Will The Doctor See You Now?
David Auerbach argues that the models suggesting a physician shortage are flawed for five reasons: (1) Models forecasting a shortage overestimate the increased utilization that PPACA will generate, (2) telehealth might reduce demand for physicians, (3) Increased efficiency, and (4) increased offloading of physician duties, and (5) physicians per-capita vary a great deal from state to state.
Scott Gottlieb goes a step forward and says there will be no doctor shortage:
Regardless of your political views, there are good reasons to be skeptical of these predictions. Take Massachusetts, where Obamacare-style reforms were implemented beginning in 2006, adding nearly 400,000 people to the insurance rolls. Appointment wait times for family physicians, internists, pediatricians, obstetricians and gynecologists, and even specialists like cardiologists, have bounced around since but have not appreciably increased overall, according to a Massachusetts Medical Society survey. Massachusetts’s experience may differ from other areas, particularly rural regions, but the results of reform there suggest shortage fears are exaggerated.
The population is indeed aging fast, but the methods of treating illness in old age are also changing quickly. Today, more patients can be cared for in subacute settings rather than in hospitals. And new technologies are turning the treatment of many medical conditions into less resource-intensive endeavors, requiring fewer doctors to manage each episode of illness.
It’s worth noting that Auerbach’s #5 and Gottleib’s Massachusetts example are connected. Auerbach points to the disparity between Idaho, with the fewest physicians, and Massachusetts, with the most. That Massachusetts has the most physicians likely means that it is best able to handle the increased workload. It’s going to be harder in Idaho, which is already shorthanded.
I suspect that Auerbach and Gottlieb are both overly optimistic about technology increasing workload, though I have little more than a gut feeling and some observations to go on. I do think that offloading to mid-level providers will ultimately provide the solution, but patients are going to have to be sold pretty hard on it. Or they’re not going to have a doctor to go to and will have to go to a MLP. Whether that qualifies as a “doctor shortage” or not depends on your perspective.
Both are right that if there is an increasing problem with a physician shortage, it will not be equally felt. Massachusetts will be fine, but that doesn’t help Idahoans very much. One of the things we are often quite guilty of is failing to differentiate between a physician shortage and a primary care physician shortage. Omega is a physician of some sort and he not only reports a lack of physicians but is worried about his job being outsourced. (Do I have that right?). And, as they say, regional shortages. Most specifically in ruralia.
But there is a cascading effect, even if we change shortage to “the low end of the range of physicians we can use.” If we’re not going to throw money at them, we need a surplus of physicians in cities to push PCP’s out to seek rural opportunities. Further, if we want to experiment with cost-saving techniques, it needs to be staffed with physicians who presently have enough better opportunities. For example, one experiment I am interested in is government-run clinics. After some success in Montana, I said:
I would like to see this repeated and expanded, though I foresee a strong possibility of scalability problems. It’s one thing to staff a hospital in Helena, but it’s another to try to form a national network. I’m not sure how many physicians, even primary care ones, are eager to join the ranks of government with government pay. The government does staff these positions – more or less – but it would have a harder time trying to do so nationwide. (Disclaimer: My wife did some work for IHS. The bureaucracy was aggravating, but there was quite a bit to like there. A surprisingly positive environment. But we can’t afford the pay cut with student loans hanging over her head and a late start in savings.) (Also, note: This isn’t a government thing. Kaiser Permanente and Mayo have workable models, but they aren’t scalable.)
I’m skeptical we can do that with the number of primary care physicians we have now. And nothing Auerbach or Gottlieb have said suggest to me that it will be less of a problem in the future, even if it isn’t going to become the (increased) problem the doomsayers are saying.
I hope, quite sincerely, that Auerbach and Gottlieb are right. Something, obviously, is going to give at some point. My guess is that it will be, as they say, more people seeking care with mid-level providers because they can’t find regular doctors and physicians taking on a more managerial and special-case role. Maybe that is the optimal outcome rather than something we’re just going to be backed into, but I don’t think so.
Because it’s going to be a tough nut to crack.
This may be the wrong logistical issue to be looking at.
From a perspective of saving lives and money, we might
actually be better off decreasing the transit time to
acute care.
I don’t know as much as I’d like about telemedicine.
But I assume that there’s a good fraction of PCP
diseases that can be identified simply through metrics
available with a webcam.
This doesn’t fix the issue of “I can’t see my doctor.”
However, “I can’t see my doctor” exists in cities too.
If you want people to be able to get checked by their
doctor within 24 hours of an issue (ahem, bloodclots
and other things that require prompt diagnosis/intervention), you’re going to need
a LOT more doctors than currently exist.
I think we need to honestly ask ourselves where we want
“moderate emergencies” to be treated. ER? UrgiCare? PCP?Report
I would support making it easier for foreign born and trained doctors to practice in the US if they are willing to work as primary care physicians in rural areas that need it. If you want to practice at a big city hospital, you need to go through the usual difficulties. If you are willing to serve in Idaho or Montana, requirements can be relaxed.
