Originally Posted by Brian Rush

all because of the Senate rules that allow a minority to hold the majority hostage.

Rules which few on your side were bashing when Senate Democrats were blocking votes on Bush judicial nominees, I'd add.

Originally Posted by Brian Rush

As the ACA has no impact on the supply of medical personnel, I hardly see how this is possible.

The issue is increased demand in face of a static supply. If you increase the number of insured without increasing the number of providers, you are guaranteed a shortage of providers.

There are already signs this is happening in the less lucrative fields of "thought" rather than "procedure" medicine(eg internists, primary care). This shortage will make the internists more picky in who they will treat. I picked my internist several years ago partly based on age. I wanted to be sure he would not retire when I got older and probably needed him most. I felt reinforced in this position lately. On a recent visit, I asked him: suppose I was 70 years old, on Medicare, and had just moved into town to be closer to my kids. Would you take me as a new patient? He said no and that he had not been taking new Medicare patients for at least 5 years due to the low reimbursement rates. Its worse in underpopulated and under-served rural areas.

James50

How is the supply static? Have we a labor shortage? Have we no medical schools or nursing schools? At worst this is a short-term problem, and calling for denying care to people to solve it is short-sighted.

Originally Posted by Brian Rush

How is the supply static? Have we a labor shortage? Have we no medical schools or nursing schools? At worst this is a short-term problem, and calling for denying care to people to solve it is short-sighted.

There is not a shortage of labor. There is a shortage of schools. Also, there is a shortage of trained physicians willing to go into the less lucrative internal medicine field.

PHILADELPHIA, March 18, 2010 -- The number of U.S. medical students choosing internal medicine residencies inched higher from 2009 but not enough to significantly impact the shortage of primary care physicians.

According to the 2010 National Resident Matching Program report, 2,722 U.S. seniors at medical schools enrolled in an internal medicine residency program, a 3.4 percent increase from 2,632 in 2009. The internal medicine enrollment numbers are similar to 2008 (2,660), 2007 (2,680), and 2006 (2,668). In comparison, 3,884 U.S. medical school graduates chose internal medicine residency programs in 1985.

“Multiple studies have shown that the U.S. is facing a shortage of primary care physicians,” said Steven Weinberger, MD, FACP, Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, for the American College of Physicians (ACP).

See here.

BTW - I am not "calling" for denial of care to anyone. I am pointing out that there is and will be a shortage of primary care physicians. This was true before HCR. It will be worse with HCR.

James50

Originally Posted by James50

There is not a shortage of labor. There is a shortage of schools. Also, there is a shortage of trained physicians willing to go into the less lucrative internal medicine field.

See here.

BTW - I am not "calling" for denial of care to anyone. I am pointing out that there is and will be a shortage of primary care physicians. This was true before HCR. It will be worse with HCR.

James50

James, on my Mom's side of the family, there are a gaggle of MD's. Most agree that they will be quitting medicine (earlier than planned) for reasons other than HCR. Why?

Mainly, the job sucks, regardless of politics or money. We've been losing GP's for decades now, with no Obama to blame. Nobody enjoys practicing medicine very much, not in our current environment. Hence, the explosion in nurse practitioners, and "doc-in-a-box" urgent care clinics.

The system will destroy itself. Costs, burnout, paperwork, empathy fatigue, overload of patients, bad medicine, lousy administrators, you name it.

Yeah, American doctors are some of the least happy despite also being some of the best paid.

The problem is professional autonomy: they have none. Whether it is the insurance company or the malpractice lawyer, the law & financial system empowers many people to second-guess the doctor's medical decisions.

The nominal pay doesn't end up amounting to much either. 60-70 hour work weeks are common, and the high salary goes in to paying back massive student loan debts (now averaging $250k despite the fact that most people in medical school were already born to families in the top 10% income bracket). A doctor's insurance can also cost in excess of $100,000 per year depending on the specialization, so they really do have to charge an insane price just to break even - forget about their living expenses, continuing education, and medical equipment.

Originally Posted by independent

The nominal pay doesn't end up amounting to much either. 60-70 hour work weeks are common, and the high salary goes in to paying back massive student loan debts (now averaging $250k despite the fact that most people in medical school were already born to families in the top 10% income bracket). A doctor's insurance can also cost in excess of $100,000 per year depending on the specialization, so they really do have to charge an insane price just to break even - forget about their living expenses, continuing education, and medical equipment.

