Another Idea

Apparently, the Obama administration is worried about the shortage of GP physicians.  Personally, I think anything we do within the present framework, or more onerous government interventionist approaches likely to be proposed by Obama, will fail at reversing this problem.  If plumbers were not allowed to contract directly for price and scope of service with individual homeowners they serve, and were forced instead to fill out 23 yards of paperwork just to get paid rates that were set by government bureaucrats, subject to thousands of pages of regulations any one of which could cause his payment request to get rejected, we would have a shortage of plumbers too.

However, since no one in Washington currently seems to be in the mood topromote commercial relationships in medicine that mirror how we contract for every other product and service, I guess we can nibble at the edges of the problem.  David Bernstein suggests:

I have yet to see in any of these articles one simple reform proposed: abolish the requirement of an undergraduate degree before attending medical school, and turn medical school into a five or six-year post-high school program instead. This would eliminate two or three years of debt, and, perhaps even more important, the opportunity costs of two or three years of college. Right now, an aspiring physician must go to college for four years (and take many classes that have nothing to do with his future career), then medical school for four years, and then typically do a poorly paid internship and then residency for another five years. By the time this aspiring physician goes into practice, he will be at least thirty-one years old, and have eight years of student loan debt.

I have a better solution.  Why do we have a one-size-fits-every-corner-of-the-medical-field education and licensing at all?  Why do I need to pay for someone with 8 years of college and five years of residency to put three stitches in my kids' cut?  Or to write a Viagra scrip?  In dentistry, why do oral hygienists all seem to be in dentists' offices?  Why do I need to pay the overhead of a dentist to get my teeth cleaned?

We shouldn't really be surprised, I guess, about this licensing approach -- when the government turns over the licensing board to the incumbents of the industry being licensed, they have every incentive to choke off supply and to kill any initiative that might create low-cost competition for themselves.

So the licensing system that is all or nothing -- you are either a full-fledged medical doctor that can handle anything, or someone who is allowed to handle nothing.  This is reinforced by the payment system we have, where people do not bear the marginal cost of the services they consume.  So, since every office visit costs them the same (zero or a fixed copay), they might as well ask for the most experienced and over-educated guy they can find -- it's not costing them any extra.

Well, this is true for most people.  I have a high-deductible health insurance policy, and we often consider the price of different alternatives. Here is an example.  I am a healthy person, but still go in for a physical each year.  Nothing complicated happens in these visits.  Surely there could be some kind of less-trained traige MD who could conduct such screenings, passing folks on to the full-fledged doctors if anything unusual pops up.  If you told me that I could be seen by such a person for $100 or a full MD for $300, I would certainly consider it, particularly since the triage guy's schedule probably runs smoother as he doesn't get bogged down with the unexpected -- he just passes those folks on.


  1. scp:

    100 Years of Medical Robbery (2004)

    A couple excerpts:
    "...In the days of its founding AMA was much more open--at its conferences and in its publications--about its real goal: building a government-enforced monopoly for the purpose of dramatically increasing physician incomes. It eventually succeeded, becoming the most formidable labor union on the face of the earth...."

    "...Since AMA's creation of the Council a century ago, the U.S. population (75 million in 1900, 288 million in 2002) has increased in size by 284%, yet the number of medical schools has declined by 26% to 123.[8] [9] In terms of admissions limits, the peak year for applicants at U.S. schools was 1996 at 47,000 applications with a limit of 16,500 accepted....

  2. morganovich:

    an interesting example of the benefits of using less broadly qualified medical professionals can be found in imaging, one of the few fields where a tech can do most of the work. an MRI, CT, or PET scan is mostly handled by the machine. such machines are expensive. to get installing one to pay off, you need high patient traffic. this traditionally mean they were all in hospitals. however, as they can be run by a technician as easily as a doctor, this has changed. many are now in malls. these providers tend to have pricing 50-75% lower than the hospitals for the exact same service with the same machine in a nicer setting and shorter wait times.

  3. Bertha:

    Doesn't this already happen to some extent? I haven't seen my ObGyn in years, although I get my annual exam regularly. A nurse/med-tech type does the routine BP stuff, a physician's assistant does the pap & breast exam, and I go out to an outside lab for bloodwork (blood is drawn by a phlebotomist). If any of that routine stuff raised a flag, I'd go back in and see the doctor then.

    On the other hand, b/c this is all on my insurance, I really have no idea whether I'm paying any less to see the PA than those people who insist on having the MD do their exam are paying.

  4. Dr. T:

    The idea that we have a shortage of "GPs" continually pops up in Washington. In the 1980s and 1990s, the feds used their financial billy club (Medicare reimbursements to teaching hospitals) to eliminate specialty training slots and increase primary care (internal medicine, pediatrics, and obstetrics/gynecology) slots. Medical students and residents were miffed, and competition for specialty training became brutal.

    Why do so many physicians want to become specialists? Because medicine is so vast that it is nearly impossible to be a good "GP" today. Family Practice is a total joke. Today's family practitioners have a broad but extremely shallow knowledge base. They can do routine exams, simple procedures, and common diagnoses, but they have to refer for diagnosis almost anything else. My wife and daughter both have chronic diseases that are somewhat rare. Family practice physicians refuse to care for them even though their diseases are stable.