I agree with you about the problem of rural doctors and primary care physicians. I also think that many doctors are no longer wanting or willing to run their own practices and find it much less stressful and still lucrative to be an employee of a Hospital or some kind of boutique medical company like One Medical. From what I hear, they still make excellent six-figure salaries and work 4 days a week or so. A friend told me about his friend who makes 300,000 something dollars by working as an employee doctor instead of running his own practice and needing to care about billing, overhead, paying staff, etc.
IIRC primary care is not as economically lucrative or glamorous as being a specialist of some kind.
This is all second hand though. The good doctor should be able to tell us more.Report
Clancy actually worked for the hospital when we were out in “Arapaho.” Several years prior, the hospital basically “bought” almost all of the physician practices, who were happy enough to sell and work as an employee. A few declined – or weren’t made offers – and ran a separate clinic.
It’s… tough relaxing standards for foreign doctors. For a variety of reasons with a number of roadblocks. The residencies are the bottleneck, there is a lot of resistance to waving this requirement for anybody, and residencies are hard to start up and fund under our current system. (And, of course, once you get through, they can’t tether you to a particular area.)
It seems to me that this ought to be something we can do, letting them work in-training for several years in a rural hospital in lieu of residency, but there just doesn’t seem to be any appetite for something like that (even among docs who are desperate for there to be more docs).Report
Some interesting stats:
The majority of doctors go into practice within 100 miles of where they did their residency. Thus the primary reason why areas without teaching hospitals have doctor shortages.
Rural vs urban is not the dividing point. Rather, proximity to a teaching hospital is the primary determinant of whether an area has a doctor shortage. Phoenix, AZ has 62.4 PCP’s per 100,000. San Francisco, CA has 117.0 PCP’s per 100,000. Buth are heavily urban areas but the SF Bay area has twice as many teaching hospitals as the Phoenix AZ area, and the numbers reflect that.
Regarding loan forgiveness for rural doctors, numerous states have loan forgiveness programs for doctors who agree to practice in rural areas of their state. But it’s hard to get someone who did not grow up in a rural area to agree to live there, and unfortunately the schools in rural areas are generally so bad that few kids from rural areas make it into medical school. So that is a problem, and will continue to be a problem.
Finally, on the question of whether the ACA will make the doctor shortage worse: No. The ACA mildly makes it better by funding more residencies. But it otherwise does not change the doctors per capita in the US. The number of people underserved due to not being able to find a physician willing to treat them will remain the same, it’s just that the reason for them being underserved will change — i.e., they will be underserved because of doctors not accepting new patients, rather than because they had no health insurance and could not afford an appointment with a physician.Report
To the extent that it’s mostly a matter of residencies, we should work to start more of them in Idaho, Montana, et al and see how it goes. Montana just started a new one last year.Report
One of the odd things about the number of physicians per capita is that, contrary to what market theology says, markets with more physicians have higher healthcare costs. That is a fact, measured statistically. More doctors = you pay more for medical procedures.
So what’s the deal? The deal is that physicians in specialties dealing with life-threatening issues have significant market power — literally, “your money, or your life”, and what value do you place upon your life? — and demand a certain amount of compensation per month. If fewer patients arrive at their doorsteps because of a surplus of physicians, they simply raise their rates. Because people facing life-ending illnesses are looking for the best physician rather than the cheapest physician (because after all, their life is literally priceless to them — you cannot buy a new life, unlike a car where if you go to a cheap mechanic and he destroys your car you can just shrug and buy a new car), this allows doctors in these areas to maximize their income while minimizing the actual amount of work they have to do. Cannot interrupt those 3 PM golf games after all!
In other words, the economics of health care work more like a mugging than like a market. When someone literally has power of life or death over you, he can ask whatever he wants, and you give it to him. Because would you rather be bankrupt, or dead? Most people would choose bankruptcy over death, in the end.
So the question is what the ACA will do to change this dynamic. Thus far, the answer seems to be “not much.” People in areas with physician shortages will continue to go to emergency rooms, but they will do so because they cannot get in to see their primary physician in less than three weeks time, rather than because they have no insurance. No I am not joking about the three weeks wait for an appointment, last time I lived in Phoenix AZ (which has had an acute physician shortage for literally decades due to having millions of old people and no major medical school), I cut my arm in a way that needed stitches. I had health insurance. I literally called *every single PCP* in my health insurer’s list of providers. Every single one of them was utterly overbooked and couldn’t see me in less than three weeks’ time. Finally I called the insurance company and complained what use was their insurance if I couldn’t get in to see a doctor in less than three weeks time, I’d either be dead or healed by then. They said “well go to the ER if you really need it treated now.” Wha?
So that’s what’s going to *continue* to happen in physician shortage areas. The upside on that, is that it doesn’t change overall health care expenses. The downside on that, is that it doesn’t change overall health care expenses that are already way too high. Meanwhile, those who continue to model healthcare as if it were a market rather than a mugging need to be beat over the head with a Clue Stick(tm). Every statistic I can gather says that for non-PCP physicians, there is no functioning market. If there was, more specialists in an area would mean lower prices for their services — not *higher* prices for their services. That’s the dynamics of a mugging, not of a market.Report
How the hell are you measuring areas?
Are you taking into account cost of living?