This is something many people don't really think about. They think about the "big money" doctors earn, but often fail to comprehend how much of these wages are lost to student loan payments and malpractice insurance premiums.

Perhaps the concept of something like the U.S. service academies could work here: In exchange for a multi-year commitment to serve as a commissioned officer in the Armed Forces, students essentially receive an education paid for by Uncle Sam.

I don't know how such a thing would work, but perhaps at some point there could be med schools along the same lines -- graduate with no debt and commit at least (say) five years to practicing medicine in the public health arena. After that you could become a "free agent" with no debts, and thus could make the choice to go into medicine an easier one. Yet this still doesn't address much of the root cause behind the "supply problem" with doctors and nurses: insufficient supply of teaching professionals to meet the demand, especially when practicing is often more lucrative than teaching (especially in specialized areas of medicine).

Yeah, I just thought of something else in response to another of your posts, too: When we say "Tax the rich" that ends up meaning doctors because they are typically in the highest income bracket.

Of course, long-term capital gains rates are hanging out at around half of that, so it is the highly-educated and highly-successful workers who end up stuck with the bill while the truly rich end up with rates roughly equal to what the working poor pays.

Originally Posted by independent

Yeah, I just thought of something else in response to another of your posts, too: When we say "Tax the rich" that ends up meaning doctors because they are typically in the highest income bracket.

Of course, long-term capital gains rates are hanging out at around half of that, so it is the highly-educated and highly-successful workers who end up stuck with the bill while the truly rich end up with rates roughly equal to what the working poor pays.

Physicians would probably do better with a single-payer system because such would cut down the costs of compliance with the health insurance cartel.

Originally Posted by JustPassingThrough

through higher taxes, higher premiums, shortages of doctors and nurses, and in many cases by losing their coverage altogether and being forced onto the dole with the others.

Which is almost exactly what has been happening to everyone in the American system of "healthcare" for the last twenty years.

At the risk of being repetitive, does ANYONE who has been in serious contact with our healthcare system lately think that it is world-class? Does ANYONE want to defend this C7^47#%F^(% of a system as being anything like what we would design if we wanted to have real healthcare in this country?

I will pass along another anecdote. My brother and nephew are physicians and part of an internal medicine practice with about 10 doctors. They use a lot of physician assistants and nurses to reduce time with the doctor. They all make a good living, and it is hard to feel sorry for them, but they are under a lot of different pressures.

Recently a doctor from this group, who is exactly my age (60) and a childhood friend decided to start a "boutique" medicine practice. For those who sign on, they will pay $1500/yr directly to him. This entitles them to 4 doctor visits per year and off hours access to the doctor. He will limit his practice to 600 patients. He will use whatever insurance you have for prescriptions, etc , but his fixed fee remains. Particularly for older folks with chronic medical conditions, its probably a good deal if you can afford it.

I suspect you will see more internists "bailing out" of the current system in this way in the future.

James50

Originally Posted by James50

I will pass along another anecdote. My brother and nephew are physicians and part of an internal medicine practice with about 10 doctors. They use a lot of physician assistants and nurses to reduce time with the doctor. They all make a good living, and it is hard to feel sorry for them, but they are under a lot of different pressures.

Recently a doctor from this group, who is exactly my age (60) and a childhood friend decided to start a "boutique" medicine practice. For those who sign on, they will pay $1500/yr directly to him. This entitles them to 4 doctor visits per year and off hours access to the doctor. He will limit his practice to 600 patients. He will use whatever insurance you have for prescriptions, etc , but his fixed fee remains. Particularly for older folks with chronic medical conditions, its probably a good deal if you can afford it.

I suspect you will see more internists "bailing out" of the current system in this way in the future.

James50

I wouldn't be surprised if that doesn't happen more often.

A close friend of mine in an MD in a mid-sized group practice. He works very hard and makes very good money, more than $300,000 a year. He owns 2 houses outright and has put all of his kids through private college. Since he's 55, he long ago paid off his student loans. He firmly supports single payer health care. According to him (and he does his research), GPs in Great Britain make more than the specialists because the GP's manage and supervise all their patients' special needs and referrals.

http://finance.yahoo.com/insurance/a...surance-health

So why does it cost so much to become a doctor?

