The primary issue is that there aren't enough residencies so we don't train enough doctors. There are literally millions of competent Americans who would love to become primary care doctors but can't.
We don't want to allow people to utilize the resources we have. There are more houses than housed and unhoused people but we keep building more and pricing out the poors. The poors grow in number every year. We just don't care. We like our society this way. This is what we want.
This is a ridiculous argument. There are 143 million housing units in the US and 600k homeless. That means that a vacancy rate of 0.4%, or 1.5 days per year is enough to make that true. Vacancy just due to people moving will greatly exceed that number.
I don't know how accurate it was, but I read that 27% of Canadians were fine with MAID (medical assistance in dying - i.e. euthanasia) for those whose only affliction was "poverty".
People love to take these statistics and make them something they are not and complain about how terrible our society is. It makes them feel morally superior.
This isn't true for primary care. There are tons of open spots every year that are filled by International graduates or aren't filled at all. The problem is nobody wants to do this job.
Thanks! Yeah, looks like there are some openings. Also looks like that is one specialty that has increased its slots by over 25% in the past 5 years. Progress
I think requiring 11 years of post high school education (undergrad + medical school + residency) is a pretty big reason why we don’t have enough primary care doctors.
It’s such a huge investment of time and money, that it’s very hard to convince anyone to get into the field.
We have this immutable education track, seemingly because that’s the way we’ve always done it in the US. But I’d be very curious if we actually achieve better outcomes than countries with shorter medical educations.
The article mentions that NPs and PAs also favor higher lying specialties - but it seems much easier to solve that supply and demand problem than paying the cost for more MDs
There are far more med school applicants than spots every year. They can't expand because of residency constraints, sure all that stuff would lead to more people wanting to become doctors, but the people who want to be doctors now largely can't. That problem would only be worse with less education.
No. Med schools desperately want to expand because they make a ton of money, there are not enough residency slots for them to expand without competent graduates going unmatched.
While there are more residency spots that graduating medical students in the us every year, they do have to compete with foreign grads, of which there are more than enough. So the us grads can’t be completely and openly incompetent. So some of them do fail to even graduate, and obviously not get residency spots.
> We have this immutable education track, seemingly because that’s the way we’ve always done it in the US.
It's not: it's only been that way since the nineteenth century. There used to be a Bachelor of Medicine degree that represented six years or so of study and was sufficient to practice medicine.
This is intentional, to keep salaries high. Only in USA do you have to get a random degree before you can go to a medical school. The only purpose served here is to reduce the number of doctors.
Also lack of respect from the medical profession. Hanging out with pre-meds at elite universities, it was considered a bit of a disappointment to only get a GP or internal medicine residency - good students try to get speciality residency. This is of course downstream of the lack of compensation from government or insurers - specialties earn more, unless you're willing to become a physician in a rural hospital.
The lack of respect by insurance companies is startling. Insurance companies effectively govern what care people receive, rather than doctors. I paid almost $1000 last year for a sleep study to diagnose sleep apnea, because my insurance company wouldn't cover it -- I wasn't high-enough risk. Turns out, I have severe obstructive sleep apnea. I'm just glad I was in a financial position to pay for the study myself.
Anecdotally, I have been using one medical since 2015. Initially it was the best service ever, you could find a ton of Physicians and Family doctors. But it started getting worse every year. Now, there are 0 doctors in my area, only nurse practitioners. As much as I buy the argument that not everyone needs an MD for primary care, I do absolutely think NP are just not sufficient. Too many times have I gone with an ailment that was met with “let it run the course” or “try this OTC medicine”, that eventually escalates into a more serious problem that put me out of commission for weeks. Thank god I have a job that didn’t fire me. And the other times it is met with “let’s just order a bunch of tests or see a specialist to be safe”, which would have been handled very differently by an MD.
Also an anecdote but I’ve had the same experiences.
The one that sticks out to me was a few years ago. I’m prone to sinus infections and this one just wouldn’t go away. I booked an appointment with an NP.
She took a brief look at me and then advised that I go to the hospital because “you might have a brain tumor”. I told her I get sinus issues all the time. She responded that her sister died of a brain tumor.
So off to the ER I went and 2k later I had an ER doc look at me like I was an idiot and diagnose me with a sinus infection.
Funny, I wasnt specific in my example, but my bad experience that I had in mind was also about a sinus infection. I had the flu symptoms and I booked the first appointment after the usual “let it run it course” period and specifically said that this feels different. Got the “let it run…”, waited another week, booked another appointment, got a bunch of otcs and finally when another week passed, I went to urgent care and the doctor there immediately diagnosed it as sinus infection and prescribed be antibiotics. Was feeling better after that in 3 days.
Urgent care is one of those scams so brazen that they can do it out in the open and get away with it. They bounce almost everything to the ER and essentially charge twice for the same work. Once at the Urgent Care and once at the ER. It's such a fantastic business model and essentially is doubling their profits.
It's not just private equity pulling these shenanigans. Our local Children's chain is a non-profit and they pull some real shady shit.
I wouldn't doubt that some urgent cares do shady stuff. The ones I've dealt with were great. Knowledgeable doctors (not just NPs or PAs), decent facilities, variety of common services like x-ray, blood draws, etc. One upfront fee for the visit and additional services are cheap ($30 xray, $10 blood tests). Really not bad.
