GOOD NEWS MORE RESIDENCY SPOTS COMING

[DermViser]

He was being sarcastic. C'mon man. A cell phone is a necessity nowadays.

Cell phone yes, smart phone no.

---

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[DermViser]

of note, the Affordable Care Act is basically fantastic for primary care. Any doctor who tells you otherwise and he's in primary care is terrified of a boogie monster rather than reality. But it is a serious pain in the ass for specialist. embracing the Affordable Care Act, although they only embrace it as it was originally written not as it has been heavily amended now, was an attempt to reach out to primary care. Whether it works or not is not totally clear since the Affordable Care Act was so heavily modified. But it remains a great thing for primary care even if Some less than ideal things were inserted. But this embrace of the Affordable Care Act has now soured specialist on the AMA. It's really a tough position they represent trying to look out for the well being of two groups that earn money in drastically different ways.

If it's so "fantastic" for primary care, why is concierge medicine/direct pay medicine taking off? I'm sure primary care docs should be rejoicing at the boost NPs are getting with Obamacare.

 

[Mad Jack]

it's not so much about numbers as is the placement of those numbers. there will be PLENTY of available primary care residencies (they are there already unfilled) especially after this merger goes through. they will be in the middle of nowhere, but that's where the shortage is, and that's where they will go. my bet it that every last primary care residency will be required to be filled before anything new opens. the big markets have plenty of docs to go around and it's easy to attract into these areas (hence the saturation).

There won't be unfilled primary care positions in 2020 and beyond, most likely, unless new v programs begin to open. The number of grads versus the number of residencies is very quickly approaching equilibrium. And this neglects the many thousands of USIMGs and FMGs in the match. Given the choice between rural primary care and not matching, my bet is many indebted students will choose the former.

 

[NontradCA]

Cell phone yes, smart phone no.

lel

 

[DocEspana]

Truly free markets never been tried in modern history. And no, countries that lack markets altogether do not count as free markets.
The solution to the government being in bed with groups like the AMA is clearly not to just have a bigger government.
Finally, just who exactly is responsible for not enforcing the ACA as written? The very same folks that fought to have it made into law. Just goes to show how much confidence they have in their own legislation.

The ACA is being enforced exactly as written. IDK where you got the idea it wasnt. Every last clause of it is being enforced 100% (obviously different things have different WRITTEN dates of starting, many of which havent been reached yet). What you might be confusing is when did the ACA went from a revolutionary (I use the term in both the positive and negative sense) bill which would be huge democratic win for the ages and huge republican win for the ages but overall a pretty "good" law to this ammended to death monster that no one likes? That came, initially, with the death of the public option. Some argue it would have been horrific. Every analysis by a group which is bipartisan/non-partisan disagrees with that and feels striking it was a horrible move for the viability of the bill, but its doesnt mean that they are right. But it really got bad when the senate locked down and the house pulled a political gambit:

The senate was unable to pass the "actual" version of the bill because they were one vote short despite having passed multiple earlier "experimental" versions of the bill. This is common. You pass versions of bills full of pork and nonsense ammendments that you never intend to actually see as law. When your constituents then go "why did you support this" you say "I supported a different version that would have built bridges over our rivers and kept our factories open". The reality is no one actually intends those bills to pass, one house simply votes up these nonsense versions of highly contested bills and never sends them to the other house because they know they only "voted it up" so they had legal proof that they voted to do x, y, and z pork move and "tried" to keep that airplane factory open in bumblesquat.

Well the senate passed a version of ACA with tons of random ammendments and pork in the bill. And the house was repeatedly sending "good" versions of the ACA to the senate to pass it, but a decree came down from the senate republican that since Teddy Kennedy died there was no way for dems to get enough votes (made even worse when a republican took his seat). So all they had to do was immediately filibuster every single bill that came their way. Which they did. After doing it once or twice and promising to do it 100% of the time, the dems stopped bringing ACA bills to the senate and had to work around it. So the house democrats decided to vote on the "flawed" bill that the senate passed almost a year ago at that point. The bill was passed through the senate with the knowledge that "no one would ever vote that into law with all this pork and nonsense". Well the democrats were so tired of not even having any debate allowed on anything, that they pulled their own trick and forced the flawed bill to pass. The opinion in washington was that "okay... so the republicans will now have a law on the books and a duty to their constituency to trim the fat out and make it 'right.' ".

Wrong. The republican response was "if the democrats want to pass a flawed law, we will do everything we can to keep it in place so they are known for passing a bad law". The republicans have repeatedly shot down attempts to trim some of the fat and fix some of the inconsistencies (they have things they want out too, but its not the pork barrel clauses or the contradictory clauses. They want those in). Its being called a "live sink" of the bill by people who study this stuff. They want the bill to go into action and fail miserable (it wont. but it wont succeed the way it should either) so that they can say 'we told you so' to the left when their refusal to compromise at all leads to making millions of americans worse off in order to never let this bill be seen as a success.