A specialist in my town pulls people in from the entire tristate MSA. Not just the 300,000 people in town.Report
PPACA has some nips and tucks, including more residency slots (which is the only surefire way to increase the number of docs), but “not much” is about right.
You’re right about more physicians not decreasing costs. Which is one of the things that make the relationship between the physician shortage and higher procedure costs as being problematic. My wife was in the area where the shortages were the greatest, and her pay position within the physician hierarchy didn’t really reflect that. There are other things at work here beyond markets (and shortages, artificial or otherwise).Report
Of course, how many of those specialists who raise their rates are being paid in cash, and how many are billing insurance?Report
It doesn’t matter. When your life is on the line, you pay whatever is asked, whether insured or not. If a mugger stops you in Central Park and demands, “your money or your life”, you don’t ask “How much?”, you give him everything you have. Everything. Because your life is literally beyond value to you, since, unlike everything else you possess, it is utterly irreplaceable.
That power of life and death gives infinite market value to muggers — and doctors.Report
Badtux,
no, that’s actively silly. Most parents care more about their children than their life.
You may be willing to pay a lot, even so, but if you don’t have it.
YOU DON’T SEE THE FUCKING SPECIALISTS.
you just die.
A friend of a friend died before she even knew what was wrong with her (it was something about her heart). Of course, if you can’t afford treatment, why get diagnosed?Report
Kim, insurance gets you through the door. But the vast majority of medical bankruptcies occur to *insured* people.Report
Badtux,
Her insurance did bloody jack shit (was it 60/40? i don’t remember) — and it was STILL better than some I could mention.Report
And when was the last time your doctor told you the price upfront for anything?
My Dentist – sure. My Vet – always. My mechanic – everytime.
My doctor? They don’t even know, they’d have to check with billing…Report
MRS,
yeah, we’re, um, working on that.
I did ask a doc once how much a heart attack cost.
from 50 to 100 grand, he said.Report
There has been some movement towards price transparency. I don’t have time to look it up, but there’s been a Linky Friday or two on it. Not much, but a start.
Having been marginally insured and uninsured, I have been in the position to ask questions about prices. You can usually get an answer, though not right away.Report
First off, let’s admit there is a significant difference between true emergency medicine (the OMG this person is going to actually die in the next hour or less if we do not do something right fishing now & said person is out of it) & the urgent care/PCP medicine (or it’s important to take care of this, & soon, but the immediate danger is nil).
I don’t expect ER docs to discuss prices during an emergency (although they should have a very clear pricing schedule that is publicly available). I do expect EVERY OTHER DOCTOR to be able to discuss prices, or at least have someone on staff who can, should a patient want to.
Especially if, as you claim, these doctors are setting their own prices to be very high because they can. If that is the case, then they should be more than happy to talk about price, because they thought about it & made that decision.Report
My understanding is that the typical doctor hands over a file of “things I did for this patient” to a billing expert (usually an outside contractor) whose job it is to figure out how bill the insurance company to maximize payments. The physicians I’ve known often have absolutely no idea how much what they’re doing actually nets them. I suspect that in a lot of cases, if they knew how much they were going to be paid for something and a customer offered them slightly less, they’d still be willing to take it. But the way the system is set up now, the only “negotiation” or “price discovery” (if you can call it that) is aggressive gaming of billing forms by a company that knows how to game the forms.Report
Your characterization of what
market theologyeconomics predicts is wrong. That prices will be lower in regions where supply is higher (more doctors) is not guaranteed unless demand is the same in all regions.What economics does predict is that, all else being equal, adding doctors will result in lower prices, but that’s not the same as predicting that regions with more doctors will have higher wages, because all else is not equal across regions.
This is pretty basic stuff. If you’re going to be an arrogant prick, at least try to know what the hell you’re talking about.Report
Except that these studies were done controlling all other factors including cost of living and found that more doctors per capita in a US healthcare market means higher health care costs. And actual per-capita demand for health care is fairly constant, people don’t get sick differently in different markets. You may want to insist that your market theology of “more supply means lower prices” is always true, but it’s not, and we can even model that in economics if willing to get away from theology and wanting to actually model reality. For example, copper prices. Did you know that when demand for copper decreases, the price of copper goes up? True! It turns out that per-unit incremental costs for producing copper are a fairly small part of the price of copper in today’s highly-automated mines and foundries. The vast majority of the costs of producing copper are fixed sunk costs. So a decline in demand for his product does not result in a decline in his costs. Since a copper producer will not sell copper for less than what it takes to cover those fixed sunk costs (otherwise he is a *former* copper producer), he will instead raise his prices on the fewer units being sold in order to cover those fixed costs. He cannot raise his prices to more than his competitors are raising *their* prices, of course. But since in a functioning market every producer is already running close to margin with close to the same level of expenses (else they become a *former* producer if they are less efficient than their competitors) everybody *seems* to raise their prices in lockstep.
This can be modeled, if you are willing to break away from market theology and do actual economics, and the models work at predicting what producer prices will do given various changes in demand based upon what percentage of their costs are sunk costs and what percentage is variable.
