Questions about Doctors

Greg Mankiw posts data showing that doctors in the U.S. make much more than doctors elsewhere. From a 1999 paper by Uwe Reinhardt, among others:

As a dollar amount, U.S. per capita spending for physician services was the highest in the OECD in 1999: $988, compared with an OECD median of $342. . . .

In 1996, the most recent year for which data are available for multiple countries, the average U.S. physician income was $199,000. The comparable OECD median physician income was $70,324.* The ratio of the average income of U.S. physicians to average employee compensation for the United States as a whole was about 5.5. Germany’s was the next highest, at only 3.4; Canada, 3.2; Australia, 2.2; Switzerland, 2.1; France, 1.9; Sweden, 1.5; and the United Kingdom, 1.4.

Mankiw posts three discussion questions. I’m just going to take a stab at the second one:

On the issue of doctor training: Suppose that in country A physicians get free training through a taxpayer-financed educational system, while in country B physicians finance their own education and then, once trained, are paid higher fees. (a) If country A classifies these training expenses as education rather than healthcare spending, which country would report higher healthcare costs? (b) Is that difference in healthcare costs real or an artifact of labeling? (c) In which country would doctors, once trained, have more incentive to work long hours? (d) In which country would there be more doctors? (e) Which country’s system, in your judgment, is more efficient and equitable?

(a)-(b) I get Mankiw’s rhetorical point. And I guess it makes sense to count educational costs as part of the production costs of healthcare. But $199,000 – $70,000 = $119,000. (Updated – I made a subtraction mistake the first time.) So the higher med-school costs people pay in the U.S. get made up in two years out of a career of 30-40 years.

(c) The short answer is that physicians would have more incentive in country B (the U.S.), because the marginal return on labor is higher. But do we want doctors working longer hours? Medicine is not like, say, baking bread – the more hours you put in, the more good stuff you end up with. We are already the country with the highest hourly wages, and one of our major problems is not lack of doctoring capacity, at least not in aggregate; on the contrary, we have the problem of overutilization of many types of services (the expensive ones). Put another way, because we have higher wages for expensive procedures, we have doctors working longer hours doing those procedures by prescribing more of those procedures than are medically appropriate. Because we overcompensate for some services and undercompensate for others (relative to each other), we have too few of some kinds of doctors (family practice, for example) – but that is a product of the way we pay for healthcare, not the way we produce doctors.

(d) You should get more doctors in whichever country gives you the higher aggregate returns to being a doctor. Right now that’s the U.S. But the key point here is not the financing of medical school; it’s the constraint on the number of doctors enforced by the American Medical Association. That’s why, as Mankiw points out, we actually have fewer doctors per capita than the average OECD country.

(e) I’ll leave that as an exercise for you.

* Yes, it says “average” for the U.S. and “median” for the OECD. I can’t tell from the original paper if that is accurate or not. The rest of the paragraph says it is dealing with averages. In any case, I think it’s fair to assume that the median U.S. doctor made well over $70,324 in 1996.

83 responses to “Questions about Doctors

  1. Pingback: friendsofdave's status on Friday, 26-Jun-09 20:37:13 UTC - Identi.ca

  2. Blackeyebart

    The market model doesn’t work for medicine, because the patients decline to make decisons as a long term finanacial model cost benefit analysis would predict. They put too much empasis on the fact that they feel sick and might, just might, die.
    Perhaps one’s spouse could make those decisions. Then if the work required exceeded the likely benefit, they could decline and in effect, trade in the spouse on a new model.
    PS If you are an economist, this is a joke.

  3. It’s very critical to note that in the US, doctors often pay the full costs of their education. Elsewhere, this is not the case, which has drawn criticism in these other countries:

    http://www.independent.co.uk/news/education/higher/why-does-training-some-doctors-cost-three-times-as-much-as-others-513659.html

    If we cut doctor pay to UK levels without subsidizing undergraduate and med school educations, we will be impoverishing our doctors. Doctors also work more hours in the US (and in the UK, they are having challenges keeping doctor hours to the targets)

    http://news.bbc.co.uk/2/hi/health/7845282.stm

    MORE points:

    – You indicate that doctors can make up in 2 years the difference in medical school costs. This is entirely incorrect. It does not take into account residency (pays lousy, last a few more years, during which you are earning LESS and probably incurring debt).

    – It does not account for taxes (especially at the higher marginal rate)

    So let’s run the numbers again:

    199k – 70k = 119k. After taxes, that’s probably 70k. So the payoff time is nearly doubled (after accounting for interest).

    MOREOVER, let’s add the fact that for 6 years the physician is deferring compensation. That is, they are NOT earning the 70k a year (which is taxed at a lower rate, and facilitates earlier savings, earlier retirement, etc.).

    ALSO, you indicate doctors can make up more lost wages over the course of a 30-40 year career. Doctors often complete residency at 26 to 28 years of age. So if they retire at the same time as someone who starts working at 21 or 22 (with an undergrad degree), they will retire at 61 to 62, with only ~24 to 25 years of work (of which they spent 4+ years paying off debt, and recognizing that they started working without the 6 year head start of savings/housing payments that someone with an undergrad degree would have).

    FINALLY – and quite critically – the person earning 70k probably does not work the 80+ hours that a typical resident has to work to earn their wings in residency.

    http://en.wikipedia.org/wiki/Medical_resident_work_hours

    Working 82 hours a week (yes, that breaks down to 13 hours a day 7 days a week) would give that 70k earner a rather higher wage in most places.

    And post-finally, the wages described herein do not fully account for the differences between primary care and specialists.

    And post-post finally, doctors are presumably more talented than the average laborer… One might assume that if they were working elsewhere, they might be better paid than average.

    So, in terms of policy comments:

    1) The US would probably benefit by lowering wages AND covering the cost of education (thus giving physicians the option of taking lower paying jobs that have more social value rather than taking the highest paying job they can find to pay back loans), or by offering forgiveness of loans in exchange for public service.

    2) The US would benefit from more doctors, and fewer hours worked per doctor (which, incidentally, has been shown to reduce occurrences of medical error).

    3) The pay discrepancy between specialists and GPs, which is largely driven by the insurance and medicare compensation schemes (that richly reward expensive diagnostic procedures by squeeze standard office visits) is greatly responsible for this – the McAllen article helped elucidate that point

  4. How does the compensation for US lawyers compare to lawyers in the EU, Japan or the BRIC countries?

  5. Does nobody have more recent figures? Pay for UK doctors shot up in the early years of this century.

    StatsGuy, I agree broadly with your conclusions (reduce the incentive for doctors to go into best paid area, rather than more socially desirable ones) but not with your numbers. Your point about foregone earnings is important (as medical degrees last longer than most other degrees in most countries, the foregone earnings point is ALWAYS important in medicine).