 

[DocEspana]

Truly free markets never been tried in modern history. And no, countries that lack markets altogether do not count as free markets.
The solution to the government being in bed with groups like the AMA is clearly not to just have a bigger government.
Finally, just who exactly is responsible for not enforcing the ACA as written? The very same folks that fought to have it made into law. Just goes to show how much confidence they have in their own legislation.

Hong Kong and Switzerland are both modern countries with full economies that function almost entirely laissez-faire and are definied as the two only true free market economies that ever existed (yes, most free market economies are more accurately a lack of any economy, which i referenced). But both have ~10% of their economy run by the government, but only in areas where there is a monopoly and no private interests to compete (which makes those economic goods 'outside the economy' for the sake of the legal definition of their economies). Singapore would be too, but singapore has ownership of certain economies of "vice" products (tobacco, alcohol, petrol) which they can artificially jack up the price of through aggressive taxation and minimum price thresholds, so they do have some highly localized areas of heavy regulation.

 

[touchpause13]

Thanks for that DocE it was very insightful.

 

[DocEspana]

If it's so "fantastic" for primary care, why is concierge medicine/direct pay medicine taking off? I'm sure primary care docs should be rejoicing at the boost NPs are getting with Obamacare.

Its mostly because of a misinformation campaign honestly. Thats the damn truth. Most doctors have no clue how this will effect them outside of implementing measures on health efficiency (measures where PMDs do amazingly generally and specialists usually blow) and being made up of nightmares and scary terms. Its the same way that thousands of doctors chose to retire early rather than use electronic records which the government would pay you back the cost of installation and switch-over. They are so terrified of what they were told (and the general sense of 'unknown') that they'd rather take their balls with them and go home.

Also concierge medcine is a hell of an amazing business plan. Its taking off because if you have a healthy population who have more money than god, why would you not milk them for all its worth at the risk of being on call 24/7-365?

 

[Mad Jack]

Question for DocE then. You did mention the AMA screwing over primary care docs. How did that go over? I also know that psych is another "low paying" speciality. So did the AMA basically decide that procedures would be reimbursed the highest or am I missing something here?

I was talking with a physician about this the other day. His two cents was that it was a combination of three things. The first was the supposed success of pharmaceuticals in the psych world. Given that drugs were viewed as equally or more effective than therapy, paying large amounts for therapy sessions that took three times as long as med consults didn't make sense to insurers. The next factor is the classic one in modern reimbursement, that procedures are more valuable than intangibles like check ups, therapy sessions, diet consults, etc that don't have an immediately visible outcome.

Lastly, particularly in relation to private insurers, he felt that the barriers in reimbursement were there to benefit employers and insurers. Insurers make the most money when people aren't utilizing their services, but people with mental health issues are often on medications for extended periods of time, in addition to needing frequent visits for either therapy or med checkups. Employers want employees that perform optimally, are not a risk to the company, and do not increase their cost of providing benefits. By having excess barriers to mental health services (pre-authorization for visits, piles of paperwork, high copays) , it is more likely an employee will simply give up seeking them, their work performance will decrease, and they can simply be fired, saving the insurance company money and allowing the employer to be rid of a "problem" employee. Basically no financial incentive exists for either organization to provide such services, so they make them hard as hell to acquire in some cases.

 

[DermViser]

Its mostly because of a misinformation campaign honestly. Thats the damn truth. Most doctors have no clue how this will effect them outside of implementing measures on health efficiency (measures where PMDs do amazingly generally and specialists usually blow) and being made up of nightmares and scary terms. Its the same way that thousands of doctors chose to retire early rather than use electronic records which the government would pay you back the cost of installation and switch-over. They are so terrified of what they were told (and the general sense of 'unknown') that they'd rather take their balls with them and go home.

Also concierge medcine is a hell of an amazing business plan. Its taking off because if you have a healthy population who have more money than god, why would you not milk them for all its worth at the risk of being on call 24/7-365?

P4P is a death knell for primary care. Primary care has not done "amazing" in that realm. Hence all of this PCMH crud coming forth where primary care doctors are essentially acting as administrators. The govt. does not pay you 100% of your costs to adopt EMR.

 

[DocEspana]

P4P is a death knell for primary care. Primary care has not done "amazing" in that realm. Hence all of this PCMH crud coming forth where primary care doctors are essentially acting as administrators. The govt. does not pay you 100% of your costs to adopt EMR.

1) models of how people would do under the current performance based standards with minimal/no (i forget which) adjustment for improvements that could be done 'towards the goals' is all spectacular for FM, peds and psychiatry. IM sucks at preventing re-admission for CHF, but is generally going great. Its the surgical fields and the sequealae of specialist care that isnt faring too well. Obviously if your care (or your hospitals care) is not good, youre not going to do well. If you are a hospital of Tb-laden immigrant smokers and drinkers who roll around in nuclear waste and parasite infected stools when not in the hospital and every other hospital around you is all middle aged millionaires, youre not going to look good, but these situations arise much less frequently than people just not being good at doing what asked of them. And poeple not doing what asked of them is much less common in primary care (despite them losing their **** over it) than similar follow up meausres on specialty fields. The hard part is that these measures mostly target primary care, because they are basically all things that can be handled outpatient if given appropriate follow up. IM/FM/Peds actually succeed at following up, despite their fear that the request is unrealistic. Other fields do not and sometimes dont even confirm follow up exists.