Health care is another of those areas where fixed costs are a major driver of pricing. A doctor’s education and his office space, staff, etc. cost the same regardless of how many patients he sees per day. Furthermore, competition in health care works different. When you are sick with a life-threatening illness, you go to the best doctor, not the cheapest doctor, because the replacement value of your life is basically infinite (since you can’t buy a replacement or substitute for a life no matter how much money you have — just ask Howard Hughes). So competition in health care works by increasing those fixed costs — by adding more MRI and other diagnostic machines so you can say “come to my facility, I have more health-saving gear!”, by creating more appealing facilities that say “this doctor is successful and someone you can trust”, and so forth. More competition in health care results in higher fixed costs that have to divided between the same patient population. Again, this can be modeled — *if* you’re willing to abandon market theology and do actual economics. And the models actually predict fairly well what provider prices will be, just as with copper production above.,
This is real economics, not the BS twaddle of market theologists, who are so attached to their religion that they’re unwilling to look at actual reality and see whether their model of reality actually fits observed reality. Models of actual reality require actually measuring reality and seeing whether your model accurately predicts what pricing will be, not making blanket theocratic statements like “all gays will go to hell” or “all other things being equal, more supply means lower prices.” Because those are statements that simply don’t match observable reality — we’ve never observed any place called ‘hell’, and the second statement has been contradicted by measurements in major markets where an increase in supply relative to demand has *not* resulted in a decrease in prices, but, rather, an *increase* in prices. Reality simply *is*, regardless of your religious beliefs.Report
Demand isn’t static. One of the reasons that more physicians can often mean more money spent is supplier-induced demand.Report
“more supply means lower prices”
This isn’t what people say. They say that price is a function of supply and demand and if the rate of supply is growing faster than the rate of demand then this will push prices down.
If demand grows exponentially as supply grows arithmetically, it’s to be expected that prices will still go up no matter how much you point to the supply growing.
Even if you say “more supply means lower prices”.Report
I should add that SID is one of the reasons why, by itself, bringing in more doctors would likely add to system costs rather than subtract from them. In order to bring the costs down, you would need to make other changes. The most commonly assumed change is “If there were more doctors, our negotiating leverage would be increased and we would lower fees overall.” Which might happen, but might not. My concern is that a certain number of unscrupulous physicians would make the money back up by drumming up more business (more demand).
Which brings me back to my hope, which is that if we had more physicians, we might be able to convince enough of them to work for government clinics so that the government doesn’t have to negotiate with independent operators as much for Medicare/Medicaid patients. It might also allow more insurance companies to do the same, though that’s a hard sell with the public that wants to see their favored physician(s).Report
Furthermore, competition in health care works different. When you are sick with a life-threatening illness, you go to the best doctor, not the cheapest doctor, because the replacement value of your life is basically infinite (since you can’t buy a replacement or substitute for a life no matter how much money you have — just ask Howard Hughes).
One problem with this is that the “Best” doctor can only handle so many patients at a time. So while Person A might want to see Dr. Best, if Dr. Best is full, or just not interested in Person A’s case, they will have to consider Dr. Second Best, or Third, & so on. Not everyone can get in to see the top, so they have to settle for something else. Also, Person A may also be thinking about the cost, and the hardship to others in the family. Mom & Dad may pull out all the stops for care for a sick toddler, but Grandpa, he may not be so inclined to bankrupt the family for his own health & will go where Medicare or the VA tells him to go.
In these cases, cost of care actually DOES matter, & you need to really stop acting as if no one thinks about it.
The top practitioners may set the top of the scale because they can demand it & control who they choose to take on, but the bottom & the median is set by everyone else, and those prices are much more driven by fixed costs.Report
BadTux:
Their tendency to get sick may be about the same from market to market, but their willingness to pay for treatment is likely to vary significantly.
I’m very skeptical of this claim for a whole host of reasons. Copper refining should happen on such a massive scale that the average cost should be pretty close to the marginal cost at any normal-ish level of demand. Is this just a piece of industry conventional wisdom, or is there some data in a paper somewhere showing a price increase with a demand-driven decrease in quantity? This is an especially sketchy claim given that copper should be a commodity with an active futures market.
The models in first-semseter microeconomics cover the problems with fixed and variable costs pretty handily, and they don’t result in anything like that result. So what kind of features are being added to get these fancier models?Report
What gets me is the assumption that there wasn’t going to be or wouldn’t be a physician shortage without ACA. People’s basic medical needs didn’t change, but uninsured people couldn’t get many of the non-emergency needs taken care of.
So we were already living in a state of rationing; it’s just that the rationing happened along the lines of who has health care insurance.
So yeah, I agree: the whole argument is bogus, but for all the wrong reasons.
/I do admit that there will be more unnecessary medicine; more running to the docs for every sniffle, but I’m not convinced that this is the driver of predicted shortages.Report
PPACA will have an impact (more people able to visit doctors will result in more people visiting the doctors), but it’s hard to argue that PPACA is the thing that is causing the problem, rather than just one of many contributors.Report
Plus as I noted, as times to visit a primary care physician increase, goods substitution comes into play — people will go to emergency rooms or urgent care centers instead to take care of needs when they can’t get in with their PCP in a reasonable amount of time. In Massachusetts ER use did not change after Obamneycare was implemented, it was just that more of the people arriving at the ER were insured, that’s all.Report
PPACA reveals the shortage that already exists; it didn’t create it. Yes, it may makes it a bit worse because of unnecessary health-care use, but all those people who weren’t getting health care before still needed it; they just couldn’t afford to get it.