Like a lot of people, I exclusively go to urgent care for routine stuff, and for the first line of care for anything more serious, and I have never once had the experience of being bounced to an ER. They share records with my PCP but can see me at the drop of a hat on no notice.
People overuse doctors. Most of what younger people (under, say, 50) go to the doctor for, a good NP can do just as well or better. One of my weird hobbyhorses is how dumb the name "nurse practitioner" is; they should just call them "associate physicians".
(Note here that we're talking about "urgent care", which are clinics run by health chains, staffed with a doctor or two, a couple NPs, and a bunch of nurses; "urgent care" is not the ER, which is a thing people gotten hung up on HN about before, because I guess every country calls their ER something different. Going to the ER for routine care is insane.)
>One of my weird hobbyhorses is how dumb the name "nurse practitioner" is; they should just call them "associate physicians".
Well, there are "physician assistants", PAs, which are the same rung of the ladder as NP but via different path. Areas tend to somehow converge either on NPs or PAs, but not both so often.
It is maybe a little bit crazy to design a system that charges people based partly on how well they are able to self-assess their need for care.
The ER and urgent care at my local hospital are next door to each other. Until the last year or so, it was the only urgent care in the area (and is the only ER).
The system I'm describing does no such thing. Urgent care is the doctor's office. It takes less self-assessment, not more, to go to urgent care, because you can go inexpensively and with no notice or appointment. Got a weird itchy bump? Stop in on your way back from work. If it's a rash, they'll tell you take Benadryl. If it's Fatal Familial Itchy-Bump-Itis, they'll square things away with your PCP and get serious diagnosis and care expedited.
It works extremely well with my doctor's health system, and I'll add that my doctor's health system is notorious in the area for sucking to work with, so if I switched to, like, Rush or Northwestern, presumably it'd be even better.
Why should that stop cost more of you walk in the other door?
One argument could be that treating non emergency cases would ruin availability or increase costs, both of which seems like big assumptions at a system design level (vs the actual constraints and incentives that have lead to the existing service configuration).
At the point where you're noticing that Urgent Care costs less than a primary care appointment and find that problematic, it really starts to feel like you're just searching for things to disagree about. It's OK if we run out of things to dispute!
ER is expensive because have to deal with life-and-death emergencies. They also have to deal with treating everyone.
Primary care is good for dealing with ongoing issues. It is cheaper because only staff what they need. But have to schedule appointments far out. They could leave slots open for urgent issues but then would cost more.
Urgent care is to handle the urgent but minor issues. Stuff that doctor could handle if they were open or had appointments. They are more expensive since they are open longer hours and less likely to get insurance.
One thing that would help fix the system is lots more free 24-hour urgent care clinics. That would keep people out of ER.
My background is CA & NYC. I am able to get same day or same week (if less urgent) appts by calling my primary (PCP). In the event that my PCP has no availability or it's late in the day, I'll consider going to urgent care since it's the only thing open.
I can understand other people posting how hard it is to find a good PCP (or even dentist frankly). I got lucky and found a good, local PCP that I've been seeing for years.
Associate physician would be a great term, but taking the analogy to the legal profession, wouldn’t we expect an associate doctor to become a doctor someday? Isn’t an associate doctor actually a resident or intern?
Married to a pediatric physician whose practice changed hands a few times and wound up in one the big local children's NPOs.
The administrators are fucking vipers. These orgs are rotted at the heart. They do everything they can to stretch the staff thin while shifting their targets and gaslighting them into thinking they're underperforming. Execs are doing great, but in the meantime they're hemorrhaging docs, nurses, and office staff because the conditions suck.
Urgent care is just a doctors office. I had to go for some stupid thing and the person at the front door would not let you enter if you had anything like chest pain.
My primary care doctor informed me a few days ago that he's shutting down his current practice. Appears to be driven by his desire to get away from the insurance companies. He's part of a new practice where you pay a monthly fee and everything's included. You can text and email with questions, stop by for an appointment and get right in, and so on.
The advantage for him is that he never deals with insurance companies again. The disadvantage for me is that, since I have few health issues, and they're minor when I do, it would cost a lot more per year.
When you have a market as distorted as medicine in the US, it's not just that crazy things happen, but also that normal, functioning versions of the thing are crowded out by the inescapable pull of the distortion.
Makes sense. Primary care would be better like dentists.
The monopolies formed for these health networks are bad for everyone. The staff are miserable, patients don’t heal, and half the time the companies are losing money. My primary care was bought by a hospital network, which was bought by some multi-state network that is under financial stress yet just boight another regional network to ruin.
The two shops around here charge about $175/month for a family ($80/month single adult). That's a difficult price to swallow when you have insurance through work, which almost everyone able to pay $175/month does. There's probably some value, but I need a doctor so little, I just can't see paying for it. It's competing with services like Zoomcare, which is basically an on-call online-scheduled prescription service which works very well for my purposes. I struggle to see these Direct Primary Care services getting off the ground unless they're in a very affluent neighborhood where price doesn't really matter anyway.
I would pay that without blinking if the care was good and getting appointments didn't take 3-12 months. We just waited a YEAR for a new patient appointment for my chronically I'll wife and the doctor is terrible. Told her he basically had no interest in helping figure out her problems and if he did, he wouldn't be a PCP.