  6. Do American Doctors also work longer hours?

  7. comet schmutz

    1) “Greg Mankiw posts data showing that doctors in the U.S. make much more than doctors elsewhere.”

    A large number of professionals in the US – other than M.D.’s – make much more than professionals elsewhere.

    And physicians in the U.S. treat an inordinately sicker population.

    I have a great deal of criticism of the medical profession, but as someone who worked for M.D.’s for several years, I do not think that the bulk of them are overpaid at 200K.

    It would be interesting to compare the relatively meager 200K a very hardworking M.D. makes (and these people are responsible for peoples’ lives) to the salaries made by less-trained people in banking and consulting.

    I am highly critical of the medical establishment, and believe it needs serious reform. But physicians’ 200K salaries are hardly the outstanding issue.

    The outstanding issue is the failure of a variety of industries in the US to coordinate on the issue of preventive care.

    It is consistently downplayed on this venue and others like it that we are paying an obscene amount of money for entirely preventable illness.

    In essence, we are paying for people to GET sick. Not to be well.

    That is the issue. Not MD salaries.

    2) As for a shortage of physicians – most health care providers understand that don’t need more physicians. You need more primary care givers and educators. These are:

    1) nurse practitioners/PA’s
    2) Phys Ed teachers
    3) Nutritionists

    and you need to overhaul the food industry. This is going to have to be a massive government program, but it’s the only one we can afford.

    The issue isn’t lots of distracting little economic tidbits such as salaries that aim to describe further how the system is already broken. We know the system is broken, and of all the waste – salaries are really the least of it.

    The issue is how do we create a new system that actually serves ‘health care’ moving it away from its current focus on inadequate procedures to fix people after they’ve broken down and toward prevention.

    I appreciate that there’s a wonky economic side to health care, but there’s also a stultifyingly obvious side to health care that gets very short shrift in all the current debates – and that’s prevention and education.

  8. Walt French

    If American doctors work longer hours, one would presume — all else equal — that other OECD nations need MORE doctors per population to provide a comparable level of service. It does NOT mean that Americans get more care.

    It also provides no information about age at retirement. It may well be that American doctors have a sense that they have salted away a sufficient nest egg to enjoy a comfortable retirement a dozen years ahead of their counterparts, so if they DO work longer hours, the ratio of training to services provided is still no higher.

    I’m not claiming positive facts, just that the arguments, which I take to approve of the incentives provided by 3X rates of compensation, don’t really address whether the same quantity of good care is delivered. In many markets (the fees etc hauled down by Financials is a fine example), the marginals end up distorting the overalls to the detriment of anybody NOT in the industry.

  9. “Questions about Doctors

    Greg Mankiw posts data showing that doctors in the U.S. make much more than doctors elsewhere. From a 1999 paper by Uwe Reinhardt, among others: ”

    If you really want something to chew on, determine how “Nurse Practioners”, would play a role.

    http://en.wikipedia.org/wiki/Nurse_practitioner

  10. The daily telegraph lists the average english GP salary as 110,000 pounds – obviously excange rates vary the $value here but it looks as if this is an entirely fraudulent calculation based on totally fictitious salaries. Csn we try again with some facts from planet earth?

  11. PS I guess that could mean average compensation in the UK is around $100,000. They are obviously seeing green shoots a lot sooner than we are.

  12. Tippy Golden

    Possible scenario? Some tough medicine?

    The American healthcare system is dysfunctional. The problem has been “spliced and diced” every possible way, several times over, for more than a decade (since the Hilary Clinton plan failed) and there is still no consensus.

    President Obama and the Democrats close ranks and create a commission of — independent — experts to come up with a healthcare reform plan. Uwe Reinhardt chairs the commission. They have one year max to draft the plan.

    The panel is independent. It is charged with doing what is right for the country. (Its mandate does not include protecting special interest groups.)

    Once the plan is complete it goes into the legislative process for vetting and debate. The Republicans attempt to shut down the Senate and Congress through every conceivable tactic. Lobbyist open their richest war chests to ultimately no avail.

    The proposed legislation is the “right plan”. It is a social contract on healthcare that will, literally, revive the Nation. Americans are no longer merely “consumers” of healthcare.

    President Obama and his “party whip” round up the votes (no earmarking allowed) to get this historic legislation passed.

    Next the logistical challenge of implementing healthcare reform. — It’s a cake walk, — compared to NASA and the American space program.

    Epilogue: By doing the “right thing” for the country (and not just the right thing to satisfy political donors) President Obama and the Democrats win the undying gratitude of most Americans for generations.

    The world breathes a sigh of relief. The Hyperpower is learning civilization.

  13. You make some excellent points. I would like to add a few more.

    1. Foreign doctors do not have the malpractice expenses of US doctors. In some cases, the expense can be over 80K PER YEAR!

    2. Most foreign doctors do not have to equip and staff private offices. The government does that for them.

    3. The pay discrepancy between specialists and primary care physicians (there are no more “GP’s”) is not universal after malpractice expenses are factored in. Furthermore, many of the PCP’s practice hospital-based medicine and have much lower overhead than specialists. Finally, some specialists are true outliers, and make well above (5X) what others in their specialty make, distorting greatly MEDIAN income figures.

    4. Medical schools used to get the best and the brightest applicants. When society decided it valued more the wonderful social contributions of financial engineers and began showering them with enormous riches, that changed. Is that a desirable outcome?

  14. You people are commenting without really reading. The numbers are from 1996, which are the most recent available. You’re probably quoting from more recent numbers, which are probably in the ball park, but not as accurate as 1996 numbers.

  15. Doctors are paid more in the U.S. because the supply is artificially limited. All other arguments pale in comparison. At the University of Michigan, pre-med students are required to take classes in Organic Chemistry and Calculus, and the T.A.s are required to flunk a certain percentage of them. Why does my doctor need to know calculus? To be able to integrate the volume of my bunion? No. To limit the supply of what would otherwise be a large number of perfectly qualified people from the market, people who would compete with each other and reduce wages. It is estimated that out of any 100 people who would make great doctors, 97 are excluded from the profession through artificial and irrelevant requirements. Doctors presently belong to the strongest union in the world.
    Most questions about getting affordable health care center on finding ways to pay for it. This misdirects people from the possibility of reducing medical costs through competition by allowing many more people, who are all perfectly well qualified in the areas appropriate to real doctoring, to become doctors.
    Advocates of the present system (doctors and the AMA) ask if you’d be willing to risk your life with a doctor who didn’t know calculus, but every day we risk our lives with products designed and built by people who don’t have PhD’s. Is it reasonable to buy a car (an item which kills many people every year) from a person who is not a professional engineer? I think it is reasonable to have health care providers whose training (and costs) are appropriate to the task. I think it is reasonable to graduate more doctors who don’t know calculus. I think it is reasonable to allow people who want to care for others to be able to do so, at whatever level they can.