The shortage was already there in the system, we just didn’t acknowledge it because the people who had their health care rationed before due to lack of insurance weren’t presenting as ‘patients under a doctor’s care.’ That’s what’s changed — the patient log, not the number of potential patients.Report
PPACA didn’t reveal the shortage. Everyone knew about it ahead of time. Yeah, it’s here either way. PPACA will merely aggravate it for reasons good and bad.Report
I predict that doctor’s STAFF will need to rise to handle the additional paper work from all the new folks on the rolls. Right now, my doc has two folks working for him–just to handle the paper work and appointments. And I think that at some point doctors will grow tired of the bureauacray and bail. How will this effect things overall, not sure, but I’m not optimistic “everything will be fine”.Report
That’s a good point. Counter it with EHR, which should reduce staffing needs.Report
I think Will has made the point before, and I hear it regularly from a friend whose wife is a doc at Kaiser, that a reasonable salary and “you don’t have to deal with the hassles of being a small business owner” is attractive to an increasing number of docs. I don’t know if it’s an actual trend, but at least in the suburban area where I live, there seems to be a shift towards larger practices. Two or three locations, each with a group of PAs and physicians, and one somewhat larger that has some test capabilities and a small number of specialists for which there is large call (eg, cardiologist). Sort of a small version of Kaiser. I have a bone-density issue and the practice of this type where I get care has a DEXA scanner at one location. After the doc argues me into getting my every-three-or-four-years scan, the appointment is always about three weeks out, so I assume they’re keeping it fairly busy.Report
Plus, at least around here, you get tech support!Report
Should we make a distinction between “shortage” and “uneven distribution”? A lot of areas in northern Canada have issues finding doctors (as well as other professionals) because doctors don’t want to live there. And when they do get doctors and nurses, they’re often people just out of med school with little experience and not enough supervision because none of the experienced doctors and nurses want to go to those places.
You get extra pay for working in northern and remote areas, but even that doesn’t make it worthwhile for most people.
I can see the same thing being true, to a lesser extent, in Idaho. And in a situation like that trying to increase the total number of doctors wouldn’t necessarily be successful: people aren’t going to go to med school if what they’re hearing is “well, California already has more doctors then it needs, but you could find work in Idaho”.Report
I’d say the shortage of doctors in rural places has almost nothing to with what sort of economic healthcare system we put in place: pre-Obamacare, Obamacare, or Medicate for all.
The cause, IMO, is entirely sociological. We make sure that only the best and brightest and most driven students go to med school and become doctors. And demographically, many of these students are children or grandchildren of immigrants, often of Asian, Indian, Middle Eastern decent. Or they are children of fairly wealthy WASPY or succesful Jewish families.
And sociologically, on the whole, members of these groups (the success driven, the moneyed WASPS, social climbing Asian immigrants, Jewish people, etc.) avoid rural areas like the friggin plague. Some of that is with good reason: stay close to ethnic ties, be where there are exciting things to do, avoid discrimination, etc.
Ask a bunch of doctors how much money they would need to make per year to live, say, 10 years in rural Idaho. Some will say they would rather quit medicine. Literally, there is no amount of money they would take. Others will say maybe for enough money that they could afford multiple high end homes or retire to San Francisco in luxury at 50.
In Shazbot’s home town where his original factory was located, no doctor will stay. Few will come even for short periods. Maybe one would stay for a fortune, but the salary/fees must be reasonable because it isn’t a wealthy place.
The best solution would be to create rural medicine programs and accept students from those areas and then give them loan forgiveness only if they stay there. But that is socialism, I guess.Report
Actually, i would create a Rural General Practitioner Degree that could only be used to practice medicine in rural areas.Report
That would imply that either 1) it’s okay for doctors practicing in rural areas to have a lower quality of education than those practicing in cities or 2) we can arbitrarily refuse to let some doctors practice in cities despite them having an equal level of education and skill.
I think that the government forgiving student loan debt (or simply paying the costs of a medical education) in exchange for a doctor agreeing to work for a set number of years (5? 7? more?) in rural/remote areas is a good policy. But I don’t think it’s sufficient to solve the problem. And yes, it runs into issues with doctors not being government employees.Report
@katherinemw As I recall, variations on this have been done in different states already. With mixed results. My impression is that the biggest problem is new graduates who fairly quickly decide, “I’d rather live with my student debt problem than live here.” I used to think that I could fairly easily go back to living in a small rural town; these days, I’m inclined to think that’s no longer true.Report
KMW,
I’d say more 2.) than 1.)
The education would be tailored to rural needs and would favor rural kids over yuppie kids with better grades.