2) PCMH have proven, time and time again, to not accomplish what they set out to do. Multiple studies have shpown the improvements are more or less non-existant and unless it can greatly increase *continuity* in primary care, it doesnt change anything over the current hospital utilization. Which sucks. Because PCMH should work. But it doesnt. Thats also way PCMH *is not* a part of the current model. Its being adopted by some (like my own hospital) to try to meet the goals, but all the studies show it wont work for that and my hospital is wasting time and money doing this. Other hospitals (Cook County for example) are taking a modified approach and giving everyone a dedicated primary care doc and making the singular hospital the basis of all of their care (slightly different from the PCMH) and has had promising results so far. I forget the term for their model, but its a term used frequently throughout the ACA as a suggestion for implementation.

3) The government does not pay you 100%. It pays you a flat amount. Estimates vary immenseley on the cost of implementation, but most etimates Ive seen put the reimbursement amount as >100% of the implementation cost. So yes. The governmetn is actively paying you to implement it (though only for a few more months), as they are probably giving you more than your cost of implementation*

*obviously what is considered the cost of implementation depends on how big the pratice is, how many people you need to train, which EMR you get, if you have EMR discounts from affiliated hospitals, how many offices you have, if you need to buy new computers because your current ones suck, etc etc. Its not a clean "number" but most people should not need more than the amount given back to implement it, and some will need many many fold more than the payment amount.

 

[ChrisGriffen]

Um, they already have. Have you not seen the Nurse Practioner movement? Nurses are already good buddies with Obama.
https://fpb.case.edu/Alumni/notes.shtm
................"

..............Obama was running for pres in June of 2008. Presidential candidates are good buddies with everybody.

 

[Dharma]

Just for those following at home: if you boil it down to the most basic answer, who is controlling costs and setting payments now: doctors.

Don't forget your reimbursement has been decided* by the AMA. That organization everyone maligns is empowered to set payment schedules and billing systems. "But DocE, insurances decide what you get paid" you say? Well the AMA more or less sets medicare reimbursement. And private insirances more or less are a percentage (almost always >100%) of Medicares base payment. So while insurances base it off of what medicare says (mostly) medicare says what the AMA says it should (mostly). This is a description lacking a lot of the nuance of reality, but ultimately its true.

Just want to make sure when everyone blames the government for poorly controlling this, they realize its not the government controlling this. They empower the gigantic physician group to make the tough decisions for them assuming that physicians will know what is fair distribution of payment better than they will.

they were basically told that they had to create a billing system. The US wanted to stop using the international coding system as the basis of billing. They wanted one of their own. The reason for this was that international coding system lent itself to high payments for primary care doctors and less for specialist, but the US had already created precedent that it would break from the system to heavily pay a specialist.

so rather than do it lightly, they empowered AMA to create a coding system it felt better represented what should be compensated and how, and the government would create a billing system from that coding system. the AMA historically is very devoid of family medicine doctors, unspecialized internal medicine doctors, and unspecialized general surgeons. the system they created represented the makeup of their own voter body. It even further increase specialist payments beyond what they were getting paid before and it dramatically dropped payments for primary care and general surgery. To the point where specialists can get paid many times more for the same procedure then internal medicine physicians can. the argument for it was a difference in the amount of people a primary care physician can see you today any special can. Which looks good on paper, but doesn't work at all in reality.

so now that drives all of the primary care people out of the AMA, and the government continues to empower them every few years to rewrite the coding system and they always do it in a way that benefits the voting body which actually pays their dues to the AMA. The specialist. They are aware of the issue that this has caused, but frankly it's hard to want to represent the people who fled from you. it's not like there are unlimited funds and they decided to screw over the primary care, it's that someone has to take a pay cut and they are not going to bite the hand that feeds them. there has definitely been attempts to rectify the issue in the last few years, but it is hard to change the momentum they set in motion when they first decided to represent the people who were paying dues rather than the people who fled long before this issue ever began.

So, it's not the government controlling this, but they empower another political entity to continue with the status quo and fiddle with the system. Still looks like government involvement to me.

 

[Dharma]

The amount of naivete and simplification to the point of absurdity about "free markets" and applied libertarianism is terrifying. Please understand that there is a reason the US was a free market for all of 3 years before Washington changed that. Laissez-Faire hasn't existed in the US since prior to Washington's second term. And there is a reason that the only true free market economies are horrifically unstable and only seen in remote locations known for pirates and warlords rather than patrons and wise leaders.

This is coming from someone who has a double major that includes political science and wrote his senior thesis on the complete disconnect between how logically appealing libertarianism is and how shockingly corrupt and ineffective (yes worse than big government somehow) it is in practice. So I'm a *tad* biased against it.