  16. “Because we overcompensate for some services and undercompensate for others (relative to each other), we have too few of some kinds of doctors (family practice, for example) – but that is a product of the way we pay for healthcare, not the way we produce doctors.”
    There are lots of reasons people choose the field they choose. Money is probably one, but generally less important than many other things. High tech is glitzy and fun. It’s exciting and draws people because of its excitement. Many of us find watching a complete knee ligament reconstruction done arthroscopically much more interesting and exciting than listening to the ‘worried well’ and fiddling with their pill dosages. Sorry, but that’s just the way it is. I’d venture that many medical students think they’ll be family doctors or internists when they arrive at medical school. Once reality hits they frequently end up in something more exciting. Do not discount the “wow” factor.

  17. I will post more general comments later. Now I just want to answer James Kwak’s exercise (e)
    My answer to (e) It seems to me that Canada is doing the best job. I know 3 or 4 Canadians and they’ve always said positive words about Canada’s National Health Care system. I don’t remember EVER hearing a Canadian complain about health care. The main comment I’ve heard from Canadians about health care is basically the same: “Why don’t you Americans get it?” So it seems they’re getting positive results while paying less. It’s interesting to me that Canada is getting much more positive results than Britain on their Public healthcare system, so it would be a worthy effort to find the differences between the way those 2 Public health care systems are applied to see WHY Canada’s is better than Britain’s.

  18. Tippy Golden

    Edit required:

    Lobbyist open their richest war chests to ultimately no avail.

    Newt Gingrich has a heart attack and is buried, with his T-Rex skull, in a dinosaur park.

  19. I neglected to mention a fix for the present situation in my previous post. I said that competition among more doctors is the answer to rising health care costs, just as graduating as many engineers as are qualified (without requiring them to work 20 hours straight, six days a week as an intern) is the key to cheap airline tickets. How can this be accomplished?
    The U of M administered personality tests in the ’70’s, presumably to find radicals who would burn down the Economics building before accepting them as students. The test had the unintended effect of indicating that doctors have the same personality traits as farmers who have very, very large farms. Both groups work with others in their profession to exclude upstarts, both invest in expensive machinery, both are very good at running a business, and both are very good at getting the government to cover their costs and to ensure that they make a profit, where a free market might not, especially without price supports. In other words, they both have a very strong, politically connected union.
    Engineers don’t have this kind of personality. Engineers hate unions. As a consequence, their wages have steadily fallen over the past 100 years (relative to company presidents).
    The key to allowing more qualified people to become doctors is to remove the false requirements to becoming a doctor. The memorization of Organic Chemistry. The arcane skills of calculus. The high cost of education. The ridiculous internship.
    Will doctors, the AMA, and medical schools voluntarily do this? Will pigs fly? It is not in the nature of the present sort of doctors to do this.
    The government should remove the false requirements to becoming a doctor, should require that schools graduate twice the number of doctors they have been (as a start), and should withdraw government support and especially grants to schools which don’t meet these requirements in three years.
    If the government did this, the cost of health care would drop like the wages of the guy who cuts my lawn (and who does a great job).

  20. I am an evil subspecialist. I attended medical school for four years, was paid subsistence wages to work 80 hours a week for four years of residency, then the same for four more years of “fellowship.” Comparing compensation without also considering differences in lengths and costs of training is simplistic and not up to the standards of this usually fantastic blog.

    I work happily for a salary (no incentive to over-utilize) with a team of dedicated nurse practitioners for an organization with sensible use of expensive procedures and excellent outcomes.

  21. The issue of the costs of doctor training is one of the main topics of Mr. Mankiw’s post and James Kwak’s comments above. In fact, ONE OF THE MAIN QUESTIONS of Kwak’s blog post above is who is paying for doctor training and how does that relate to overall healthcare costs. I thought reading/seeing that, wasn’t too difficult.

  22. socialize_medicine

    “I work happily for a salary (no incentive to over-utilize) with a team of dedicated nurse practitioners for an organization with sensible use of expensive procedures and excellent outcomes.”

    Translation: I am part of the rent-seeking elite.

  23. it is not just the educational costs of MEDICAL SCHOOL that mr kwak should consider in his analysis, but also the opportunity cost of the the additional training that can last up to a decade. but if that training were to be streamlined as in other countries, then hospitals would be stuck paying (appropriate) wages to other workers to replace the cheap labor.

  24. personal_responsibility

    Pink elephant standing in room:
    We live in the fattest country in the world. Why does a 400 lb diabetic who smokes 2 packs of cigarettes per day and eats at McDonald’s 3 meals a day deserve insurance or to have “free” health care? 10% of the Medicare population consumes 67% of the total Medicare resources. Normally I love this blog, but to expect the medical profession, hospitals, insurance companies, and pharmaceutical industry to “suck it up” while expecting nothing of our obese population is disheartening and unfair to those of us working in healthcare.

    Given the lack of insight in this post and discussion, I’m not sure I’ll even read this blog again. Does the ignorance extend to the financial discussion as well?

  25. Carson Gross

    Oh, for Christ’s sake. How many lives did *you* save today?

    Doctors in the U.S. work harder, go to school longer and forego pay longer than any other profession out there. At the end of the whole thing, and only if they are a sub-specialist, they make what a partner in a law firm makes. And then only if they sign up for a private practice grind-it-out existence.

    Lawyers? Pfffft. C’mon. Bankers? A two year MBA? Hell, I did two years hard labor in CS grad school. My wife is a doc. I can tell you: she worked harder in a month of residency than I did my entire grad school program. And her internship year was even more intense.

    This whole conversation is absurd.

    Cheers,
    Carson

  26. This cruel comment is revealing about the author.

  27. This cruel comment is most revealing about the author.

  28. The reality is that we can’t make healthcare in the US as “cheap” as other industrialized countries without limiting some care to some people. Right now it appears to be the cost of care and the insurance industry. Who will make these decisions?

    For those that think the system is completely broken: Cancer death rates have fallen 20% in the US in the last 15 years. Way more of a decrease than any other country in the world. Be careful what you ask for, you might get it.

  29. It’s interesting your wife is a doctor and you think this WHOLE conversation is “absurd”. I think people taking counsel with each other and getting many different opinions is useful.

    It’s a fact that American doctors’ salaries are (approximately) TWICE as high as ANY other country on the OECD list? Do you think the service and care we get is twice as good as say Germany? or say Canada? Would you have us just consult the AMA and see what they think? I guess you and your wife would be happy if we just let the AMA decide.

