I had a frustrating experience yesterday. I often read Megan McArdle’s blog, and occasionally comment on it. Yesterday, she had a post on a proposal to solve some of Medicare’s problems by dropping the “doc fix” and letting reimbursement rates for doctors drop by over 30%. The post was based on an article by Bruce Bartlett, who thinks,
That would cut Medicare’s costs very substantially over current policy – something Mr. Boehner has demanded as a price to prevent the Treasury from defaulting on the debt. The virtue of this approach is that no one has to do anything – the sustainable growth rate is already in law. All our leaders have to do is promise not to change the law and instead allow it to take effect on schedule.
The doctors will scream bloody murder and threaten to stop treating Medicare patients. It will be ugly.
But everyone knows that Medicare needs to be cut, and as the biggest contributor to long-run deficits, doing something meaningful to reduce spending on this program will demonstrate resolve and commitment to deal with entitlement spending. It’s exactly the sort of thing Mr. Boehner says he wants in order to raise the debt limit.
I think if he and Mr. Obama jointly committed not to implement another so-called “doc-fix” — the delay in cutting Medicare fees — it would be a solid first step on finding a bipartisan approach to dealing with the deficit.
In a way, he is right. The doctors would leave Medicare en masse and patients would have a very hard time finding a doctor so spending would go down. Megan’s commenters, however, think doctors have no choice and will just accept a 30% cut in gross income and continue to treat Medicare patients.
One suggestion:
The problem is that medicine needs to adopt the same cost structure as other professions. Doctors shouldn’t see patients, rather they should delegate day-to-day surgery and recommendation of medicine to technicians who are less expensive and have maybe two years of training initally.
PhD aeronuatical engineers don’t repair aircraft, they delegate it to mechanics with associates degrees. This system works well even though the aircraft are expensive and problems would have serious consequences.
I hae no idea why investment banking happens to pay well right now, but at $7/trade it isn’t impacting me much. Medicare tax is. At the very least Doctors should be doing medical research and supervising large staffs at a minimum ratio of 1:600 to front-line staff.
To some degree, this is what Kaiser now does. MDs do not give anesthesia; PAs and NPs do. I have been an expert witness for and against Kaiser on these issues. Kaiser is also heavily unionized. One case I was involved with was an instance of a very obese male having pilonidal sinus surgery. This is a 15 minute procedure to excise a hair filled sinus tract at the end of the spine. It is done face down and, in this instance, with a spinal anesthetic. The PA gave the spinal, then because it was his lunch time and the union rules do not allow any flexibility in these times, he left to eat his lunch and another PA came in to take over for the lunch break. The patient was positioned and the surgeon began. The problem was that the patient was put face down and, in all the changes taking place, the new PA was not watching the patient’s respiration closely enough. The patient got a “total spinal.” Just as the other PA got back from lunch, the patient had a respiratory, then a cardiac arrest. He died.
There is also an undercurrent of doctor hatred in all these public fora discussing medical reform. First, far too many non-medical people think the AMA is all powerful.
shorter AMA = we are underpaid and hold no responsibility for skyrocketing medical costs.
and
It is not so difficult to imagine if 60 million seniors demand it. My guess is that if the political establishment decides to steamroll doctors, they will do so all the way.
The only way to make Doc Fix work is to open the floodgates for new doctors and medical practitioners to soak up the demand, which means forcing schools to expand capacity(or lose NIH and NSF funding) and to force providers to open residency slots that are shorter in duration.
It would take 10 years for the supply base to adjust completely, but it would close. Doctors will still be well paid, just not as well paid as they were.
The howling from doctors would be immense, but if there is no more debt to be issued, they will be howling to an empty room.
If I am an ailing senior I would rather see a rookie doctor than no doctor at all.
After all, studies show that more highly educated, experienced doctors are not necessarily better at satisfying patients than the alternative.
Always, the assumption is that doctors are “well paid” and can be crushed by public will with no harm to the profession, as a profession, or to the supply of students willing to incur $250,000 in loans to subject themselves to this.
And then there is the theory that “the Guild” is blocking reform.
There is always a consequence of choice. Pick the wrong health care provider and indeed it can be a bad thing. However there’s also a consequence to NOT going to a doctor because it’s too expensive, too far away, too much of a hassle to go to the city free clinic, or many other possible reasons people have for not going to the MD. A knowledgeable first tier of diagnosis and treatment that is cheap, relatively effective, and nearby would give better outcomes less expensively than the MD or nobody dichotomy.
But unfortunately that’s not allowed in most localities, thanks to the guild and their influence on policy.
The same “expert” on the AMA.
They don’t control the doctors, but they do lobby for exclusivity in laws at every state capital and in Washington DC. You missed the reason for the comparison to medieval guilds. The comparison has to do with limiting competition via lobbying the state to put an end to competition. The reason the guild system worked well was that products outside the guild system were outlawed, not matter if they were of greater value to the customer.
In fact, the AMA lost that battle against chiropractors many years ago. Now, many orthopedists in workers comp practice use chiropractors as PAs. It is still an unscientific cult but nobody pays any attention to that anymore.
Anyway, I wish that someone would spend some time discussing health care reform without showing such abysmal ignorance about the issues. I was threatened with banning by Megan:
Dude, your comments are valuable, but there’s a lot of personal insult in there that’s contra blog policy. Can you please tone it down? I’d hate to ban you.
Best,
M
Since it seemed that personal insult was going mostly the other way, I don’t care.
Oh, go ahead. I get so frustrated with people who haven’t any idea about how medical economic works that I should probably stay on medical blogs. At least we are talking in the same terms. One reason why medical savings accounts don’t work well is the inflated charges that Medicare demands. If I should lower my charges to the realistic level of what I am getting paid (I’m retired so this is rhetorical), Medicare will discount my profile to that amount THEN pay me 20% of that.
The orthopedic surgeons who have dropped out of Medicare and work for cash only achrage about $1750 for a total hip. People who don’t know any better think they get paid $5,000 by Medicare. \
I thought you would know better. I’m just worried, like one of your commenters that gets it, about my own care.
The answer, by another commenter who is very sure of himself:
You sound like someone who has a vested interest in the status quo. Maybe you should stay on a medical blog along with everyone else who has a vested interest in the status quo (and pretend that the status quo is sustainable).
As an economist of sorts, I can tell you there are clearly not enough medical practitioners in the market.
How do I know? PRICES ARE RISING–effective prices, net of discounts.
Supply, Demand, Simple…if you are an economist.
I actually do have some thoughts about reform, which are possibly even more informed than the “expert” economist of sorts. However, the public will not be educated.
So there you are. Reform will be a bastard approach because the people talking about it know nothing about the subject.
Tags: health care, medicine, politics
I think this is true about any subject really. Willful ignorance everywhere. And the ad hominem attack (to your background as an MD) is the standard rebuttal, its fallacy notwithstanding.