Reasons? Go! You're the expert.

 

[DocEspana]

Reasons? Go! You're the expert.

Every attempt, both philosophically and in reality, to create a true free market leads to the rules of supply and demand being immediately broken by groups collaborating to set my minimum prices, create false scarcity, and ration goods to assure that items that are quality are exceptionally overpriced and the the only reasonably priced options are so subpar (due to controlling the resource market) that they do not qualify as competing objects due to how flawed they are. And there would never be a "need to lower prices as no one can afford anything" moment because history has shown there are enough intractably wealthy people for those who run the markets and other "high-profit" areas in this system to just sell to themselves and effectively close out any hope of social.mobility or market access to the poor who would be forver locked out by the momentum of a system forever distancing itself from them.

Want a modern example? Hobbes, the father of everything we recognize as modern government basically equated this to returning to a warlord state very quickly. Economics books refer to a true free market as a death sentence for the middle class. You want shades of it? Absolutely. You want no regulation? You're literally asking for the collapse of an economy and the build of an "elite or nothing" economy. The invisible hand never said it had to function at reasonable values, only that it would modify the market. If the market exists entirely at a level that cuts off 95% of the population, it won't drop down to let in the lower 95%, it will form two markets. One of goods worth buying and one of the scraps of beggars. Until there is war among the classes. Many people see the evil government does and MASSIVELY underestimate the evil it prevents.

If you want a totally perfect example of what I mean, go look at MSRP between cars (a regulated business) and video games (an entirely market controlled economy outside of the ESRB ratings). Both have MSRP. Cars can't sell above a certain point and have some price adjustment for imported cars to keep american cars competitive.... but anyone will sell you under MSRP if that closes the deal. Video game producers have all joined in cahoots and agreed that they set the price point for video games and for x-many months a new title cannot be sold under $59.99 for any reason. Stores that are foubd to be selling even a penny under that price are literally blacklisted because they do not want any market movement in the cost, despite it being an entirely free pricing system. They control the resource the stores want to sell and they artificially agreed to form a pricing monopoly with the power to destroy any company that goes against them. If tomorrow they decided to make it $70 they could. Or $80. You say to yourself "at some point it will out price their customers willingness to pay". It will, but the cost and demand curve is parabolic. Raise it enough and you stop losing customers that fast, but your profit over unit rises rapidly until you have a new economy of the rich and *that* has market responsiveness.

The difference is in who controls the market and says "that's enough". Every isolated experiment shows the resource managers will game the system before the peoples economic choices assert a downward force. It is the fear of a big hand (government) squishibg their plans AND them getting bad PR that prevents it in this system we have. Attempting it when the ability to be shot down exists is no longer an appealing option.

 

[DocEspana]

God, I miss economic and political philosophy class. I <3 Hobbes. He was so much more than just the leviathan.

 

[BestDoctorEver]

Yet if we don't increase primary care doctors we'll see the nurse lobby having more muscle against Washington. I recommend opening more primary care slots.

You are so right! And once they are done with primary care, they will go for some non procedural specialties like derm etc... I see a lot of derm are being done by PAs these days...

 

[DocEspana]

Dharma, if you want to continue this discussion, let's take it to the sociopolitical forum (a subforum of the wolfs den here). This threads isn't about idealism of a theoretical market vs the pessimism of old philosophers and foibles of small market failures. Its about.... something vaguely resident related.

So let's not clog it up with our philosophic discussion.

 

[MalachiConstant]

This thread makes me wish I'd had more foresight years ago and hadn't dropped out of college after 1 semester of studying poli sci. With a recently rekindled interest in policy, I feel like I have much to catch up on. But, won't be following into the anarcho-capitalist circlejerk that is the SPF these days.

 

[Dharma]

Dharma, if you want to continue this discussion, let's take it to the sociopolitical forum (a subforum of the wolfs den here). This threads isn't about idealism of a theoretical market vs the pessimism of old philosophers and foibles of small market failures. Its about.... something vaguely resident related.

So let's not clog it up with our philosophic discussion.

I appreciate your response. Good examples. I think there is something that exist can between extremes and right now I see it tipping towards government growth and increased control/influence. Like I said, there needs to be rules and regulation, but only so much as necessary, which I feel there is a quickly growing trend to go beyond (that "touch of Laisse Faire" I mentioned earlier, not a full-out unregulated system). I'm not sure anyone can say something won't work if it hasn't been given a solid try. Maybe some of the DPC models out there will provide such an example on a small scale.

Anyhow, that's all I got. (Boards dude!!!) But good points you made there DE.

 

[NOsaintsfan]

Well I think since the people controlling the costs now have no incentive for the socioeconomics of it, that there is no conversation for what is best for the patients (and physicians don't have the power here). The government has that responsibility.

Can you site even ONE example where the federal government has implemented a nationwide program that was efficient and within budget?