    I’m sure your wife works very hard. I’m sure she had many difficulties on her journey and is highly skilled and 99% of her patients like her. But the question is, is it proper that she makes TWICE as much as doctors do on the OECD list (which we might as well just say is ALL the developed countries)? You think they grab German doctors off the streets and hand them a scalpel?? Or maybe you think in Japan they just fly through Medical School in a month?? YOU may think the conversation is “absurd”. Many of us think differently.

  30. That should be a period, not a question mark, after the first sentence in my second paragraph above.

  31. just to be frank, going to the hospital is already like going to the government for help… will understand it, will probably help, have no idea how the price structure works ive seen multiple bills-copays-LanI-insurance… and based on who pays, the price can vary 100%, people dont know when i have to copay -> ‘surgical doctor visits, do i give this to you, uh sure’ and the recovery room can be empty and cost $1400hr with no machines just toast with margarine ‘coverd at 90%’ if you forget to pay your bill in 90 days and they cant get ahold of you they will ruin your credit, you have to wait for a year to see a doctor and get a surgery ‘gosh its nice to have insurance’, if its LanI people are like you suuuure its not something you just brought in with you could pay for this ‘no i dont just explode’, and most visits seem to be ’emergencys’ costing 400->$1k a pop ‘im not that stupid’… and then theres having to go see the doctor
    .
    the doctors are great tho seriously, kind people

  32. Your doctor needs to know basic calculus to understand the rate of drug filtration by body organs, to allow them the basic intellectual faculties to make informed decisions that deviate from official “recommended dosages” or practices, and to understand basic epidemiological data so they can make their own decisions about the validity of the studies that my profession continually puts out.

    Advanced calculus is, admittedly, something they never use. Many people think it’s simply used as a quality/intelligence filter.

  33. post partizan depression

    I shall point out that your subsistence wages are at least $50-70K and that $50k is the median income in the US. So I guess it is in the eye of the beholder what a subsistence wage is- for you subsistence, for an auto worker according to congress a princely wage.

  34. post partizan depression

    The american healthcare system is broken

    1) America has a sick care system not a healthcare system- doctors need to be compensated to keep you healthy.

    2) The nonsense about letting individuals shop for the best prices is silly on its face. Does no one read the bills they get? there is one price if your doctor isn’t “on the plan” and another after they “accept” the negotiated down grade. It is supposed to make you think you are getting a bargain. The bigger the pool you bring to the table the better the price you get.

    3) You are not going to shop around when you or your child or spouse are really sick. And you have no real basis/data to do that even if you were so inclined.

    4) The AMA limits the supply of doctors to keep wages high and tries to make you think it supplies you with smarter, better doctors that way. Then they allow the import of “cheap” doctors from places like India and China to fill the low paying specialties like family practice and clinical pathology. None of you obviously live in rural areas where one is hard pressed to find a native english speaking doctor.

    5) Please lets put to rest the malpractice insurance ploy. McAllen, TX has the highest prices and medical malpractice awards were limited to practically nothing several years ago.

    And nothing that Obama and the Congress are considering will fix any of this. The only thing that will fundamentally change the system is to have a strong public option to compete ( and hopefully put out of business) the private insurers. If that doesn’t occur we are simply moving the deck chairs around on the Titanic and I only see Obama doing what he always does, compromising with people before he has to and giving away the game before we even start to play.

    PS – if UK wages for doctors have increased dramatically it is because of the Maggie Thatcher effect. They deregulated the doctors whose education was paid for by the state and allowed them to do “private practice ” on the side. Unfortunately these guys short changed their NHS patients and put much more “time ” into their private patients – and that has been part of the down fall of the National health system there. Health care is not a business and when you treat it as such it will be outsourced to the lowest paying countries as well.

  35. Do you want to compare everyone who went to law school in each country, or everyone who is a member of the bar, or everyone who actually practices law in some capacity; and whatever your choice, if you raise this question here shouldn’t you look at comparable data for law and medicine, and how would you deal with discrepancies in the percentage of graduates practicing in each field; and wouldn’t it be a nice idea to examine the actual distribution of compensation and not just ranges or maximums?

    And you know this list of quibbles could go on. But really, what is the point of numbers without context?

  36. 1) The U.S. health care system is not a free market because it does not operate under free market principles. You know how much it cost to fix your roof and repair your car and therefore use cost benefit rational in determining what repairs to make. These are free markets. How often do people made a similar consideration when making heath care decisions? In addition, emergency rooms are required by law to treat anyone who is within 200 feet of their doorways regardless of ability to pay. In my experience, they always do and don’t consider cost in an emergency. Can someone state similar situation in what is considered a free market economy? There are many more examples. I just needed to get that off my chest since people often want to use free market principles to fix health care. While a free market system is clearly possible U.S. health care, it would require many more changes than those that include a single payer or even a government option that is currently under debate. The proponents of using real free market systems to fix health care costs rarely explain how such a system would work since it would almost certainly (and rightly) terrify the public.

    2) I agree with much of Atul Gawande’s article in the New Yorker. I am a physician (but in a specialty without many clinical tests). I have not personally observed colleagues ordering tests just to make money. However, I think that if you stand to make a lot of money by doing a specific procedure, your threshold to perform that goes down in an insidious. It should not be that difficult to fix this situation. If think that too many tests of a certain type (knee MRIs as an example) are being ordered, Medicare can reduce the reimbursement rates for this test. Most insurance companies base their payments in a similar way to Medicare (Medicare plus 15%, for instance). If you think there are not enough general internists, pay them more. This does not happen because people scream when you reduce payments in any way because people do not like to make less money.

    3) Insurance companies’ administrative costs and profits cost the health care system more than all physician salaries put together (The Physicians’ Working Group for Single-Payer National Health Insurance. Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance. JAMA 2003;290:798–805.) How is this expense contributing patients’ health compared to physician salaries? Again, the fix to this is fairly clear. But again, with all of the money involved, people are going to scream if you reduce their profits.

    4) In the end, if you are going to fix the system there will be some losers financially. If you don’t fix the system, we will all lose eventually.

