google for US are ~15-30% spent on administration, not that those zero out under single-payer. It's not just the physician/surgeon aspect of US healthcare that's expensive, it's all of it. I'm on the Canadian side, and drugs have never been single-payer outside of a hospital, but that leg of the system is still much cheaper (on average) in Canada.

HEmanZ 3y ago

Medical school debt and physician insurance. Some specialties have just wildly high insurance. My wife is an OB and has to pay $140,000/yr per year for tail insurance in my state. So she literally needs to make, after all other costs of the practice, $140k just to break an even $0/yr. And people wonder why it costs so much to have a baby.

Scoundreller 3y ago
Why is insurance just a flat rate? Shouldn’t it be per procedure or something else better correlated to risk? (Sure, charging precisely for risk would just result in some patients/scenarios being avoided, but per case or a percentage of billing would make much more sense).
- HEmanZ 3y ago
  It isn’t flat, that’s the average of the last two years. It does adjust for a lot of things, like any insurance. It is higher than avg in the state for my wife right now because she is only a few years out of residency. Mid career, she should only expect to pay about $120k/yr…
- devilbunny 3y ago
  Doing more procedures exposes a physician to more risk, but those who do a lot of procedures generally are better at them. I'm an anesthesiologist, but I don't do infants or cardiac cases, and I haven't done them in long enough that I wouldn't want to do them without someone around to get me back in the groove. Someone who does one vaginal delivery a month is not going to be as good at doing them as someone who does two or three a day. And they certainly won't be as good at cesarean sections. Delivering just one baby costs a hell of a lot of money in insurance, which is a major part of why family doctors in rural areas don't do that anymore. By contrast, people who drive more miles - even if they are excellent drivers - are at higher risk of being in a collision because they have to deal with other people on the road, who may be terrible drivers.
FireBeyond 3y ago
If she is still working as an OB, what would be the difference in premium to renew her claims-made policy with prior acts coverage? I can't imagine (but do not know) that it is more efficient to pay claims-made AND tail, versus claims-made with prior acts (unless of course your employer is paying the claims-made). For those not in the medical field, tail or ERP (extended reporting period) coverage is liability coverage for when the original policy has ended - i.e. you were insured for 2024, but in 2025 a malpractice suit comes to you for an incident in 2024. In the auto/general world, this is fairly well accommodated, but in the medical liability world, insurers say it is because of the preponderance of claims that may arrive significantly later than coverage. However, many insurers absolutely ream providers on it. Tail insurance is typically double the actual claim premium, i.e. insurers are saying that your insurance premium is only covering 1/3 of the claims they expect to pay on your behalf. I ... have doubts ... on that number. And I also suspect that there is a bell curve happening where certainly, complex malpractice claims may take time to be built out and filed, and that may extend beyond coverage, but then at a certain point, you can relatively confidently assume that the incoming claims are asymptotically approaching zero. Additionally, I cannot exactly remember if malpractice insurers are required to abide by MLR - profit restrictions - like the 80/20 rule, but in your wife's case, the insurers as a whole (claims-made and tail) are implying that they expect to pay out $168,000 a year for her liability.