 

[NontradCA]

Can you site even ONE example where the federal government has implemented a nationwide program that was efficient and within budget?

http://en.m.wikipedia.org/wiki/Interstate_Highway_System

 

[NOsaintsfan]

http://en.m.wikipedia.org/wiki/Interstate_Highway_System

Ok then serious question.

Based on the current state of affairs in Washington (gridlock, dysfunction, lots of corporate control/influence) and considering how social security and Medicare have been managed (WAY over projected costs and lots of inefficiency/fraud/waste for Medicare, SS effectively robbed from and therefore short of funds) what makes you feel confident that the government can effectively administer healthcare to the entire nation?

Don't misunderstand what my question is implying. Our current system is fragmented and needs reform to say the least. We should find a way to provide medical coverage for all citizens. Having said that I'm not convinced having government run the show completely is the answer.

For a lot of people I think the goal in general is the same however many (myself included) don't think giving government control (single payer)is the answer. On the other side the ACA all but guarantees a single payer system will be in our future.

 

[NontradCA]

Ok then serious question.

Based on the current state of affairs in Washington (gridlock, dysfunction, lots of corporate control/influence) and considering how social security and Medicare have been managed (WAY over projected costs and lots of inefficiency/fraud/waste for Medicare, SS effectively robbed from and therefore short of funds) what makes you feel confident that the government can effectively administer healthcare to the entire nation?

Don't misunderstand what my question is implying. Our current system is fragmented and needs reform to say the least. We should find a way to provide medical coverage for all citizens. Having said that I'm not convinced having government run the show completely is the answer.

For a lot of people I think the goal in general is the same however many (myself included) don't think giving government control (single payer)is the answer. On the other side the ACA all but guarantees a single payer system will be in our future.

You agree that all Americans should have access to care? Ok well then there's nothing to argue. It has to be a single payer system and there's no other entity that's better for that than the government.

 

[NOsaintsfan]

You agree that all Americans should have access to care? Ok well then there's nothing to argue. It has to be a single payer system and there's no other entity that's better for that than the government.

That's the only way? I'm not convinced, glad you are. To me it doesn't seem rational to give an entity that has a proven track record of mismanaging our money complete control over providing our healthcare. Ideals and reality have to be considered.

 

[NontradCA]

That's the only way? I'm not convinced, glad you are. To me it doesn't seem rational to give an entity that has a proven track record of mismanaging our money complete control over providing our healthcare. Ideals and reality have to be considered.

Yea it's the only way. You act like the government isn't a bunch of bureaucracies. The Man isn't out to get you.

Let's put it this way. It's better to have the devil that you know than the one you don't. Private entities are not nearly (by a long shot) subject to the same criticism and accountability as the government.

The mere fact that so many people hate the government is proof of this.

 

[NOsaintsfan]

Yea it's the only way. You act like the government isn't a bunch of bureaucracies. The Man isn't out to get you.

Let's put it this way. It's better to have the devil that you know than the one you don't. Private entities are not nearly (by a long shot) subject to the same criticism and accountability as the government.

The mere fact that so many people hate the government is proof of this.

You act as if debate and consideration of ideas counter to your own are a bad thing.

Skepticism of government is healthy and should be encouraged. Blind faith in government without critical analysis or a skeptical eye = complacency. I don't know how well versed in history you are but historically a complacent attitude toward government hasn't worked out so well.

I'll throw another concept out there to you in order to illustrate why some are skeptical of government as food for thought. Keep in mind this is a macro concept.

Many people like predictability.

Government, specifically politicians running the government are highly unpredictable and often do things counter to what they campaigned on. In short political behavior is erratic.

Business/Corporation behavior is HIGHLY predictable. Why? Because businesses are motivated by profit. Without profit a business doesn't exist. How much profit is enough? Since corporations are publically owned (shareholders) then no amount of profit is ever enough. That's ok. Understanding this simple concept allows you to predict business/industry behavior on a macro scale. This doesn't mean business is bad or evil, its simply the rules that business live and die by.

Once you know this it becomes very easy to predict business behavior. Why do businesses pollute? Its cheaper. Why do they pay lobbyist to influence government/laws? To protect profit and earnings. Ect., ect. When looked at from this perspective it's really simple to predict how a corporation will behave (in a broad general sense).

Sure some, even many businesses will act as good stewards of the environment and be "socially responsible" but to expect this means you don't understand business. Businesses do the right thing because doing the wrong thing will jeopardize profit (upset consumers) or because the "wrong" thing is illegal (ie. government absolutely has a role in business regulation).

What is a politicians motive? Don't know. Maybe they are acting for the good of the country, maybe they have an "agenda", maybe they are corrupt and seek to exploit their position. Who knows? You see its difficult to predict what politicians will do and for SOME this makes trust difficult as well. It creates skepticism.

Should you be skeptical of business and corporations? Absolutely! The difference here is that predicting what an industry will do is much easier. Another key difference is that business behavior is generally constant throughout time. Business has always been motivated by profit and always will be. The only thing that changes throughout the millennia is the regulations under which business must operate (the rules if you will) but the motivation (ie. driver of behavior) stays the same.