  37. c) I don’t think that doctors working longer hours is good for patients, or for doctors. But I disagree that there is necessarily more incentive for US doctors to work longer hours than elsewhere where pay is lower. Based on my experience knowing doctors in the US and in Australia the US doctors often work less hours because they don’t have to work full time to maintain their lifestyle while the Australian doctors I know tend to work at least a 40 hour week. Personally I don’t think I’d be inclined to work full time if the full time salary was $200k and I could choose how many hours I worked.

    e) Efficiency and equitability should be fairly straight-forward to calculate. The most straight-forward measure of health outcomes is life expectancy. The US has a life expectancy of 77.8, the OECD average is 79. So if the US spends almost three times as much money for lower return then the US system is clearly significantly less efficient than the OECD average. I made a stupid spreadsheet comparing life expectancy to health care costs as a percentage of GDP: http://spreadsheets.google.com/pub?key=rcxBXdZTHi45F_NmVwaXbgg&output=html The US is clearly the least efficient OECD country for health returns (if we just use life expectancy). As for equitability, we could look at the standard deviation for life expectancy…

  38. 62-28 = 34 not 24!

  39. Ian McKellar: “The most straight-forward measure of health outcomes is life expectancy.”

    Life expectancy is heavily skewed by infant and child mortality. In the U. S. the big difference between life expectancy in the 20th century and life expectancy in the 18th century was the survival of children. Improved public health also played a role. If you made it to 21 in Benjamin Franklin’s day, your life expectancy was comparable to the life expectancy of a 21 year old in the U. S. 200 years later.

    IIUC, there are two major factors in the relatively low life expectancy in the U. S. First, there is poor neonatal care for lower class mothers, and poor medical care for their infants. Second, U. S. statistics include the deaths of babies who die in their first day of life. In other countries, newborns with very little chance of surviving their first day are often not treated, and are treated as stillborns in the mortality statistics. In the U. S. they often receive heroic treatment, and, as patients, affect the statistics. The great majority of them die, and, of those that survive, many of them die in their first year, also adding to the infant mortality rate.

    If we want to compare adult health care, life expectancy at 20 would be a good statistic. Life expectancy at 50 would be affected by adult lifestyle choices. And life expectancy at 80 would say something about end of life issues.

  40. I said poor neonatal care for lower class mothers. I left out poor prenatal care.

  41. inside view

    I am a physician who has practiced in the UK, Australia, canada and now the US.

    The article about US pay being higher than elsewhere ignores the cost of education and the length and poor pay of US residency. The details are better argued by many above.

    As for the arguments about MDs not requiring Organic Chemistry or high intellectual standards is silly. I have witnessed healthcare in many places. The lowest standard of healthcare occurs where most of the care is delegated to non-Doctors who do not use judgement and do not have the overview of medical science to make the right decisions. Reducing medicine to a mechanical activity is dangerous. “Artifically keeping doctor numbers low” is crazy: the US is overserviced partly because it does not restrict doctor numbers. Many of the complications that occur here occur because doctors in certain specialties do not have enough of certain procedures to do and hence get “rusty”.

    The US healthcare system encourages the delegation of care to PAs and Nurse Practitioners. Many of the tests you see overordered are done so by:
    1) Nurses and PAs acting without physician oversight because they do not know how to take a proper history or examination.
    2) Physicians who own the facility they are sending lab and imaging tests ie conflict of interest.

    If you really want to keep the system running whilst retaining:
    1) the incentive to work hard (lacking in the UK), ie fee for service.
    2) Higher quality of care
    3) Lower cost without cutting insurance or medicare rebates.

    Then you have to take the following steps which have been taken around the world, and reduce costs, increase quality and will buy time to deal with the insurance companies which have to be changed to “not for profit”.

    1) All Radiology, Pathology (lab), and Radiation Oncology (Radiotherapy) facilities must be independently owned by physicians who cannot refer to them and must finance them themselves ie no co-ownership deals. Currently there is a loophole in the anti-self referral legislation called the Stark II laws which allows a physician to place imaging or lab facilities on their premises and refer and bill. A clear cut conflict of interest which has blown out imaging costs since 1998.

    2) In order to access a specialist of any type, an individual must see a family practitioner first. The FP should be of their choosing. 90% of health care can be handled at the level of the FP. No substituting with Nurse Practitioners or PAs. The lack of training that these groups suffer from makes them more investigation dependent.

    3) Restrict what a physician can bill for to their specialty. ie only Radiologists can bill for Radiology, Cardiologists can only bill for Coronary artery stents (currently they bill for stents placed anywhere in the body), no non-physicians should do operations, etc.

    4) Change the way billing is run. Currently, if 100 dollars is billed for a service, 95 is what is called a “technical fee” ie goes to the facility that has the equipment/facilities, and only 5 goes to the physician ie the “professional fee”. Silly. The intellectual content of medicine is what counts not the pocket of the businessman owning the hospital.

    Don’t listen to the people above who say that doctor’s don’t need detailed theoretical knowledge. This intellectual rigor is required to sort problems out. It also opens the field to those who want to pursue research as a career. As a doctor, I would never see a PA or Nurse Practitioner for a consult.

    The failure in the above discussions is to understand the nature of over-servicing and the specific, perverse financial incentives that exist. Cut the ownership rights and cut the number of people billing for certain procedures and you will kill the ability to overservice. Deal with the conflicts of interest in self referral of lab and imaging and radiation therapy. Then watch the cost curves flatten. Deal with the insurance companies whilst they are doing so.

  42. I’m a primary care internist (i.e., I specialize in internal medicine) in practice for many years. I expect I’ll need to keep working full time for at least another decade (well past the usual retirement age) before I can afford to retire. Two other part-time jobs supplement the income from my medical practice.

    I am a refugee from the managed care system: I got really tired of rushing through patient visits, spending half my time apologizing for the restrictions we faced. Now I see only patients willing to pay the extra cost for “out of network” care. I have no managed care contracts, which allows me to spend the time I believe my patients need for proper care. As a result, my income is less, but I sleep well at night and deliver the best care I know how.

    Most of the commentators above and elsewhere commit multiple conceptual errors about the practice of medicine:

    1. Medicine is intellectually extremely challenging and difficult to do well. It’s easy to slide through a patient visit and treat only what’s obvious, but this yields incorrect diagnoses and treatments a substantial minority of the time. Most MBA and economist types view physicians as commodities — replaceable parts. If you obtain your personal care in this manner, you deserve the poor outcomes you will receive. (Similarly, if you blindly pick your attorney out of the phone book, you will lose your case.)

    2. Occasionally patients are harmed or killed by perfunctory care, but more often the result is spinning one’s wheels. Many doctors compensate for inadequate assessments by ordering a bazillion tests; then they treat the test results. But unthoughtful tests are notoriously unreliable and lead to wild goose chases, wasted time, and poor outcomes.

    3. I’ve worked in several systems with nurse practitioners and greatly value their contribution. Nurse practitioners and physicians assistants are valuable adjuncts in providing treatment, but they rarely save money. The NPs I’ve worked with take twice as long as a skilled physician to treat a patient and are paid half as much. They work best treating simpler cases or, in a large system like Kaiser, specializing in one problem, e.g., treating low back pain or providing birth control. Bluntly stated, few NPs have the training, experience, or intellectual resources of a competent physician and are out of their league in complex cases. (Would you want to be represented in court by a paralegal?)