I no longer support licensing primary care physicians after some of the things I've seen. I know someone that had high blood pressure (a condition that's easy to verify even if you don't have a doctor) and their doctor refused to do anything about it. As in, the patient repeatedly brought it up, and the doctor ignored the problem. That's not the worst I've seen by a long shot.
Licensing serves no purpose if you're not going to take it away in cases of incompetence and malice. This has turned me into a fan of malpractice suits with large punitive damages.
Well, Mister "lol"; what does "have doctors" mean to you. Because it seems to me without needing any sort of special education that one could conceivably take the term 'have doctors' to mean one thing according to how one poster describes their experience and mean something else entirely depending on how another poster would describe their experience. So, explicitly, what exactly does " have doctors " mean to you?
Unfortunately there's very little reprocuasion for a doctor being bad at their job. As long as they don't do anything That'll revoke their license they don't care. That's the problem and naturally when people get beaten down enough they stop trying, and you get people like yourself who will just say "why go to doctors they usually don't help me anyways so might as well save myself the time."
This model is doing very very well actually. Most people hate getting whatever doc their crappy work insurance offers. Once people find a doctor they like they stick around for decades.
My dad is a GP and ran a practice that at its height in the mid 00s had around 5000 patients, 4 doctors, a slew of nurses and probably 15 office staff. He worked about 50-60 house a week and was ultra stressed out. Then in the early 10s he switched to this concierge model. Now he has 1 office staff/med assistant, 300 patients, and makes literally 4x what he made with the previous model.
Insurance companies, along with declining pay and the gobbling up of private practice by giant medical corporations who treat doctors like low level employees are driving GPs away, and into specializations.
If the government wants to stem this shit tide they need to tell insurance companies to get fucked, limit the intrusion of corporate bean counters, and give incentives like the cancellation of school debt to folks who go into GP. No number of highly paid specialists will ever replace GPs
The medical industry employs about 15 to 20 percent of all active US workers [0]. Some people read that and think it's a good thing, "wow, such job creators", like measuring software accomplishment by the number of lines.
No wonder my medical costs are so high. Every high premium and medical bill is my turn to personally support 20% of the nation. I wonder how much is left over for the doctor?
This will be difficult to solve because "make the system simpler and fire lots of people" is painful and not politically popular.
I've had a lot of family time in the hospital systems in a relatively well-managed part of the US. And, I worked in the 'back office' of a medical system a while ago. Talking to billing people, etc, I came to the conclusion that "reform" with existing vested interests is... not going to happen. I don't know what a _good_ solution is, but I can imagine the least painful way is to have a parallel universe of MDs with a wholly different billing, licensing, board-certification regime.
One interesting question is: why is one hospital's rate for procedure X different than another? how can providers work at different hospitals? The answer lies somewhere in the "it's a maze of subcontractor relationships", "it's a maze of one off insurance contracts"...
It's a very good example of why vertical integration beats subcontracting. :)
How about ending the AMA Cartel from limiting the supply of doctors, easing the requirements for foreign doctors to practice medicine in America, and far expanding the list of services that can be performed by a Nurse or trained technician?
Do you have an idea what the difference is in cost? A subscription clinic opened up by me and their price was shockingly reasonable to me after years of insurance deductibles and whatnot.
He charges $80/month. In the most common year, I only have my annual physical, and that's covered by insurance. That translates to $0 out of pocket. Other years I have visits for other reasons. With the deductible and copay, it's more than $100 for any visit. I'd need 7-8 visits a year to reach $80/month out of pocket.
On the other hand, not having to make appointments weeks in advance, and even being able to send a text message to save a visit has some value. I don't think that would be possible with my insurance (the doctor wouldn't get compensated).
I have several friends / acquaintances that have converted to this kind of concierge practice. At least a few years ago, $5k / patient / year was a going price for one of them, which gave you basically 24/7 more-or-less direct access to a physician. I'm not sure how it worked WRT lab and radiology costs, but it seemed that people could subsidize the expense significantly by changing to catastrophic insurance only, as simple visits (just a history and exam) were already covered, and many simple meds (eg antibiotics) available on the $4 list.
One BIG reason that my wife and I remain working in a U.S. Federal system (in which the federal government pays for all necessary care) is that I don't have to deal with insurance. It is soul-crushing to have pencil pushers hundreds of miles away díctate the care you provide.
It's weird how there's a scarcity of all the important things--physicians and medical specialists, houses, cars, etc. Why can't is supply not increasing to meet demand? It seems like our modern economy has lost focus on the basics. It seems like a scam more than anything.
The age of value creation has passed us by, now is the age of value capturing. If you're creating value, you're a loser to those who specialized in capturing the value you produce.
The supply of doctors in the US is primarily limited by the number of residency slots. Unlike many countries, foreign medical graduates can't practice here without doing a residency. I think the number of residency slots is kept low by the federal government (which funds them) and also by physician organization lobbying.
Exactly, just like the number of homes is artificially limited by zoning, permitting, etc. It's all artificial scarcity and it's for life's essentially--which is why I said it's a scam because it seems intentional.
This is a clear consequence of devaluation of currencies (inflation).
It's documented to have happened at least as early as with the romans. The exact same things happened that we're seeing now: people made less babies, rich got richer, the middleclass turned into poor(er), most people stopped being productive and switched to rent seeking (owning land and properties became the goal instead of actually making things or delivering services) and so on.