    The market is quite adept at "regulating" specialties. For example, dermatology and dermatopathology specialties are booming because more people are moving south, people are living longer, and there are more skin lesions and skin cancers. Other specialties have undergone relative declines such as orthopedics (safer cars and fewer smashed bones). It takes some work, but physicians can change specialties. My pathology program recently acquired a urologist and a surgeon for retraining.

    The feds should butt out. Not much chance of that now, and there will be no chance of the feds butting out if some form of national health insurance or (worse) nationalized medical care gets enacted.

  5. EvilRedScandi:

    Do we even really need licensing anymore? It's friggin' 2009. If we wanted to check somebody's credentials, we should be able to get a name and ID number and look it up with the people who trained and / or certified them. Cisco does this for their CCIEs (an extremely difficult certification to get).

    I should be able to verify somebody's training / certifcation in 30 seconds on my iPhone. I'd trust an independent organization far more than I'd trust the government. Various organizations would get better / worse reputations based on experience, and better training / certification would become more valuable.

  6. Dr. T:

    "So the licensing system that is all or nothing — you are either a full-fledged medical doctor that can handle anything, or someone who is allowed to handle nothing."

    Incorrect. In the US there are physician's assistants and nurse practitioners. They both are masters degree programs. The types of clinical tasks they can perform independently varies by state. Most PAs and NPs work under the supervision of a physician, and they can handle most things that a family practitioner would deal with. They can bill independently for their services.

    Some physicians dislike the idea of PAs and NPs practicing even low-level medicine, but most physicians like them. The PAs and NPs can handle simple problems and leave the physicians more time to handle the tougher problems. Some physicians also use the PAs and NPs for routine counselling on diet, exercise, or medication use and side effects.

  7. John Moore:

    The AMA's restriction of supply has to be one of the most important parts of the problem. Medical school admissions, though the MCAT and undergrad scores, screen for hyper-studiers who are very ambitious. Is it surprising that the resulting MD's feel entitled to high fees and move into high paying specialties?

    I know of an MD-PhD student (almost through her schooling) who refuses medicine for her pronounced OCD because it would interfere with her studying!

  8. Paul McLellan:

    I just finished reading "The Innovator's Prescription" by Christansen (the guy who wrote "The Innovator's Dilemma", one of the best couple of business books I've ever read), which looks at a lot of this and, in particular, how low cost providers are likely to disrupt the status quo. Highly recommended.

  9. orthodoc:

    The AMA has absolutely nothing to do with setting enrollment numbers for medical schools, as that's done by the AAMC (Association of American Medical Colleges). Further, the big choke point is at entry into residency - and that's set by the Federal Government, because residency funding is carried out by CMS. The AAMC has for years called for increasing the number of medical school and GME (Graduate Medical Education) slots.

    In any case, the AMA now represents less than 20% of physicians - I don't belong, and I've never missed it.

    Increasing med school enrollment as a solution is quick, attractive, makes a good sound bite - and is completely wrong!

    There are any number of reasons for physician shortages:
    1. Early retirement
    2. MDs can't make enough to pay staff, rent, overhead, etc. and still take home enough to make the whole thing worth it - I can remember as a resident (years ago) hearing from one of my mentors that the taxi driver bringing his patient to his office would make more than he did!
    3. A much higher percentage of women as physicians, who work fewer hours than men at all comparable stages of practice, with the possible exception of late in their careers (this is from AAMC demographic data)
    4. Changing demographics - the population gets older, and utilization of all medical services increases
    5. No matter how hard payers bang on MDs to become more "productive," there's a limit on how many patients you can see, how many procedures can be done; and switching to EMRs compounds the problem, because most EMRs are horrible and timeconsuming, rather than time-saving
    6. It's just not particularly fulfilling anymore, and the attractions of getting up in the middle of the night to fix some drunk in the ER begin to wane.

    I have three kids, and none of them will be physicians if I have anything to do with it....

  10. DirtyJobsGuy:

    As an Engineer and principal in a small consulting firm, I'm always interested in how other service professions set fees etc. My guess is that the general internist has nominal rates close to mine. Subtract a rather substantial overhead for offices, equipment, G&A and insurance, staff and you get just what we have. Short visits and long days are the only way to get the billable hours up. THis is not really a consequence of insurance companies etc, but I think its an explosion of paperwork. This paperwork is not primarily in patient records, but in the regulatory burden on the physician and medical office in general.

    Next time you're in the Doc's office see if you have to sign a new privacy form! I've done dozens and I'm pretty healthy. Now multiply that in every area. Electrical equipment has to be tested (lamps included), staff audited, continual retraining and training....

    Cut even a small amount of this deadweight and the effects will be astounding.

  11. Josh:

    Watch out bro, we may soon require bloggers to be licensed.

  12. Bob Smith:

    The AMA has absolutely nothing to do with setting enrollment numbers for medical schools, as that’s done by the AAMC (Association of American Medical Colleges).

    The AMA doesn't have to set enrollment numbers. Who do you think accredits said medical schools? The AMA does, and if a school enlarges enrollment too much the AMA will threaten their accreditation, without which their students can't get a medical license. The Bar Association engages in similar tactics at law schools.