    4. Quality care and good outcomes require spending enough time with the patient to perform a thorough history and physical examination. By then the problem is usually obvious. Mostly one does tests as a form of due diligence: to confirm the diagnosis and to rule out unlikely alternatives that must be considered, like anemia, thyroid disease, cancer, etc.

    5. Specialists and physicians specializing in performing procedures form the backbone of treating certain conditions in the same way that the car repair business requires shops that specialize in overhauling engines or transmissions. But only an idiot would take their car to a transmission shop for a vague engine problem. Patients like the glitz of high technology, rarely realizing that it’s a tool that’s only as valuable as the thought going into its use. One great example: total-body CT scans to screen for illness turn up dozens of red herrings (subtle abnormalities that almost always mean nothing but require follow-up) at the cost of a massive radiation dose.

    6. By now it should be obvious why the scientific data clearly show that in areas like Miami where most care is provided by specialists and proceduralists, the cost of care is 30% higher, and outcomes are demonstrably poorer. In contrast, in Minnesota and other parts of the country where primary physicians dominate, the cost is substantially lower and quality much higher, however one wishes to measure quality.

    7. But the unique propensity of the American system to pay for doing things TO patients — rather than properly thinking through the diagnosis and treatment — means that to practice primary care is to constantly wrestle with insolvency. Thus only a tiny minority of medical students are entering primary care specialties, and the whole healthcare system is at risk. (See “The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care,” http://www.txpeds.org/u/documents/statehc06_1.pdf, from the American College of Physicians.)

    8. Finally, I’m with Paul Krugman. I and most of my colleagues regard medical insurance companies as having the same ethical rectitude as tobacco companies in their heyday. Their ONE expertise is sucking the resources out of the healthcare system to pay their executives and shareholders.

  43. Carson Gross

    Ted,

    Fair cop. I had had a bit to drink, and I get pissed when, after seeing my wife work way harder than any other person I’ve seen work, people get on docs for having high salaries.

    It just seems crazy to me that we’ve got bankers running around ruining the economy making far more, lawyers running class action scams making far more, politicians running around making far more when you account for perks and “favors” and state workers retiring at 80% highest salary, and people get on doctors.

    I think there is also a time-lag problem here. A lot of the docs pulling huge salaries are the old guard private practice types. My wife works at a university hospital in the bay area, and I’ve got inside information on how much she works and gets paid. I can tell you that her work/pay ratio is *way* higher than mine. (OTOH, maybe I’m just overpaid. James, don’t tell anyone.)

    In any event, discussing healthcare costs is of course a reasonable thing. Me mal.

    Cheers,
    Carson

  44. Possibly, although I seriously doubt UK salaries have really risen that fast in the last 13 years. If your paoint is valid as it relates to the discussion then there shouls have been some really dramatic behavioural changes sparked by this remarkable reversal of status.

  45. Also, there is a huge problem with information assymetry, which prevents people from making the kind of informed decisions that a market-based health care system needs.

    This doesn’t mean that there is no use for market systems in health care. It might be useful for surgeons to compete for price on procedures. But determining if those procedures are needed might not be something that should be left to the market.

    Incidentally, it’s funny how people are so scared that universal health care will take away their choices, when they often don’t have the information they need to make the choice in the first place.

    Given that, I’d rather have a government doctor help me with those choices, than a doctor who gets paid extra for cutting me open, or prescribing me drugs.

  46. It actually works OK. You may have heard that several famous people with chronic, progressive, terminal diseases died this week in hospital beds with a current capital cost of $2-3,000,000 each (thanks to the Northridge earthquake and the stupidity of the CA legislature). They could have died comfortably at home with hospice, but the hospital is “free.” Isn’t that the “law of the commons”?

  47. Unfortunately, it is 5:05pm and your government doctor is gone for some long weekend!

  48. The number of physicians in the US is limited, but not by flunking pre-med students. The number of US medical schools is small (130 MD and 28 DO granting schools) each having strictly limited enrollments. The University of Michigan enrolls 170 new medical students each year.

  49. What planet would this occur on? The Democrats have larded up all their legislation so far with special treats for special interests. How much and how many did they have to bribe to get the 1200 page cap-and-trade nonsense through the US House?

    No earmarks? That’s not a credible scenario.

  50. Ummm, not cruel. He’s a realist. Plus, it is immoral to abuse your own body and claim a “right” to reach into someone else’s pocket to pay to mitigate your own self-abuse. I call that theft.

  51. I believe the McAllen Texas article in The New Yorker when they say that the most expensive care is not the best care. It’s just more expensive, because there are many unnecessary and excessive operations, tests, procedures, and prescriptions.

    There is statistical proof that some communities have very high standards of care, good outcomes, and half the cost of other communities.

    The question is how to turn the expensive areas into efficient areas.

  52. There is a point here. In 1962 13% of Americans were obese. Now we’re over 31%. I’ll leave it to the reader to graph per capita cost of medical care over time with obesity rate per capita over time. Anyone care to guess the R-value?

  53. See comment above. Could it be that those communities have healthier populations? It’s hard to be efficient when 1/3 of the population is obese.

  54. I have never seen the kind of data you are stating. Please give a reference. Thanks.

  55. In 1996, US doctors were making 200,000 a year. I graduated from college with an engineering degree in 1998, so that is when I joined the workforce. Every year, absolutely every year without exception, the human resource department has had a meeting to say that we are having to change health care plans because the cost has gone up so we are lowering coverage for a lower cost increase. Basically, health care costs have been increasing much higher than inflation for the last 13 years, so I would expect that Doctors on average make significantly more than $200K right now. And that is the problem. they make too much, especially considering the country looks to go broke if these cost increases continue. And don’t give me the ‘high cost of medical school, long hours and low pay in residency’ as reasons for needing to pay older doctors more money. What is this, some sort of college fraternity with hazing rituals that can’t be broken. What is the purpose for working somebody 80 hours a week? What is the purpose for paying them much less than the fully licensed rate after loading them up with debt? What is the purpose of requiring doctors to go so far into debt with medical school training (I mean, if my argument is that doctors are overpaid, wouldn’t the doctors at the medical schools be overpaid by default as well)? Its the system that the medical profession itself has created, and the medical profession can change it if they wanted to . . . don’t complain about your own system and use it as justification for why you make so much.