This particular one is a self-inflicted problem in most major US metro areas, by way of medium density housing being explicitly or implicitly banned for decades.
Are not all of these caused by some form of gatekeeping or artificial restriction? Of course some of that is benign and intentional, such as only letting people practice medicine after they've been thoroughly trained and certified, but are we perhaps restricting access to the things you list too much?
Exactly. Most of the things I listed are artificially scarce--they are intentionally restricting new supply. These are not issues in other countries. That's why I called it a scam.
Inelastic supply is a well-known phenomenon. The usual reasons are "it's hard to add supply" or "suppliers are working at full capacity"
The medical field has both. Suppliers are working at capacity - there's a limited amount of residency spots[1]
Increasing supply is also incredibly hard, because it has a decade+ of lead time.
Neither one of those "our modern economy" can fix. The latter requires loosening training requirements. That's why we have Nurse Practitioners, which folks are loudly complaining about a few threads above.
The number of residents is capped because new residents cost money. Hospitals used to make up for that by relying on Medicare, but that funding hasn't been increased. And so the economy works exactly as designed, the expensive good of "residency slots" is only offered to a limited amount, where it makes financial sense.
It doesn't matter that additional doctors would make sense, the hospitals can't make money of more residency spots. Existing doctors don't complain, because it drives their salaries up.
All of this very much makes the eloquent point that our modern economy is not the right tool for education or medical services. It can't work, given the forces around it.
> And fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.
I've already outlived my ancestors, and the world's a pretty dismal place, or at least the US is, so why not let an otherwise preventable disease take me 20 years earlier?
Oh yeah. Just a little bit of snark-slash-commentary since humans are being treated as profit centers. My FP of 20+ years also retired after selling his practice, as per the article. I do think it's sad (no, I'm not depressed!) that the race to the bottom, with a dash of enshittification, now encompasses health care, which we all need.
I had a sort of similar view and then I heard about a boy attending kindergarten in my area with Sanfillipo syndrome. There are different types of it but basically their bodies can't break down certain kinds of carbohydrates which means that they accumulate in their cells and eventually cause havoc. As a result, they continuously lose motor and brain functions until they die at about 20. There are no cures. Him (well, I don't know how much he knows given his age) and his parents would probably kill for more days. It also made me realize that my day to day problems were utterly trivial and that I should be grateful for even having day to day problems.
Medicine in the US has become a game of billing for the most number of procedures possible. For those doctors that don't want to play, well, they go concierge.
In primary care especially the fees are low, and to be any good you need to explain things to the patients - which takes time. In the current medical billing culture it's about throughput, so taking time to explain falls by the wayside.
The problem is prevention is worth less than the cure. Attia talks about it in his book - the heroes of medicine are the ones that operate and save people, not the ones that ensure that people never get to that poont/
I moved a year ago and still have not found a new primary care doctor. The search is almost comical:
Take a search space of all doctors within 50 mile radius. Now start applying filters: Must be "in network" with my insurance (-A%), must be of specialty "primary care physician" (-B%), must be accepting new patients (-C%), actually picks up the phone when called or returns your call (-D%). A%xB%xC%xD% leaves me with about 3 candidate doctors.
New patient appointments are out 3 months for Doctor X, 5 months for Doctor Y and 9 months for Doctor Z.
Doctor X
So I set up an appointment for Doctor X. 3 months later, the front desk receptionist calls and informs me that Doctor X is unavailable on the day of my appointment, so I need to make a new appointment--a wait of another 2 months. So I make that appointment. 2 months later, front desk receptionist calls and says Doctor X is retiring and no longer taking patients.
Doctor Y
Next I set up an appointment for Doctor Y. 4 months later, I get a call from Doctor Y who informs me he is also no longer taking new patients.
Doctor Z
Finally, I now have an appointment with Doctor Z for some time in 2024. Fingers crossed...
It seems a better strategy would have been to just set up appointments with all of them in parallel and just go with the first one to actually want to take my money.
When people try to argue against socialized medicine they like to point out how the American system doesn't have wait times, and systems like Canada and U.K. make you wait many months for a doctor. Obviously they haven't tried finding a USA doctor recently.
If you had an actual problem that needed a specialist, and you had a PPO plan (most people do), you'd pick a regional provider chain and find their urgent care, walk in, and get an initial consultation done the same day. Stipulating you need a specialist, they'd make a referral, which you could either use directly or use to book with another specialist. Last time, I was 6 weeks out for my referred specialist from my PCP, and 3 days out from the one I called.
It is annoying to book an annual physical, and to establish a long term PCP relationship. It takes forever to book my PCP; months. But I've learned simply never to go to my PCP directly for stuff.
I have a PPO, but each specialist I contact still wants a referral from my PCP. I suspect that it is the insurance companies that create this and every other distortion of our ridiculous HC situation in the US
It's normal to want a referral, but have you tried getting a referral from an urgent care clinic? They just want a primary care / family medicine doctor to confirm your case merits specialist attention.
My wife waits months for specialists. She's currently been trying to find someone to do a biopsy on something that's probably not but could be cancerous. She has an appointment for December. That's the soonest she could find someone. We're an hour north of Boston and we've searched all directions. Medical has become impossible.