IMO, rural areas get the worst MD’s now. So my RMD’s would be as good practitioners even though the students would have lower GPA’sReport
Loan forgiveness is a thing, but it doesn’t come close to compensating for the salary disparity. Had my wife stayed back west, her entire student loan would have been paid off in six or seven years. Had we moved Sioux Falls, the extra money would have paid it off in less than two years.Report
@shazbot3
“Actually, i would create a Rural General Practitioner Degree that could only be used to practice medicine in rural areas.”
i like the concept but it needs a different name, because that one reads as “lousy doctors for hicks” which is a bit of a tough sell. but exporting the physician assistant model is not a terribad idea. i don’t think you could call them doctors per se even if they were doctors in all but name.Report
Sounds like what the military does…Report
You’re right that a lot of doctors are turned off by not living in the city. We call those assholes “surgeons”… kidding, though fortunately for our purposes I suspect it’s disproportionately surgeon-specialists that have that particular allergy and it’s not surgeon-specialists that are particularly the problem.
But here’s the thing: We don’t need that many doctors, numerically speaking. Heck, if we could just get all of the people who went to Rural Family Medicine residencies to actually practice in ruralia, that might work wonders. But even there, the retention rate isn’t good. And this is among people who actively chose to be trained for it.
So why isn’t the retention good? For some of them it’s pay, though for a lot of them it’s workload. That makes it circular. Few are out there, jobs go unfilled, putting more work on everyone else, then those leave, and so on. The job out west that my wife left had her on call two days and off one. Because the ER was heavily staffed with mid-level providers, it meant that call-ins were not infrequent.
Where pay comes into play is that for all that… there were jobs elsewhere, in cities (granted, we’re talking about cities like Fargo and not cities like Minneapolis) that paid 50% more and had you on call only once a week or so (and jobs in smaller places, who needed doctors even more, paid less). Had her last job been fully staffed, she would have been on call about twice a week. That was what she had initially signed up for.
The money matters for a couple of reasons, but mostly because the shortage begets more shortage. If these places merely became a place where young doctors cut their teeth while paying off their student loans, that would have a huge impact. But even if we account for underserved area loan repayment programs, they’ll pay if off faster in Fargo.Report
Lots of doctors in the extended fam, and all have doctor friends. the percentage willing to practice in Bumblefart Idaho for anything but insanely high wages is not 5% but zero percent. Sure that’s anecdotal, but we’re both trading in the unemprical here, and I strongly suspect that the percentage willing to work in rural areas for anything less than crazy high wages is near zero.Report
@will-truman
“You’re right that a lot of doctors are turned off by not living in the city. We call those assholes “surgeons””
i did indeed lol. #brodaps
but yeah living in nowhere sucks. i can get decently competent er care, but the closest pediatric urologist is an hour away. thankfully we’re only an hour away from a good childrens’ hospital in wilmington but coming from nyc this adjustment has been totally balls.*
people still say the local hospital is “bad” largely because they shut down ob/gyn and peds services about three years ago. not enough patients, too much insurance, too many lawsuits, and ob is a loss leader to begin with. it sucks, as everyone has to travel at least 30 minutes to deliver somewhere, but i also can’t really blame them. the local pediatrician is great but he’s overloaded in part because he’s great and in part because there’s only three other choices in the entire county, none under the age of 50. admittedly there’s not a ton of young people in this county but still.
* get it?Report
People become doctors for all sorts of reasons, and family practitioners and rural family medicine physicians are a different breed. You can talk about doctors in the vague sense, but I am talking about doctors that are actually in the orbit of rural medicine. A great many of whom quit or, despite having trained to practice rural medicine, end up leaving. The two big reasons seem to be workload and the combination of workload and pay. (If nothing else, this is indicated by how much more difficult it is to retain family practitioners as it is internal medicine docs, even though the latter is less rural-oriented and tends to have doctors who are less rural-minded.)
At this point, I’m not even thinking about those doctors who have an aversion to the sticks. If we can just get more of the people who go into rural family practice fellowships to go into rural medicine, we’ll be making real progress. Even if most doctors have no interest… most doctors don’t need to. It won’t actually take that many to right that ship. Four doctors back west would plug the hole in a service area the size of Delaware.
I do actually think that Badtux may be on to something… put more residencies out there. If doctors are that inclined to practice where they trained (or near it), that could help a lot.
Special rural medicine degrees isn’t feasible, though, for a number of reasons. It’s just not the way that licensure and accreditation work. It would actually be more conducive to the system to wave residency requirements for foreign doctors if they agree to work at certain jobs in certain places, and that’s practically a non-starter itself.Report
@dhex It’s extremely difficult to get specialists to move to the sticks. I don’t even spend much thought on them. This is especially true for subspecialties. We had to travel three hours to see a pediatric cardiologist and two hours to see the pediatric orthopedist… and it’s always going to be that way. It’s one of the costs of living in rural America. And you don’t even see a pediatrician, you just see a family doc if you have kids (or an internal medicine doc if you don’t).