Originally Posted by ziggyX65

Perhaps the concept of something like the U.S. service academies could work here: In exchange for a multi-year commitment to serve as a commissioned officer in the Armed Forces, students essentially receive an education paid for by Uncle Sam.

Doesn't something like this exist -- the US Govt will pay for you to attend medical school if you agree to spend the first few years (can't recall how many) practicing in either an underserved rural area or an inner city as a primary care provider?

Originally Posted by The Wonkette

Doesn't something like this exist -- the US Govt will pay for you to attend medical school if you agree to spend the first few years (can't recall how many) practicing in either an underserved rural area or an inner city as a primary care provider?

The National Health Service Corps has something like that, you just have to work for five years to get $145,000 forgiven. Unfortunately, there are like 30 jobs right now that qualify for the forgiveness program in FL, and that includes jobs for nurses, social workers, dentists, and physicians of varying specialty.

There's also no saying if that $25-30k per year benefit is actually worth the lost wages compared to a competitive job. (Not to mention the typical 10% interest rate on private student loans which is annually adding $25k to the balance on a $250k loan)

There are similar private programs, but they often expect a new doctor to work for $40-50k in order to earn $20k of loan forgiveness. These are pretty close to a total ripoff and I've tried to get them removed from some of the scholarship & financial aid databases.

Originally Posted by Seattleblue

So why does it cost so much to become a doctor?

First you must graduate from a credible 4-year university. if you are temperamentally unsuited to the bureaucracy-heavy land-grant colleges (great educational buys if you are the right sort of person) you have to attend a 4-year private college or university. That can easily run up over $100,000 before you get a bachelor's degree.

You can't work your way through college any more; your grades will suffer if you do and you will end up well qualified to do the sort of work that you did through college. The best that you can hope to do is to pay off some of the expenses and keep the debt load down.

Then there's medical school, which is a long haul. That is expensive in itself. Then there is the internship in which you get to prove that you really are a doctor, but because the pay is such a pittance you can't afford to pay such costs as housing and transportation. Your balance of student loans probably gets more severe. If you want to make the really good money you specialize, which makes you a physician who can command a huge income. But you are about 30 when you complete the expensive part of your life, and you had better get the income while you can.

Start with the room and board and incidentals of college, and you are perhaps $100K in the hole if you didn't buy your way into serfdom to Discover, American Express, Chase, Bank of America, Citibank, Capital One, Wells Fargo on airline travel, electronics, video, dating, etc.

Originally Posted by James50

I will pass along another anecdote. My brother and nephew are physicians and part of an internal medicine practice with about 10 doctors. They use a lot of physician assistants and nurses to reduce time with the doctor. They all make a good living, and it is hard to feel sorry for them, but they are under a lot of different pressures.

Recently a doctor from this group, who is exactly my age (60) and a childhood friend decided to start a "boutique" medicine practice. For those who sign on, they will pay $1500/yr directly to him. This entitles them to 4 doctor visits per year and off hours access to the doctor. He will limit his practice to 600 patients. He will use whatever insurance you have for prescriptions, etc , but his fixed fee remains. Particularly for older folks with chronic medical conditions, its probably a good deal if you can afford it.

I suspect you will see more internists "bailing out" of the current system in this way in the future.

James50

Correct; this is called boutique medicine, and is cash based.

Originally Posted by KaiserD2

I don't think that is right about Nelson--I think he had bailed as well, and others might have. But Lieberman was the most vocal.

Nelson was paid off - remember the 'Cornhusker Kickback?' Later, the conference with the House cut his kickback out which, by then, had become too visible and a liability for him to fight. In the end, he didn't need the payoff because his buddy, Lieberman, killed the public option.

By the way, I wasn't suggesting that you were doing the knee jerk and needed a thinking cap; I realize you were just posting background.