Depending on the complexity and acuity of the problem, I'm surprised that urgent care providers are willing to make these referrals. It puts them on the hook for reviewing consultation notes and followup results on potentially dozens of visits, time for which I assume they have no capacity to bill, since they are not your PCP and have no longstanding relationship (just an acute care provider). Not to mention a lack of context (no followup visits to see how PT is going), lack of infrastructure for keeping track of consultation results (for us they just show up in a big manilla envelope and need some kind of system for reviewing, scanning, storing).
My system thankfully has great access to PCPs, so I virtually never make a nonemergency referral; coordinating this care is the role of the PCP and entirely outside of my scope of expertise and training. Urgent care seems like a poor replacement for having fair access to a PCP, but maybe that's just like, my opinion, man.
The wait times and socialised system are close to orthogonal. In the UK, 15 years ago, I could get a new doctor and an appointment the same week after I moved. Apparently the wait time is way higher now, with the UK aiming for a more privatised approach.
In Australia, in a semi-socialised system I can usually get an appointment the same week, and often the same day it needed. On the other hand I needed to wait 4 months for a specialist.
So yeah, the relation between those things is not that simple.
One of the biggest factors is the US government pays the salaries for doctors in their residency programs. They indirectly set, and therefore limit, the number of seats available in US programs by the amount of funding they provide.
There are many other failures as well. For example, most programs requiring a bachelor degree to start. This artificially raises the cost. There are a few programs now that intake high-school graduates and add a year or so to cover the basic courses that they need, such as anatomy and physiology, but effectively cut off about 3 years of higher education.
I live in Canada and it is also difficult to get a family physician. Not that I would even entertain trading our socialized system of course, but it is still a problem here.
I'm a medical sub-specialist. When I trained, my primary care mentors were simultaneously some of the smartest and most poorly compensated physicians in the system. I have to master a very narrow body of knowledge to function well. To make a good differential, a family medicine physician has to know a lot about everything. This skill saves the medical system tons of money by preventing unnecessary testing, lab work and specialist referrals. It also saves lives and dramatically increases patient quality of life. I can't emphasize enough how hard this is to do since, in the American system, you can be held liable for any missed diagnosis. You have to be sure that you're correct and it's much easier to just order everything and discharge the liability to a specialist.
Practicing primary care in this era is a nightmare. Like the article says - most clinics are run by PE or hospitals that push 'providers' to see a complex patient every 10 minutes while absorbing none of the liability for rushed, low-quality care. The compensation for these positions is now significantly less than most of the salaries that you see in the "Who's hiring?" threads on HN except with a tremendous amount of liability attached, a ton of customer service and a guarantee that your salary will go down relative to inflation.
The idea that NPs or PAs could just fill in the holes in our primary care system was always laughable to anyone who understands how medicine is actually practiced - to do the job well you need well trained, highly intelligent people. The punchline of the joke is that very few PAs/NPs ever intended to go into primary care and now the market is flooded with "Psych NPs" and "Derm NPs" pedaling Ritalin and botox.
Nothing will fix this problem short of a complete, ground-up rebuild of our healthcare system.
The fundamental problem with US health care is that the incentives are exactly backwards. With “fee for service” the prevailing system, of course we get the maximum number of “services”, with providers being driven to provide the most specialized and rare “services”. All while the primary care doctors, who are the ones avoiding the need for services, also known as keeping people healthy, and thus are the most valuable from the point of view of actual societal good, are being driven away.
The system literally generates more revenue the sicker people are. So it’s no wonder it optimizes itself away from keeping people from getting sick. It worked for a while, perhaps because most doctors have morals, but now it seems the shareholders are in charge rather than the doctors.
There is an alternative (“value-based care”) that is slowly catching on, as the governments and companies paying for all these unnecessary services are starting to wonder if there’s a better way. Essentially, you pay a fixed amount per person, so the system is incented to keep people healthier, not sicker. But lord, there are so many entrenched interests fighting against improvement. And even that system can of course be gamed at the expense of society.
> There is an alternative (“value-based care”) that is slowly catching on, as the governments and companies paying for all these unnecessary services are starting to wonder if there’s a better way. Essentially, you pay a fixed amount per person, so the system is incented to keep people healthier, not sicker.
This sounds like rationing. Sorry buddy, they only pay a fixed amount per person so we can’t actually afford that expensive surgery or MRI or whatever else you need, go home and walk it off.
The costs per person are pooled in those cases, similar to insurance, so it's expected that some people will "use what others paid in". That's ok. And sure, you can call it rationing, but whatever model of funding you're thinking of, at some point you'll get to make a decision like "do we spend 5M to save those 6 people or that 1 person?" - it's not a few layers detached.
The setup is more complicated than I described (I was trying to make the core difference clear). You have metrics to ensure that you’re actually keeping people healthy. The amount you get paid per capita is set by negotiation and informed by past spending.
I think if you compare the “expensive” MRI in the US to other countries, you’ll find it’s “expensive” because it’s connected to an infinite money spigot and there’s no upper limit on how much it can cost, not because it’s a better MRI.
Providing bad service under value based care comes with heavy penalties. If the patient actually needed the surgery their health outcomes would be bad when they don't get it and the healthcare provider would lose a lot of money.
How does this happen under value based care? What’s to stop providers from just gaming the metrics and gaslighting people into thinking there’s nothing that can be done for their complicated and expensive medical problems?