I’m sorry to hear about the obstetrics. That’s what it’s starting to look like Back West. I’ll be pleasantly surprised – but surprised – if they still offer obstetrical services ten years from now. FP/OB’s are getting burned out and tired of the litigation. Obstetrics was one of many hats that my wife wears, but it was the only hat that ever had us worried about lawsuits. One of her colleagues was sued too many times and decided to let his board certification go. One of my wife’s colleagues has said that he wants to stop delivering babies.Report
There may be a rural track for PA’s, I’m not sure. Specifically training PA’s for rural areas would likely help somewhat. Training PA’s to deliver babies might help, too. Though you still run into the same problem my wife had: There’s a lot that MLP’s can’t do (as in are incapable of or uncomfortable doing, not just as a matter of licensure), and when that happens, they need to call a doctor. And if they’re trained to do everything a rural provider needs to do, chances are they’re qualified for a job elsewhere that pays more and has less responsibilities. And it’s going to be rather difficult to argue that they should be prevented from doing so.
The exception to all of this is, of course, if they are here on a Visa. You can put a lot more restrictions on that.Report
At this point, I’m not even thinking about those doctors who have an aversion to the sticks. If we can just get more of the people who go into rural family practice fellowships to go into rural medicine, we’ll be making real progress. Even if most doctors have no interest… most doctors don’t need to. It won’t actually take that many to right that ship. Four doctors back west would plug the hole in a service area the size of Delaware.
I disagree with this. If you train them as MD’s who can work in the city, they will do that. They do do that, which is why there aren’t enough doctors in rural areas.
Special rural medicine degrees isn’t feasible, though, for a number of reasons. It’s just not the way that licensure and accreditation work. It would actually be more conducive to the system to wave residency requirements for foreign doctors if they agree to work at certain jobs in certain places, and that’s practically a non-starter itself.
We can control accreditation through legislation. We can pass a law saying this is how it will be, dear doctors, there will be a rural medicine degree that will have x, y, and z requirements.
Foreign doctors in Canada don’t want to stay in small towns and ruralia for all the same reason that immigrant and second generation kids who become doctors here don’t want to work in ruralia.
Nothing works unless they are required to work in rural areas as part of their acceptance to the country.
Literally, doctors would rather work at nurses wages or as nurses (or in an office building and junking their medical degree) than live in ruralia. The tiny few that don’t are not enough to staff ruralia. You literally can’t find the four or five people.
You need to use accreditation to force a solution to the problem instead of expecting a market solution. Yay nudge socialism.Report
I honestly don’t know whether the pay bump would work or not. Rather, I’m relatively sure it would plug at least some of the holes, if we had more doctors, but I don’t know how far it would get us.
I do know that the RMD idea, as explained thus far, is not feasible. It is not remotely compatible with the licensing and accreditation system, even as a proposed change to that system.
I do know what I have been watching unfold over the last five or ten years, as I’ve been close to the thick of it, and it does not lend much credence to the certainty you express.Report
It is feasible since accreditation can be changed through legislation.
There is no reason to believe that the pay raise will add even one doctor until there is empirical evidence.Report
We’ll let others decide if even a single doctor responds to financial incentives and focus on your plan. Accreditation can be changed through legislation, but there are so many moving parts that you would have to have a degree of universal agreement and cooperation that I do not believe is possible, and it would require a re-evaluation of what the accreditation boards are there to do. But perhaps I am misunderstanding it. Let’s walk through it, starting at the beginning:
How would an RMD education compare to that of an MD? What would their training consist of, relative to that of an MD?
What would an RMD be permitted to do? And by whom?Report
Foreign doctors in Canada don’t want to stay in small towns and ruralia for all the same reason that immigrant and second generation kids who become doctors here don’t want to work in ruralia.
Nothing works unless they are required to work in rural areas as part of their acceptance to the country.
I don’t want to stereotype, but the problem I see with that is that small rural areas are likely to be, on the whole, less welcoming to foreign doctors than cities; at the least, someone from India or China or the Philippines would be much more likely to find other people from their culture in a city. And I would think that’s an important thing in mitigating culture shock for a new immigrant.Report
FWIW, one of the reasons that I believe that the Visa program is better-suited for this sort of thing than starting a whole new path to medicine is that the Visa programs are already geared towards putting people where they are needed rather than where they would prefer to be. I think it would be easier to fit the Visa around putting doctors where they’re needed than it would be to create an entirely new path to become a doctor with intrastate geographical restrictions. (Both are exceptionally unlikely to ever be implemented, however.) (I should add, foreign doctors choosing to stay in small towns has been known to happen.)Report
Kat,
Depends on the place. Lotta war brides in some parts of the country.Report
“We’ll let others decide if even a single doctor responds to financial incentives..”
No, let’s let the evidence decide. And there is no evidence that increased salaries will make a difference here.
And my use of “a single doctor” may be hyperbolic, but the point stands that there is no evidence that increased salaries will make a measurable, more than marginal impact.
“Accreditation can be changed through legislation, but there are so many moving parts that you would have to have a degree of universal agreement and cooperation that I do not believe is possible”
No. You don’t need agreement. You legislate that this is how accreditation will work.
Now, you are right that doctors as a political special interest would kill this plan politically before it even got up for a vote (just like they will continue killing the idea to let foreign doctors in). But it is a feasible plan that is politically not viable. (Just like a lot of good ideas in the U.S.)
it would require a re-evaluation of what the accreditation boards are there to do.
Not really. The RMD’s would have to everything the General Practioner MD’s do. They will just have a different degree assigned to work only in rural places.