Originally Posted by James50

The issue is increased demand in face of a static supply. If you increase the number of insured without increasing the number of providers, you are guaranteed a shortage of providers.

http://voices.washingtonpost.com/ezr...care_refo.html

...As the bill prepares for full implementation, there are some other policies worth pointing out. Many have been concerned that there will be a shortage of primary care doctors to deal with the influx of new patients. [u]Starting in 2010, a variety of new loan repayment and scholarship programs kick into effect. But more importantly, in 2011, the government directly expands primary-care training programs and sends a 10 percent increase in payments to primary care doctors in the Medicare program (which makes being a primary care doctor relatively more lucrative). [u]

You can pick through the policies yourself, and it's anyone's guess whether they'll be enough. But the architects of the bill are thinking about how to build a medical workforce that works with this legislation. That's why the American Medical Association, the American Nurses Association and the American Hospital Association all endorsed the legislation.

While some actually work to move the ball down the field, many just choose to bitch and whine about the distance.

Originally Posted by independent

Yeah, American doctors are some of the least happy despite also being some of the best paid.

The problem is professional autonomy: they have none. Whether it is the insurance company or the malpractice lawyer, the law & financial system empowers many people to second-guess the doctor's medical decisions.

The nominal pay doesn't end up amounting to much either. 60-70 hour work weeks are common, and the high salary goes in to paying back massive student loan debts (now averaging $250k despite the fact that most people in medical school were already born to families in the top 10% income bracket). A doctor's insurance can also cost in excess of $100,000 per year depending on the specialization, so they really do have to charge an insane price just to break even - forget about their living expenses, continuing education, and medical equipment.

My first cousin is chief radiologist at her hospital in Texas, and you have just described her life.

Originally Posted by ziggyX65

Rules which few on your side were bashing when Senate Democrats were blocking votes on Bush judicial nominees, I'd add.

Welcome to politics. Nobody said it was fair.

Democrats should have been bashing those rules when they were in the minority. However, it's not very surprising that they didn't.

Just the same, the rules need to be changed. The Senate is dysfunctional. The rules worked reasonably well when Senators abided by certain unwritten rules, that is, when they were all or mostly gentlemen.

Unfortunately, these days they are mostly Boomers.

Originally Posted by independent

The National Health Service Corps has something like that, you just have to work for five years to get $145,000 forgiven. Unfortunately, there are like 30 jobs right now that qualify for the forgiveness program in FL, and that includes jobs for nurses, social workers, dentists, and physicians of varying specialty.

There's also no saying if that $25-30k per year benefit is actually worth the lost wages compared to a competitive job. (Not to mention the typical 10% interest rate on private student loans which is annually adding $25k to the balance on a $250k loan)

There are similar private programs, but they often expect a new doctor to work for $40-50k in order to earn $20k of loan forgiveness. These are pretty close to a total ripoff and I've tried to get them removed from some of the scholarship & financial aid databases.

It takes 2 years, and anecdotally, $2 million to go from Primary Flight, to an assignment in a line squadron. I don't owe a cent of it. The public does not bitch about it. Killing people is apparently OK. There's no public screaming about training military pilots. (Drones are the future. Flying is for droids).

We need to treat health care the same way. Use the NHS as the base "service", with a minimum service commitment, perhaps in one of the traditional armed forces, then a civilian commitment. No exceptions.

This will probably occur after the system collapse. The military is about the only entity capable of stepping in during a real national health crisis.

Oh, yeah. No more residency. Enough with the medieval bullshit. Either you hack it, or you don't.

Another article on the coming shortage of doctors

Medical Schools Can't Keep Up
http://online.wsj.com/article/SB1000...8.html?mod=wsj

Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.

That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000.

The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.

The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.

Meanwhile, a number of new medical schools have opened around the country recently. As of last October, four new medical schools enrolled a total of about 190 students, and 12 medical schools raised the enrollment of first-year students by a total of 150 slots, according to the AAMC. Some 18,000 students entered U.S. medical schools in the fall of 2009, the AAMC says.

But medical colleges and hospitals warn that these efforts will hit a big bottleneck: There is a shortage of medical resident positions. The residency is the minimum three-year period when medical-school graduates train in hospitals and clinics.

There are about 110,000 resident positions in the U.S., according to the AAMC. Teaching hospitals rely heavily on Medicare funding to pay for these slots. In 1997, Congress imposed a cap on funding for medical residencies, which hospitals say has increasingly hurt their ability to expand the number of positions.