So it comes down to trust. Trust erratic and unpredictable (government) or trust very predictable (business).

The choice is for everyone to make on their own. Just because businesses do things that can be seen as bad doesn't mean they are unpredictable. If business behavior as a whole surprises you well......it shouldn't. Its easy to put trust and faith in something you understand and can predict.

Government behavior on the other hand is erratic.

 

[NOsaintsfan]

The Man isn't out to get you.

Actually the "MAN" is very much out to get me.

If you think class warfare doesn't exist then your simply wrong.
http://www.cnbc.com/id/101264757

The "man" may not be out to get me as an individual but I am planning on being able to generate an income that would put me in a higher tax bracket. Most doctors do. As such I will absolutely have a target on my back and will most likely be one of the "evil rich".

Wanna be doc? Then you most likely will me a member of the evil rich as well.

If you're not concerned with how uncle sam is spending an ever increasing percentage of your hard earned income.........you should be. You should also ponder the question "At what % of my income will I have paid my fair share?" Why? Because as a doctor you will be faced with that reality all the time.

 

[NontradCA]

 

[NOsaintsfan]

Great illustration of current day challenges! Nice chat.

 

[hallowmann]

You act as if debate and consideration of ideas counter to your own are a bad thing.

Skepticism of government is healthy and should be encouraged. Blind faith in government without critical analysis or a skeptical eye = complacency. I don't know how well versed in history you are but historically a complacent attitude toward government hasn't worked out so well.

I'll throw another concept out there to you in order to illustrate why some are skeptical of government as food for thought. Keep in mind this is a macro concept.

Many people like predictability.

Government, specifically politicians running the government are highly unpredictable and often do things counter to what they campaigned on. In short political behavior is erratic.

Business/Corporation behavior is HIGHLY predictable. Why? Because businesses are motivated by profit. Without profit a business doesn't exist. How much profit is enough? Since corporations are publically owned (shareholders) then no amount of profit is ever enough. That's ok. Understanding this simple concept allows you to predict business/industry behavior on a macro scale. This doesn't mean business is bad or evil, its simply the rules that business live and die by.

Once you know this it becomes very easy to predict business behavior. Why do businesses pollute? Its cheaper. Why do they pay lobbyist to influence government/laws? To protect profit and earnings. Ect., ect. When looked at from this perspective it's really simple to predict how a corporation will behave (in a broad general sense).

Sure some, even many businesses will act as good stewards of the environment and be "socially responsible" but to expect this means you don't understand business. Businesses do the right thing because doing the wrong thing will jeopardize profit (upset consumers) or because the "wrong" thing is illegal (ie. government absolutely has a role in business regulation).

What is a politicians motive? Don't know. Maybe they are acting for the good of the country, maybe they have an "agenda", maybe they are corrupt and seek to exploit their position. Who knows? You see its difficult to predict what politicians will do and for SOME this makes trust difficult as well. It creates skepticism.

Should you be skeptical of business and corporations? Absolutely! The difference here is that predicting what an industry will do is much easier. Another key difference is that business behavior is generally constant throughout time. Business has always been motivated by profit and always will be. The only thing that changes throughout the millennia is the regulations under which business must operate (the rules if you will) but the motivation (ie. driver of behavior) stays the same.

So it comes down to trust. Trust erratic and unpredictable (government) or trust very predictable (business).

The choice is for everyone to make on their own. Just because businesses do things that can be seen as bad doesn't mean they are unpredictable. If business behavior as a whole surprises you well......it shouldn't. Its easy to put trust and faith in something you understand and can predict.

Government behavior on the other hand is erratic.

I actually disagree with this. Government behavior tends not to be erratic. Its motivated by the same things you mentioned, money (that's a big one), as well as things that affect it (re-election, power, etc.). That's about it. Everything else is more or less rhetoric.

The difference between a (democratic) government and a corporation is that occasionally you can more easily convince government officials that its in their interest to do things that are good for you. Its harder to do that in the corporate world, mainly because you have little to no say in who's in charge.

 

[NontradCA]

Great illustration of current day challenges! Nice chat.

Lol well when you start your conversation with the typical "liberals don't want to hear anything they don't agree with" line I take you less seriously. The system is already run for profit of private entities and it's broken. Government run systems have proven to work (and allow for private health systems as well). How is this not the logical thing to do? (You've already agreed everyone should get healthcare)

 

[touchpause13]

That's like my new favorite gif. That's even better than the bush dancing one

 

[NOsaintsfan]

Lol well when you start your conversation with the typical "liberals don't want to hear anything they don't agree with" line I take you less seriously. The system is already run for profit of private entities and it's broken. Government run systems have proven to work (and allow for private health systems as well). How is this not the logical thing to do? (You've already agreed everyone should get healthcare)

When you reply "Yes its the only way" referring to government administered healthcare to me that implies not being open to contrary ideas. I was responding directly to your words, not giving some stereotypical response.

I do agree that its a good thing to find ways to provide healthcare for everyone. I'm simply open to exploring various ways to achieve that, it seems as if you are not open to consider anything but a single payer option.