There are a variety of metrics that are tracked and difficult to game. The easiest to explain is rate of rehospitalization. If patients return to the hospital within x months of being treated at a higher rate than other hospitals you face heavy penalties. Then there's survey results and the like, it's not that hard to come up with reasonably objective metrics that are out of providers hands and therefore difficult to game. In the end it's still a competition, if a patient is unhappy with the care they can switch providers.
The model that used to work, and still would if we hadn't made it practically illegal, is the 80%/20% high-deductible insurance model. That model gives the consumer the incentives to keep consumption levels reasonable, but if they must consume lots (accidents, serious illness) then the insurance company kicks in.
Young people today have never experienced such a system, but for decades it was the system. We started moving away from it in the 90s, and completed that move away from it in 2011. Coincidentally (or maybe not so-coincidentally) we've had faster-than-inflation healthcare cost increases since then.
You cannot pay a physician enough for the sacrifices they have made — just to an ugrateful diagnose You.
To any pre-medical students, please seriously consider a better pathway forwards. There are literally SO MANY BETTER METHODS "to help people" and "to make money." If these are two of your primary reasons for joining medicine, please spend the time thinking about how you want a well-lived life.
src: dropped out of medical school, after ER rotation, prior to ACA. Hadn't thought enough about a livable professional experience. I became an electrician.
Finding a doctor in general is becoming harder. When you check the insurance site all you see is NPs and PAs. I just moved to the area, I don't need an NP. An NP can't even prescribe me my meds.
And that hip surgery I had? Yea, I need to see a doctor, not a PA who just sends me for an MRI and then refers me to a doctor.
And then there are DOs. Also something I avoid.
Insurance is really trying to pay less for a visit... They can start by not re-imbursing homeopathic stuff & chiropractors.
I have a primary care doctor now for the first time in many years. I don’t know how essential it is to keep his practice running, but he also does cash-only appointments for weight loss prescriptions. Insurance is probably a bad model for primary care compared to fee-for-service, and one way around it is to do a separate fee-for-service practice that lots of people will want or need.
What are primary care doctors for? They either just prescribe OTC drugs or refer you to a specialist that you can just schedule yourself. Primary Care usually has a >month waiting list so its not for emergencies. No doctor I have had takes questions without an appointment or even picks up their phone. I just skip them entirely now and go to a specialist if I have a health problem.
In my experience specialists will not take patients without a referal. So that is the express purpose of a primary care. Referalls. That and vaccines/physicals
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[ 3.5 ms ] story [ 189 ms ] thread"Opinion"
Seems like the primary issues are poor compensation and lack of respect.
We want this. This is us.
https://nationalpost.com/news/canada/canada-maid-assisted-su...
I've been thinking about that a lot recently. You're right: this is who, at least a large group of us, are.
It could equally be argued that 27% of Canadians do not agree that MAID should be restricted, the poll question was preambled:
and went to list other conditions (povety, homelessness, disability, etc).One extreme interpretation is that all those replies indicate support for culling the weak.
The other extreme interpretation is that all those replies support the self determined right to seek assisted suicide regardless of conditions.
Do you have a source for that?
The stuff I saw says that a certain number of slots are reserved for international students, which further constrains the supply.
https://www.nrmp.org/wp-content/uploads/2023/03/Match-Rates-...
It’s such a huge investment of time and money, that it’s very hard to convince anyone to get into the field.
We have this immutable education track, seemingly because that’s the way we’ve always done it in the US. But I’d be very curious if we actually achieve better outcomes than countries with shorter medical educations.
The article mentions that NPs and PAs also favor higher lying specialties - but it seems much easier to solve that supply and demand problem than paying the cost for more MDs
The filter is on entering med school.
It's not: it's only been that way since the nineteenth century. There used to be a Bachelor of Medicine degree that represented six years or so of study and was sufficient to practice medicine.
Of course, the end result of all the short-term cost saving, is that care is switching to emergency only, which is a lot more expensive for everyone.
If you have a mole or something that needs to get checked out, try a plastic surgeon.
The one that sticks out to me was a few years ago. I’m prone to sinus infections and this one just wouldn’t go away. I booked an appointment with an NP.
She took a brief look at me and then advised that I go to the hospital because “you might have a brain tumor”. I told her I get sinus issues all the time. She responded that her sister died of a brain tumor.
So off to the ER I went and 2k later I had an ER doc look at me like I was an idiot and diagnose me with a sinus infection.
It's not just private equity pulling these shenanigans. Our local Children's chain is a non-profit and they pull some real shady shit.
People overuse doctors. Most of what younger people (under, say, 50) go to the doctor for, a good NP can do just as well or better. One of my weird hobbyhorses is how dumb the name "nurse practitioner" is; they should just call them "associate physicians".
(Note here that we're talking about "urgent care", which are clinics run by health chains, staffed with a doctor or two, a couple NPs, and a bunch of nurses; "urgent care" is not the ER, which is a thing people gotten hung up on HN about before, because I guess every country calls their ER something different. Going to the ER for routine care is insane.)
Even then it was phrased as more "If it were me, and I had similar comorbidities, I'd get that looked at ASAP"
Ended up hospitalized for 4 days.
Well, there are "physician assistants", PAs, which are the same rung of the ladder as NP but via different path. Areas tend to somehow converge either on NPs or PAs, but not both so often.
