6 ms·

The payment model probably isn't the biggest problem with the US system. My belief is that it's the relatively complicated regulation of capacity (federal and

The payment model probably isn't the biggest problem with the US system. My belief is that it's the relatively complicated regulation of capacity (federal and state regulations on facilities and providers), which pairs poorly with government programs that increase access to care with direct subsidies. We should train lots more providers and eliminate barriers to entry (so for instance, if someone wants to open an MRI suite, let them).

nradov 2y ago
I generally agree, but many states don't have certificate-of-need rules blocking new imaging centers and those states don't seem to have significantly lower healthcare costs. The most immediate bottleneck on producing more physicians is lack of federal government funding for residency programs. Every year there are students who graduate from medical school with an MD but are unable to practice medicine because they don't get matched to a residency program (some do get matched the following year). At one point the AMA lobbied Congress to limit the supply of doctors but some years back they reversed that position. So far Congress hasn't acted. https://savegme.org/ https://savegme.org/ The other thing we can do to increase the supply of providers is to rely more on physician assistants and nurse practitioners for primary care. There may be some reduction in care quality but it's good enough for routine treatments and patients will just have to accept that. Real physicians should be reserved for more complex cases.
- mindslight 2y ago
  > There may be some reduction in care quality but it's good enough for routine treatments and patients will just have to accept that. Real physicians should be reserved for more complex cases. Every efficiency idea is ultimately just used as an excuse to make the system worse and worse. As it stands "real physicians" are already mostly phoning it in, because their attention has been sliced up into 10 minute slivers by "insurance" companies. I'm not saying that NPs or PAs are going to be worse than that (in fact individual NP/PAs can be more engaged than individual MDs!), but it's still galling to be on the receiving end of negative-sum cost optimization - "our next appointment with a doctor is in four months, or you can see a PA next month". The sweeping reform we need is to drastically introduce actual market dynamics into the industry. This applies regardless of the payer structure - the entire industry needs to be moved from cost-externalizing negative-sum interactions towards cost-internalized positive-sum interactions. Imagine having actual supply and demand for doctors and hospitals funding their own residency programs rather than a set number of government funded residency slots.
  - nradov 2y ago
    How exactly would doctors fund their own residency programs? They already graduate from medical school $500k in debt. There's no more room to squeeze them further. And teaching hospitals have no real incentive to fund more residency program slots. Their customers aren't willing to pay more for it. In game theory terms this is essentially a free rider problem: many entities in the healthcare system would benefit from a larger supply of physicians but they all want someone else to pay for education. There have been some attempts to introduce market dynamics such as high-deductible health plans (HDHP) with HSAs. Those can work fairly well for a minority of engaged and intelligent consumers but overall aren't an effective solution to systemic problems. Classical supply and demand economics don't function very well in healthcare. Demand is effectively infinite: sick people want all the healthcare they can get (even if it doesn't really help them much or causes iatrogenic harm) and they think someone else should pay for it. Thus the only way to constrain total system costs is by artificially limiting supply and imposing some sort of rationing. So the real argument ends up being about how we do the rationing.
    - mindslight 2y ago
      > How exactly would doctors fund their own residency programs? I said hospitals. You'd do your residency and then have a commitment to keep working at the hospital for say 3 years (or otherwise repaying the training). > In game theory terms this is essentially a free rider problem Yes, this is exactly what I mean by founded on negative sum interactions. Every player is focused on avoiding costs rather than providing value. In a sane market, when a business can't find employees they offer higher wages, overtime, train new employees, etc. That's positive sum that grows the industry, rather than just throwing their hands up and letting the shortages build. > There have been some attempts to introduce market dynamics such as high-deductible health plans (HDHP) with HSAs I guess if you squint really hard, just subjecting patients to even more unknown charges is some kind of attempt? I'm talking about things like making providers beholden to the basic legal norms of commerce that apply everywhere else. End this nonsense where providers won't answer questions about how much anything costs, but then shake you down after the fact with a volley of fraudulent bills - that foundation is already askew from how every other industry works. Imagine going to the grocery store, and then receiving bills over the next year from the cashier, shelf stocker, distributor, etc, all claiming that you're also responsible for paying them. Healthy industries work by consolidating costs and making prices legible. The healthcare industry is stuck in a state of doing the exact opposite, but yet has managed to entrench itself with the entitlement of still getting paid. If providers want to be able to bill patients directly then they need to do the work of forming actual contracts based on fixed price services, estimated work, hourly rates, etc (once again like every other industry). Or if you've got a healthcare plan and go to providers they point you to, the only entity you should ever be receiving bills from is the plan itself. > Thus the only way to constrain total system costs is by artificially limiting supply and imposing some sort of rationing. So the real argument ends up being about how we do the rationing. So just scrap the entire concept of individual agency? Are you a doctor or something? And lest people jump on me for not just toeing the party line of "single payer" - as I said this is orthogonal to who may be ultimately paying. Furthermore, if we're going to be paying for a base level of care with public funds (which we're already doing for a large part), then we want to be spending that money wisely and not squandering it on a system sick with organizational cancer.
lostlogin 2y ago
> We should train lots more providers and eliminate barriers to entry (so for instance, if someone wants to open an MRI suite, let them). Is there something blocking them now? Presumably you would still require qualified staff, safe and maintained equipment?
- unyttigfjelltol 2y ago
  Yes, Congress and the American Medical Association capped the number of new doctor trainees in 1997.[1] That is one cited reason why there is a serious shortage of medical doctors in the US. [1] https://www.openhealthpolicy.com/p/medical-residency-slots-congress https://www.openhealthpolicy.com/p/medical-residency-slots-c...