  56. This whole discussion is woefully in need of some perspective. Physicians get about 20 cents of every healthcare dollar (CBO, 2008 Medicare data). Their reimbursement has been flat for the past 10 years. We are all patients here. Do you really want to point the finger at the people that are actually doing something directly to help you? Not me. I vote for hacking at the insurance companies first, then the trial lawyers, then the pharmaceuticals, THEN the physicians. I’m not denying that the physicians reimbursement system needs to be changed – I’m just saying that in a society where CEOs make 10s or 100s of millions of dollars we don’t need to be pointing the finger at physicians FIRST. Some of the comments here make me wonder how much physician envy there is. How many of you have actually gone to the 24th grade? That’s a long time before you actually get a job. I’m not saying the salaries aren’t too high, I’m just saying that the MBA that makes 10x (or JD that makes 5X) needs to be addressed before the poor schmucks that go to school forever to learn a trade.

  57. Don’t worry eric. The twice divorced, 3 times married, recently converted to Catholicism, hero Newt Gingrich will save the day. Never fear. Maybe you can share Holy Communion with him if he’s elected President.

  58. I am one one of those evil subspecialists. Let me make a few points.

    1) Shouldn’t we be looking at pay per volume of work or pay per hour? If U.S. docs are working twice as long, then their hourly pay is not that much out of line. If you cut our hours you will need more docs and the cost to the system will not change.

    2) Just to emphasize what was written above, you do not make up the difference in education costs in two years. Shouldn’t an economist understand taxes and basic living costs?

    3) I hope no one takes seriously the idea that we do not need to study science and math as an undergrad. You need the intellectual rigor derived from those courses. You also need to determine who has the smarts and ability to work hard enough to pass those challenging courses.

    4) We have lots of Foreign Medical Graduates practicing in the U.S. I am not sure who determines the number of US medical graduates, I am pretty sure it is not the AMA, but there is no lack of foreign physicians to take up the slack.

    5) As stated above many times, much of the problem is improper utilization. Incentives favor docs doing procedures that will make them money. We need to realign incentives.

    6) My concern, especially with posts talking about salaries, is that we will see across the board cuts. I see a lot of the poor, often unethical IMO, utilization Gawande described. We need to target the over utilizers, not make cuts that will affect everyone.

    Steve

  59. Interesting post, I think you are on to something with the rent-seeking capabilities of people who enter different professions. I would appreciate it if you could point me towards academic papers or articles (anything really) on this topic.

  60. To the physician who wrote this: Artifically (sic)keeping doctor numbers low” is crazy: the US is overserviced partly because it does not restrict doctor numbers”, how do you explain this description in USA Today?


    The marketplace doesn’t determine how many doctors the nation has, as it does for engineers, pilots and other professions. The number of doctors is a political decision, heavily influenced by doctors themselves.
    Congress controls the supply of physicians by how much federal funding it provides for medical residencies — the graduate training required of all doctors…(Even)
    doctors trained in other countries must serve medical residencies in the USA to practice here.

  61. I posted the comment above from USA Today. He is the link:

    http://www.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm

  62. Thank you, ‘inside view’. Your cross-cultural perspective has helped inform this discussion. You also point out something that, for some reason, I know about but didn’t factor into my analysis, which is self-referral. Clearly a large part of the McAllen problem is self-referral, or referral to a facility you own. I would, however, suggest that you amend your recommendation to allow physicians to own laboratories and other facilities like outpatient surgery if they are their own insurance company.
    Since they get the money directly, rather than from the insurance company, they can make the ‘make or buy’ decision based on the market economics rather than their projected return on investment. A group obviously can’t overcharge themselves. Two examples of this are Geisinger Clinic, which has their own health plan, and Group Health Puget Sound, which also does. Mayo does not have their own health plan, but they have such cachet that they probably don’t need one. And they may receive per-patient, rather than per-procedure, dollars so their economic analysis would be similar. Don’t know how their arrangements work. Even with Kent Conrad’s health care cooperatives idea, without physician management of the plan dollar I don’t see it saving much money.
    As a retired surgeon, I would second your concern about inadequate volume in some procedures leading to rustiness. I have wondered about this for a long time. The literature, however, by-and-large doesn’t support the contention. Specialization does matter; specialist volume doesn’t seem to, which surprises me.
    Thanks again for the analysis. Are you willing to amend your recommendation on physician ownership?

  63. Maybe that’s why Arnold Relman in his must-read book “A Second Opinion” calls them ‘parasites’!
    As a retired surgeon, I found many primary care doctors waiting way too long to refer obvious surgical problems, hoping against hope that the particular problem would go away, or that they could cure it with some kind of non-surgical treatment. Which then results in too much being spent. For example, I could completely relieve carpal tunnel symptoms with an injection, but often the patient was referred to 6 weeks of hand therapy first. Shot cost–maybe $100. Therapy cost? Ouch.
    Any comments about medical groups managing the health care dollar, like Geisinger and Group Health?
    Thanks again for educating the commenters.

  64. Do you know if the CBO numbers include laboratory, outpatient surgery, radiology and therapy charges in that 20%. If not, I suspect physicians get quite a bit more of the dollar than 20%.

  65. It’s great to hear the comments from the specialists; mostly I agree with what they say. My objection to specialist-first care is the science shows it increases costs and lowers the quality. This point is best demonstrated by the recently posted story (I believe on the NY Times website, but I can’t find the link) of an IBM executive, who saw a cardiologist for chest pain. Several serious complications and $200,000 later, the cardiologist cleared the man of any heart problem. The patient then saw a gastroenterologist, who performed yet another big workup without finding the source of the pain. Finally he saw a primary physician, who discovered the problem was muscle spasm.

    To me this story speaks of the tunnel vision and procedure proclivity of some specialists. For example, a large minority of gastroenterologists in our area have reputations as “scope jockeys”: whatever the symptoms, the patient needs endoscopy.

    One of the more unpleasant aspects of practicing primary care in a managed care system is being a “gatekeeper.” This means patients can’t have the procedures or referrals they request without a primary MD’s written authorization. The request then has to go through “Utilization Review,” whose motto too often is “deny, defer, delay.” The hassle factor is terrific. Moreover, many managed care systems lower primary physicians’ reimbursement if they order too many procedures or referrals. This creates a horrible dynamic: patients hate it, and the incentives for the primary care physician are skewed. In the 1990s, during the heyday of the HMOs in our area, a number of GPs were notorious for never referring out a patient for ANYTHING until they wound up in the hospital. The HMOs loved it and paid these guys big bonuses.

  66. http://www.kff.org/medicare/upload/7305-04-2.pdf

    I was wrong – it’s 19% (May 2009). If you include private insurance’s 30% overhead (versus 3% for Medicare), physicians are getting an even smaller chunk of the total. Yes, so let’s really go after the providers who are responsible for 20%. Fine, throw in some of those other charges (which are not significant, by the way. I’m a specialist and get NOTHING from those other charges.) If you halve their income, then you’ve decreased the total cost of care by 10%! Problem solved.
    /s

  67. So we think health care in the US would be better if docs made $70K a year?

    Somehow, I doubt it.