The ER and urgent care at my local hospital are next door to each other. Until the last year or so, it was the only urgent care in the area (and is the only ER).
It works extremely well with my doctor's health system, and I'll add that my doctor's health system is notorious in the area for sucking to work with, so if I switched to, like, Rush or Northwestern, presumably it'd be even better.
One argument could be that treating non emergency cases would ruin availability or increase costs, both of which seems like big assumptions at a system design level (vs the actual constraints and incentives that have lead to the existing service configuration).
I'm sure that there are regulatory drivers, but I expect they are things we should seek (as a society) to improve, rather than accept and ignore.
Primary care is good for dealing with ongoing issues. It is cheaper because only staff what they need. But have to schedule appointments far out. They could leave slots open for urgent issues but then would cost more.
Urgent care is to handle the urgent but minor issues. Stuff that doctor could handle if they were open or had appointments. They are more expensive since they are open longer hours and less likely to get insurance.
One thing that would help fix the system is lots more free 24-hour urgent care clinics. That would keep people out of ER.
My background is CA & NYC. I am able to get same day or same week (if less urgent) appts by calling my primary (PCP). In the event that my PCP has no availability or it's late in the day, I'll consider going to urgent care since it's the only thing open.
I can understand other people posting how hard it is to find a good PCP (or even dentist frankly). I got lucky and found a good, local PCP that I've been seeing for years.
Agree NP is a poor term.
Administrative bloat is killing these places
The administrators are fucking vipers. These orgs are rotted at the heart. They do everything they can to stretch the staff thin while shifting their targets and gaslighting them into thinking they're underperforming. Execs are doing great, but in the meantime they're hemorrhaging docs, nurses, and office staff because the conditions suck.
The advantage for him is that he never deals with insurance companies again. The disadvantage for me is that, since I have few health issues, and they're minor when I do, it would cost a lot more per year.
One of the older models for a physician went like this:
- you opened a practice
- you charged a "subscription" to be a part of your practice
- people could come as much as they wanted
What's crazy to me is that MORE doctors don't do this since I'm 100% sure there is a demand for a service like this.
The monopolies formed for these health networks are bad for everyone. The staff are miserable, patients don’t heal, and half the time the companies are losing money. My primary care was bought by a hospital network, which was bought by some multi-state network that is under financial stress yet just boight another regional network to ruin.
Licensing serves no purpose if you're not going to take it away in cases of incompetence and malice. This has turned me into a fan of malpractice suits with large punitive damages.
Finding a doctor is easy. Finding a good doctor that will try to figure things out when things go very wrong is very challenging and frustrating.
Insurance companies, along with declining pay and the gobbling up of private practice by giant medical corporations who treat doctors like low level employees are driving GPs away, and into specializations.
If the government wants to stem this shit tide they need to tell insurance companies to get fucked, limit the intrusion of corporate bean counters, and give incentives like the cancellation of school debt to folks who go into GP. No number of highly paid specialists will ever replace GPs
No wonder my medical costs are so high. Every high premium and medical bill is my turn to personally support 20% of the nation. I wonder how much is left over for the doctor?
This will be difficult to solve because "make the system simpler and fire lots of people" is painful and not politically popular.
[0] https://www.census.gov/library/stories/2020/10/health-care-s...
One interesting question is: why is one hospital's rate for procedure X different than another? how can providers work at different hospitals? The answer lies somewhere in the "it's a maze of subcontractor relationships", "it's a maze of one off insurance contracts"...
It's a very good example of why vertical integration beats subcontracting. :)
On the other hand, not having to make appointments weeks in advance, and even being able to send a text message to save a visit has some value. I don't think that would be possible with my insurance (the doctor wouldn't get compensated).
One BIG reason that my wife and I remain working in a U.S. Federal system (in which the federal government pays for all necessary care) is that I don't have to deal with insurance. It is soul-crushing to have pencil pushers hundreds of miles away díctate the care you provide.
It's documented to have happened at least as early as with the romans. The exact same things happened that we're seeing now: people made less babies, rich got richer, the middleclass turned into poor(er), most people stopped being productive and switched to rent seeking (owning land and properties became the goal instead of actually making things or delivering services) and so on.
This particular one is a self-inflicted problem in most major US metro areas, by way of medium density housing being explicitly or implicitly banned for decades.
The medical field has both. Suppliers are working at capacity - there's a limited amount of residency spots[1]
Increasing supply is also incredibly hard, because it has a decade+ of lead time.
Neither one of those "our modern economy" can fix. The latter requires loosening training requirements. That's why we have Nurse Practitioners, which folks are loudly complaining about a few threads above.
The number of residents is capped because new residents cost money. Hospitals used to make up for that by relying on Medicare, but that funding hasn't been increased. And so the economy works exactly as designed, the expensive good of "residency slots" is only offered to a limited amount, where it makes financial sense.
It doesn't matter that additional doctors would make sense, the hospitals can't make money of more residency spots. Existing doctors don't complain, because it drives their salaries up.
All of this very much makes the eloquent point that our modern economy is not the right tool for education or medical services. It can't work, given the forces around it.
And so it goes.
[1] https://www.medicaleconomics.com/view/match-day-2023-a-remin...
Is this true?
https://www.nrmp.org/wp-content/uploads/2023/03/Match-Rates-...
There's still a lot of things I want to see and do.