nradov 2y ago

I generally agree, but many states don't have certificate-of-need rules blocking new imaging centers and those states don't seem to have significantly lower healthcare costs. The most immediate bottleneck on producing more physicians is lack of federal government funding for residency programs. Every year there are students who graduate from medical school with an MD but are unable to practice medicine because they don't get matched to a residency program (some do get matched the following year). At one point the AMA lobbied Congress to limit the supply of doctors but some years back they reversed that position. So far Congress hasn't acted. https://savegme.org/ https://savegme.org/ The other thing we can do to increase the supply of providers is to rely more on physician assistants and nurse practitioners for primary care. There may be some reduction in care quality but it's good enough for routine treatments and patients will just have to accept that. Real physicians should be reserved for more complex cases.

mindslight 2y ago
> There may be some reduction in care quality but it's good enough for routine treatments and patients will just have to accept that. Real physicians should be reserved for more complex cases. Every efficiency idea is ultimately just used as an excuse to make the system worse and worse. As it stands "real physicians" are already mostly phoning it in, because their attention has been sliced up into 10 minute slivers by "insurance" companies. I'm not saying that NPs or PAs are going to be worse than that (in fact individual NP/PAs can be more engaged than individual MDs!), but it's still galling to be on the receiving end of negative-sum cost optimization - "our next appointment with a doctor is in four months, or you can see a PA next month". The sweeping reform we need is to drastically introduce actual market dynamics into the industry. This applies regardless of the payer structure - the entire industry needs to be moved from cost-externalizing negative-sum interactions towards cost-internalized positive-sum interactions. Imagine having actual supply and demand for doctors and hospitals funding their own residency programs rather than a set number of government funded residency slots.
- nradov 2y ago
  How exactly would doctors fund their own residency programs? They already graduate from medical school $500k in debt. There's no more room to squeeze them further. And teaching hospitals have no real incentive to fund more residency program slots. Their customers aren't willing to pay more for it. In game theory terms this is essentially a free rider problem: many entities in the healthcare system would benefit from a larger supply of physicians but they all want someone else to pay for education. There have been some attempts to introduce market dynamics such as high-deductible health plans (HDHP) with HSAs. Those can work fairly well for a minority of engaged and intelligent consumers but overall aren't an effective solution to systemic problems. Classical supply and demand economics don't function very well in healthcare. Demand is effectively infinite: sick people want all the healthcare they can get (even if it doesn't really help them much or causes iatrogenic harm) and they think someone else should pay for it. Thus the only way to constrain total system costs is by artificially limiting supply and imposing some sort of rationing. So the real argument ends up being about how we do the rationing.
  - mindslight 2y ago
    > How exactly would doctors fund their own residency programs? I said hospitals. You'd do your residency and then have a commitment to keep working at the hospital for say 3 years (or otherwise repaying the training). > In game theory terms this is essentially a free rider problem Yes, this is exactly what I mean by founded on negative sum interactions. Every player is focused on avoiding costs rather than providing value. In a sane market, when a business can't find employees they offer higher wages, overtime, train new employees, etc. That's positive sum that grows the industry, rather than just throwing their hands up and letting the shortages build. > There have been some attempts to introduce market dynamics such as high-deductible health plans (HDHP) with HSAs I guess if you squint really hard, just subjecting patients to even more unknown charges is some kind of attempt? I'm talking about things like making providers beholden to the basic legal norms of commerce that apply everywhere else. End this nonsense where providers won't answer questions about how much anything costs, but then shake you down after the fact with a volley of fraudulent bills - that foundation is already askew from how every other industry works. Imagine going to the grocery store, and then receiving bills over the next year from the cashier, shelf stocker, distributor, etc, all claiming that you're also responsible for paying them. Healthy industries work by consolidating costs and making prices legible. The healthcare industry is stuck in a state of doing the exact opposite, but yet has managed to entrench itself with the entitlement of still getting paid. If providers want to be able to bill patients directly then they need to do the work of forming actual contracts based on fixed price services, estimated work, hourly rates, etc (once again like every other industry). Or if you've got a healthcare plan and go to providers they point you to, the only entity you should ever be receiving bills from is the plan itself. > Thus the only way to constrain total system costs is by artificially limiting supply and imposing some sort of rationing. So the real argument ends up being about how we do the rationing. So just scrap the entire concept of individual agency? Are you a doctor or something? And lest people jump on me for not just toeing the party line of "single payer" - as I said this is orthogonal to who may be ultimately paying. Furthermore, if we're going to be paying for a base level of care with public funds (which we're already doing for a large part), then we want to be spending that money wisely and not squandering it on a system sick with organizational cancer.

lostlogin 2y ago

> We should train lots more providers and eliminate barriers to entry (so for instance, if someone wants to open an MRI suite, let them). Is there something blocking them now? Presumably you would still require qualified staff, safe and maintained equipment?

unyttigfjelltol 2y ago
Yes, Congress and the American Medical Association capped the number of new doctor trainees in 1997.[1] That is one cited reason why there is a serious shortage of medical doctors in the US. [1] https://www.openhealthpolicy.com/p/medical-residency-slots-congress https://www.openhealthpolicy.com/p/medical-residency-slots-c...