 

[NOsaintsfan]

I actually disagree with this. Government behavior tends not to be erratic. Its motivated by the same things you mentioned, money (that's a big one), as well as things that affect it (re-election, power, etc.). That's about it. Everything else is more or less rhetoric.

The difference between a (democratic) government and a corporation is that occasionally you can more easily convince government officials that its in their interest to do things that are good for you. Its harder to do that in the corporate world, mainly because you have little to no say in who's in charge.

Government behavior is intrinsically erratic. Policies change with almost every election, political philosophies differ widely, look at the differences between the two major parties and how they govern. Carter and Regan, Bush and Obama, all are very different in leadership style and governance and as such general governmental policy (behavior) changes.

Business has to abide by the different rules/regulations that constantly change by government but in the end business is still trying to achieve the same basic goal --> profit.

What is Obama trying to achieve? What was Bush trying to achieve? Both different. Sure commonalities exist but overall goals are different.

 

[hallowmann]

...What is Obama trying to achieve? What was Bush trying to achieve? Both different. Sure commonalities exist but overall goals are different.

I guess I don't see as big of an inherent difference as you do between the two parties. They both are motivated by the same thing (which I mentioned before). The only difference being that who they get their money/support from is slightly different. If your argument is that there will be differences between the parties, then that may be.

But your previous statement was that government is less predictable than corporations, because their motive is not as transparent. I stand by my original statement that both have blatantly transparent motives, making them very predictable.

You may be better off trying to make the argument that government tends to oscillate in terms of policies, than trying to make the argument that its not predictable. To be honest though, I think oscillating between two extremes is more desirable than just going further to one extreme in search or profits (as corporations tend to do).

 

[NOsaintsfan]

I guess I don't see as big of an inherent difference as you do between the two parties. They both are motivated by the same thing (which I mentioned before). The only difference being that who they get their money/support from is slightly different. If your argument is that there will be differences between the parties, then that may be.

But your previous statement was that government is less predictable than corporations, because their motive is not as transparent. I stand by my original statement that both have blatantly transparent motives, making them very predictable.

You may be better off trying to make the argument that government tends to oscillate in terms of policies, than trying to make the argument that its not predictable. To be honest though, I think oscillating between two extremes is more desirable than just going further to one extreme in search or profits (as corporations tend to do).

I think their is a fairly big difference between the two parties in terms of policy. You may be right that money motivates many in politics but some may be altruistic others may have a different agenda not related to money. Point is there isn't a single common motivator.

The real point I was making however isn't on political motivation it was actual political action. The actual policies between different politicians can vary greatly. Business has to play by the rules that are written by government. (laws/regulations) So when you take the regulatory environment into account and combine that with the fact that every business has to make profit actions become more predictable.

It is nearly impossible at this point to say with a high degree of certainty who the next president will be and what type of policy (actions) that president will take. You are correct that you can predict that policy will change ect. however what those changes will be are unknown.

Government policy in the 1920's was very different than today, however business in the 20's was doing the same thing it is today. In general terms it was abiding by government regulation (or lack there of in the 1920's) and seeking profit.

Bonus info: This is also how you can predict what effect laws will have in a general sense on business. Ex: As currently written the ACA will bring and end to private insurance companies in the near future. The only reason people say "we don't know how this will affect things" is because of the uncertainty surrounding the actual implementation of the entire ACA, (unpredictability of government) once that is known the uncertainty will be no more.

 

[NontradCA]

I think their is a fairly big difference between the two parties in terms of policy. You may be right that money motivates many in politics but some may be altruistic others may have a different agenda not related to money. Point is there isn't a single common motivator.

The real point I was making however isn't on political motivation it was actual political action. The actual policies between different politicians can vary greatly. Business has to play by the rules that are written by government. (laws/regulations) So when you take the regulatory environment into account and combine that with the fact that every business has to make profit actions become more predictable.

It is nearly impossible at this point to say with a high degree of certainty who the next president will be and what type of policy (actions) that president will take. You are correct that you can predict that policy will change ect. however what those changes will be are unknown.

Government policy in the 1920's was very different than today, however business in the 20's was doing the same thing it is today. In general terms it was abiding by government regulation (or lack there of in the 1920's) and seeking profit.

Bonus info: This is also how you can predict what effect laws will have in a general sense on business. Ex: As currently written the ACA will bring and end to private insurance companies in the near future. The only reason people say "we don't know how this will affect things" is because of the uncertainty surrounding the actual implementation of the entire ACA, (unpredictability of government) once that is known the uncertainty will be no more.

Do you have any idea how the government runs? Log rolling and special interests. Once you take insurance out of it, you cut out big pharma and hospital systems dictating costs once the Gmen buy up the hospitals. The government will determine wages, but they will be comparable to amount of work out in. It won't be quantity but some measure of quality. That's where we're headed.