In primary care especially the fees are low, and to be any good you need to explain things to the patients - which takes time. In the current medical billing culture it's about throughput, so taking time to explain falls by the wayside.
This is industrial medicine.
Take a search space of all doctors within 50 mile radius. Now start applying filters: Must be "in network" with my insurance (-A%), must be of specialty "primary care physician" (-B%), must be accepting new patients (-C%), actually picks up the phone when called or returns your call (-D%). A%xB%xC%xD% leaves me with about 3 candidate doctors.
New patient appointments are out 3 months for Doctor X, 5 months for Doctor Y and 9 months for Doctor Z.
Doctor X
So I set up an appointment for Doctor X. 3 months later, the front desk receptionist calls and informs me that Doctor X is unavailable on the day of my appointment, so I need to make a new appointment--a wait of another 2 months. So I make that appointment. 2 months later, front desk receptionist calls and says Doctor X is retiring and no longer taking patients.
Doctor Y
Next I set up an appointment for Doctor Y. 4 months later, I get a call from Doctor Y who informs me he is also no longer taking new patients.
Doctor Z
Finally, I now have an appointment with Doctor Z for some time in 2024. Fingers crossed...
It seems a better strategy would have been to just set up appointments with all of them in parallel and just go with the first one to actually want to take my money.
When people try to argue against socialized medicine they like to point out how the American system doesn't have wait times, and systems like Canada and U.K. make you wait many months for a doctor. Obviously they haven't tried finding a USA doctor recently.
It is annoying to book an annual physical, and to establish a long term PCP relationship. It takes forever to book my PCP; months. But I've learned simply never to go to my PCP directly for stuff.
My system thankfully has great access to PCPs, so I virtually never make a nonemergency referral; coordinating this care is the role of the PCP and entirely outside of my scope of expertise and training. Urgent care seems like a poor replacement for having fair access to a PCP, but maybe that's just like, my opinion, man.
In Australia, in a semi-socialised system I can usually get an appointment the same week, and often the same day it needed. On the other hand I needed to wait 4 months for a specialist.
So yeah, the relation between those things is not that simple.
Wait till you find out why America has a shrinking number of primary care physicians.
There are many other failures as well. For example, most programs requiring a bachelor degree to start. This artificially raises the cost. There are a few programs now that intake high-school graduates and add a year or so to cover the basic courses that they need, such as anatomy and physiology, but effectively cut off about 3 years of higher education.
I am curious what the post above was alluding to.
Practicing primary care in this era is a nightmare. Like the article says - most clinics are run by PE or hospitals that push 'providers' to see a complex patient every 10 minutes while absorbing none of the liability for rushed, low-quality care. The compensation for these positions is now significantly less than most of the salaries that you see in the "Who's hiring?" threads on HN except with a tremendous amount of liability attached, a ton of customer service and a guarantee that your salary will go down relative to inflation.
The idea that NPs or PAs could just fill in the holes in our primary care system was always laughable to anyone who understands how medicine is actually practiced - to do the job well you need well trained, highly intelligent people. The punchline of the joke is that very few PAs/NPs ever intended to go into primary care and now the market is flooded with "Psych NPs" and "Derm NPs" pedaling Ritalin and botox.
Nothing will fix this problem short of a complete, ground-up rebuild of our healthcare system.
The system literally generates more revenue the sicker people are. So it’s no wonder it optimizes itself away from keeping people from getting sick. It worked for a while, perhaps because most doctors have morals, but now it seems the shareholders are in charge rather than the doctors.
There is an alternative (“value-based care”) that is slowly catching on, as the governments and companies paying for all these unnecessary services are starting to wonder if there’s a better way. Essentially, you pay a fixed amount per person, so the system is incented to keep people healthier, not sicker. But lord, there are so many entrenched interests fighting against improvement. And even that system can of course be gamed at the expense of society.
This sounds like rationing. Sorry buddy, they only pay a fixed amount per person so we can’t actually afford that expensive surgery or MRI or whatever else you need, go home and walk it off.
I think if you compare the “expensive” MRI in the US to other countries, you’ll find it’s “expensive” because it’s connected to an infinite money spigot and there’s no upper limit on how much it can cost, not because it’s a better MRI.
So providers have an incentive to encourage adverse selection and keep the “difficult patients” away from their practices.
Young people today have never experienced such a system, but for decades it was the system. We started moving away from it in the 90s, and completed that move away from it in 2011. Coincidentally (or maybe not so-coincidentally) we've had faster-than-inflation healthcare cost increases since then.
To any pre-medical students, please seriously consider a better pathway forwards. There are literally SO MANY BETTER METHODS "to help people" and "to make money." If these are two of your primary reasons for joining medicine, please spend the time thinking about how you want a well-lived life.
src: dropped out of medical school, after ER rotation, prior to ACA. Hadn't thought enough about a livable professional experience. I became an electrician.
And that hip surgery I had? Yea, I need to see a doctor, not a PA who just sends me for an MRI and then refers me to a doctor.
And then there are DOs. Also something I avoid.
Insurance is really trying to pay less for a visit... They can start by not re-imbursing homeopathic stuff & chiropractors.
They take the same licensing exams, and the same residencies.
U.S. WILL PAY TO REDUCE DOCTOR GLUT
Washington Post, August 24, 1997
https://www.washingtonpost.com/archive/politics/1997/08/24/u...