How would an RMD education compare to that of an MD? What would their training consist of, relative to that of an MD? What would an RMD be permitted to do? And by whom?
Same training as general practitioner MD’s. Or you can even do some RMD specialists if you’d like. Same board exams, etc. Some further subsidies can be given to hospitals to ensure their training and that kids from rural areas are selected for admittance. Some current subsidies can be withheld for teaching hospitals and residencies that don’t play along. Or it can be made illegal to train MD’s without some RMD’s. (Constitutional? Meh.) If you want the government to enforce and sanction your accrediting body, you play along.Report
If they go through residencies, like regular doctors to, you’re going to have an extremely difficult time with states giving them full licensure because it’s a medical board’s job to give assess capability and training, not to determine who should be working where. You’d have to redefine what a medical board does.
Further, you’d have a problem with Montana saying “While we might prefer this RMD take a job in Thompson Falls, we can use physicians in Butte and Bozeman and just about everywhere and if we allow RMD’s to practice here, we can get some that might otherwise go to Idaho (or vice-versa) and if we don’t do this Idaho might. We should direct the state agency to grant them all full licensure. We don’t have one medical board in this country, we have 70 governed by the laws of more than fifty jurisdictions. We have DO medical boards that might see allies in RMD’s and, having been discriminated against themselves, might find common cause. RMD’s are, after all, completely qualified. They have, after all, the same training.
Further still, you will run into the same problems that they ran into with DO’s. Once DO’s received the same training as MD’s, the courts ruled that they couldn’t be discriminated against. They have, after all, the same training. The ability to maintain this distinction is suspect, at best.
Further further still, even if you didn’t have the above problem, you would have difficulty getting quality applicants. Even physicians who want to practice rural medicine would not want to be completely boxed into it. As the country urbanizes, there might be a glut of such physicians.
And some candidates would likely be disgruntled med school rejects who never wanted to practice in ruralia, find themselves miserable, and will go to court to be given full licensure on the basis that it is unfair discrimination. They’d stand a pretty fair chance of winning for the same reasons that some contractors have been able to successfully argue that they are “common law employees” regardless of the contract that they signed.
The amount of overhaul required in order to do this would be monumental and even then could still be unsuccessful depending on how the judges feel about it. It’s a plan that might work under a different system, but not under this system. It relies on a degree of control the government doesn’t have over the process. Not because of the doctors, but because of the doctors, the states, and possibly the courts. If it’s feasible at all, it’s feasible in the same way that abolishing the Senate is feasible.Report
People become doctors through intense competition. The best and the brightest and all that. They don’t compete to live in rural Idaho.
The solution might be to train some doctors (my rural RMD’s) who aren’t culled from the most go-getter competitive students, but rather from the kids who live in rural places and want to stay there.Report
We should all look into the Alternative Healthcare options rather than going to PCP’s for everything. A Naturopathic Doctor is as good as PCP in treating most common illness. A sharp headache can be treated by an Acupuncturist or a Chiropractor at 20% to 30% less cost.
They all are certified to treat almost all of health issues a regular PCP treat. Having more awareness about Alternate Health Care options reduces dependency on PCP’s and you find ACH professionals willing to serve rural locations unlike PCP’s.
DocHelp.com
One interesting observation is that many independent PCP’s and AHC’s facing swift competition in urban areas and struggling to get more patients. They may choose to move to rural areas as the corporate hospitals eating up their business and they don’t to be employees.Report
I wonder how much of the rural medicine problem is related to facilities. Would doctors be more interested in working in rural areas if they had ready access to digital X-Ray systems, CT scanners, & MRIs (& the like for the various disciplines).
I mean, we can apparently afford to equip every podunk town in this country with a SWAT team armed with explosives, fully-automatic weapons, & urban APCs (whether they need it or not). Could we not re-direct such funds toward modern medical facilities?Report
Depends on what you mean by “access to.” Generally speaking, the more rural you are, the more different things you get to do. That was one of the draws for my wife when it came to rural medicine. She wanted to do endoscopies. Well, the more proctologists there are around, the less likely it is that you can do endoscopies. The same would apply to all sorts of tests and procedures. So while they don’t have a CT scanner at a rural hospital, if they were at a city hospital they would likely have to turn it over to somebody else anyway. And the person who trains in CT scanners isn’t going to end up at a rural hospital anyway. (Like I said, this is about PCP’s far more than specialists. My wife’s hospital needs all of one surgeon, and they’ve got that.)
On the other hand, if they don’t want to wait for CT results and don’t care about doing it themselves, then it’s possible that they would prefer being in a place that has one around.
However, even if this was a factor, and even if it would bring more doctors into ruralia, trying to get CT scanners into these hospitals would be a cure worse than the disease. Really, really bad idea. It would, I believe, create a huge overutilization problem.Report
The question is what would be the problems about moving to telemedicine in the rural areas. Given that an Iphone can be a stethescope right now as well as other devices such as blood pressure monitors that can transmit their readings, why does the PCP have to be local. Put in a good video circuit. Perhaps a nurse at the rural end of the link if needed? After all if the Tx department of corrections can move all their in house physicians to Galveston and do it, why not towns of 1000-4000, and for specialists even larger towns.Report