    I love love love the impulse to force everyone except the executive elite to accept lower salaries. We see it in virtually every industry around.

    What I really want to know? I want to know why the CEO of UnitedHealth Care made $124 million in 2005. That’s a grotesque amount of money paid to a man who leads the charge at limiting payouts to pay for healthcare.

    Here’s my source for that: http://healthcare-economist.com/2006/02/14/united-health-ceo-earned-1248-million-in-2005/

    (Full disclosure – I was a very very unhappy UHC customer for a few years. The worst health insurance company I’ve ever dealt with in my life.)

    What we really need more than anything is an analysis of the cost of health care in the private sector. If the private sector is too fragmented to understand practice habits and pricing, our efforts to reform the system will be for naught.

  68. Physicians, attorneys, professors, graduate engineers, and accountants are generally drawn from the top decile (by IQ)of Americans of their age cohort. Reducing the attractiveness of an American medical career relative to alternative careers may result in a greater fraction of physcians in the future coming from less able groups. It is unreasonable and unscientific to compare American doctors’ incomes with those in other countries without making similar comparisons among the alternative professions.

  69. Tippy Golden

    Anne,I checked out the link Ted gave you to Uwe Reinhardt’s Economix block. Uwe rocks!

    Check out this lecture if found.

  70. Tippy Golden

    Here’s the link.

  71. I hope you don’t think I advocated ‘specialist first’ care. I did not. What I tried to say is that sometimes the primary care doctor could make better use of the phone or e-mail rather than waste time with marginally helpful treatments. I was available by phone all the time, and one group used that to their advantage. The rest did not, and didn’t even change their practices when I outlined for them by e-mail a better way to handle those patients. I expect part of the resistance is their fear of being seen as ‘promoting surgery’. But the patient suffers as a result.
    The story you relate sounds like one I heard Dr. Michael Pramenko tell on Science Friday.
    On managed care, how about if your group collected the premium and did all the analysis and UR locally? It’s a much different scenario and can lead to very efficient care, like Geisinger and Group Health. If your group is on the hook for the hospital stay, I suspect the referrals would become much more appropriate. How can a primary care doctor want to both be in charge of referring his patients appropriately and also not want to be a gatekeeper. What’s the difference?
    What kind of system did you work in before? I was in solo private practice and running an office took too much away from providing care.

  72. Pingback: Debating the Public Plan « The Baseline Scenario

  73. Indeed Robert, your analysis found the gap that I did not address. Only a physician who has worked in the system could come up with a comment such as yours, thank you for doing so.

    Yes, I agree with you, if you are paying, you will not pay to overutilize! Self referral is a conflict of interest problem and can be quite easily changed by amending Stark II provisions in Imaging. Lab tests must have a similar amendment that can be put through. Many physicians will howl in protest but curbing self referral is the lowest hanging fruit I can think of in curbing overutilization.

    Many of the physician commentators above and below, including Jim Gagne below make the same observation I have made about NPs and PAs. The lack of background intellectual training, maligned by more number oriented folk above, makes them “concrete thinkers” best suited to doing one particular task eg lactation training, maternal and child welfare, diabetes education etc. Often they do this better than the physician who takes a broader overview.

    Your comment about “rustiness” or the lack of it intrigues me. I made the comment more by anecdote than analysis so I am interested in your source, so I can be more informed. I am hoping to contribute to this debate on a more formal level.

    However, practicing outside one’s area of expertise is at a level I have not experienced before in the US. eg Psychiatrists owning cosmetic surgery centers staffed by PAs. Orthopedic surgeons owning MRIs and reading the images themselves to claim the fees and self diagnosing conditions that require surgery (very expensive surgery). Podiatrists performing tendon surgery instead of orthopedic surgeons.

    Its scary. The public has no protection. Even the title “Doctor” does not mean MD, making it hard for the lay public to know whom they are seeing.

    Also, the problem of “for profit” insurance companies, their expensive administrations and convoluted claiming processes must be addressed. Frankly they don’t contribute anything to healthcare and should be gradually, firmly and completely removed, replaced by not-for-profit companies.

  74. Here’s the reference for the procedure/specialization article:

    http://www.medscape.com/viewarticle/703324?src=mp&spon=14&uac=112796CY

    Enjoy. Thanks for participating.
    RDL

  75. Pingback: Debating the Public Plan

  76. Coming from outside into US, I find doctors as another businessmen. It was a shocking realization. I saw word ‘discount'(on insurance report) and till then I was under the impression word ‘discount’ applied to other businesses. I visit ophthalmologist, the main doctor answers to my questions like an attorney, as if I am going sue if he wavers. Doctors work like clock, their behavior makes very clear(to patient) that they are spending time!!!.

    I think others also share responsibility for this state. How can doctors be immune when the society’s pulses are ‘profit’ & ‘earnings’?
    People file frivolous law cases. Everyone makes mistake, penalty should be to punish without destroying and also should not be for profiting.

  77. I am a doctor. It was 80 hrs / week for me every week. Week, after week after week after week… Never made more than $45,000 a year. less than minimum wadge…

    yes, we do work longer and harder.

  78. Tippy Golden

    Uwe rocks!

  79. IIRC Canada’s system is much more expensive than Britain’s, in terms of health care expenditures/GDP.

  80. While some label Canada’s system as “socialized medicine,” the term is inaccurate. Unlike systems with public delivery, such as the UK, the Canadian system provides public coverage for private delivery. As Princeton University health economist Uwe E. Reinhardt notes, single-payer systems are not “socialized medicine” but “social insurance” systems, because doctors are in the private sector.[21] Similarly, Canadian hospitals are controlled by private boards and/or regional health authorities, rather than being part of government.

  81. Oh, and BTW, In Canada, $87 a month to cover 2 people who make over 30K a year. No co-pays, nothing to pay when you go to the hospital! Wait times are exaggerated and purely propaganda.
    My aunt’s elderly father broke his hip a few weeks ago and was in and out of surgery within 24hrs..they kept him in the hospital for 17 days.
    Dr’s in Canada make in excess of 200K and that is for a General Practice..not specialist.

  82. Of course, doctors need the requisite background in basic science. If not used, one’s facility in calculus and quantum electrodynamics is likely to become rusty, hence why take courses like that in the first place? Arcane subject matter is all well and good, if you want to be a great conversationalist, but doctors need usable knowledge that keeps the rust off. I certainly don’t remember all the laws of James Clerk Maxwell,but why should I, heavens, I am a doctor.