 

[stlrams22]

If the free market were allowed to determine physician reimbursement (rather than Medicare/Medicaid), any physician shortages would self-correct within a few years, since individuals and insurance companies would compete for these services and as pay increased, more new docs would choose to enter these fields.

As it is, however, the government essentially determines physician pay by setting reimbursement rates and exacerbates physician shortages by perpetuating the current residency paradigm.

Why have free markets when our government can do things better? The inefficient big government is the future if the health care takeover is any indication.

 

[DocEspana]

I actually disagree with this. Government behavior tends not to be erratic. Its motivated by the same things you mentioned, money (that's a big one), as well as things that affect it (re-election, power, etc.). That's about it. Everything else is more or less rhetoric.

The difference between a (democratic) government and a corporation is that occasionally you can more easily convince government officials that its in their interest to do things that are good for you. Its harder to do that in the corporate world, mainly because you have little to no say in who's in charge.

This x100. I was choking when someone said that government is erratic. The very issue with our government right now is that they wont do ANYTHING that would move in the slightest away from the status quo that could have been vaguely predicted years ago.

 

[premed1001]

so is it clear whether the 2015 budget proposes more or less GME spots?

 

[Tommyguns89]

The problem isnt that government is by definition drastically more inefficient than the private sector. In our case it is, but that is only because the top .1% of the private sector essentially controls the government by making investments(donations) for favorable laws to them(unfavorable to you and me) knowing that if anybody is held accountable it will be the politician not them. Most of the more efficient governments in the world have stricter standards on lobbying and campaign donations.

 

[Ogmora]

The problem isnt that government is by definition drastically more inefficient than the private sector. In our case it is, but that is only because the top .1% of the private sector essentially controls the government by making investments(donations) for favorable laws to them(unfavorable to you and me) knowing that if anybody is held accountable it will be the politician not them. Most of the more efficient governments in the world have stricter standards on lobbying and campaign donations.

It's also unfortunate that the supreme court just removed the restrictions capping donations to parties...looks like the "democracy" is enroute to becoming a capitalistic oligarchy of corporations.

It will take a heavy amount of bipartisanship to levy more funding into GME. Assuming a center-focused electorate wins in 2016, we may be in luck. But if there is as much party-play as there has been the past 6 years, I doubt much will happen.

 

[GUH]

It's also unfortunate that the supreme court just removed the restrictions capping donations to parties...looks like the "democracy" is enroute to becoming a capitalistic oligarchy of corporations.

It will take a heavy amount of bipartisanship to levy more funding into GME. Assuming a center-focused electorate wins in 2016, we may be in luck. But if there is as much party-play as there has been the past 6 years, I doubt much will happen.

Corporations and labor unions.

 

[Mad Jack]

Yea it's the only way. You act like the government isn't a bunch of bureaucracies. The Man isn't out to get you.

Let's put it this way. It's better to have the devil that you know than the one you don't. Private entities are not nearly (by a long shot) subject to the same criticism and accountability as the government.

The mere fact that so many people hate the government is proof of this.

The man isn't out to get you, he's out to get ahead. Throwing constituents under the bus is par for the course in politics. Look at the AMAs behavior when the ACA was being passed for a crystal clear example.

Corporations are no better. They'll throw customers under the bus or squeeze then for everything they can spare. At least they're honest about their motivations most of the time.

We need both corporations and the government around to keep each other in check. Without both of them fighting for power via regulatory battles and the like, they'd be free to focus on screwing the populace full time. Not because they're evil, mind you, but because human nature pretty much dooms those in power and with money to want more power and money, and when there's no other big dogs in the room, they turn on the little ones.

 

[Siggy]

I can't tell you how many times I've seen people with the most recent Galaxy/Android/iPhone at the homeless shelter while I just have my "old fashioned" flip phone. For them it's the most valuable thing they actually own, so it probably means more to them to have a nice phone than it would mean to me. Not that I condone this kind of spending since it could easily pay a month's shared rent and open up a spot at the shelter for someone who really needs it.

The one catch to the cell phone issue (and I know I'm late to this post) is that the monthly cost of the cell phone decreases the longer the cell phone is used. A $500 cell phone after a year is only $41 a month. A $500 apartment rent gets you an apartment for 28-31 days depending on the month and nothing more after that month. Additionally, a cell phone (arguably a flip phone would be a better investment, but the point of phone v apartment stands) is a necessity in this day and age where employment opportunities are going to be filled fast.

 

[AnonymousD.O.]

Do we really want them to increase residency spots? Doesn't anyone else worry about going the way of law school grads?

Nope.

There was also a shortage of lawyers and pharmacist not too long ago.

Ya but It costs a lot more money to train a doctor than a lawyer. The increase in doctors via medical schools admission increases etc. will be much more gradual than what occurred in law. It's a different situation.

 

[dyspareunia]

can we stop with the law school comparison? every thread somebody posts about how hard it is for lawyers to get jobs. there is a SHORTAGE of doctors, and the shortage is predicted to get worse. we are a loong way from market saturation

There's no shortage. Urban areas are just saturated with specialists and there aren't enough primary care docs in most areas.