Best resource to learn about US healthcare problems/MD shortages

[Engrailed]

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My friend and I got into a heated debate today about this and (yes I know there are lots of threads on here already) but does anyone have a good source like a long article or even a contemporary nonfiction book that honestly and objectively distills the complicated landscape of healthcare in the US?
Long answer short, an advisor simply put the MD shortage as a by product of Congress not releasing funds for residency funding, which is where the bottleneck is. Is that an accurate description?

 

[benjamin94559]

Its kind of a really complicated issue to distill into one article or even book.

Poke around kaiser family foundation, commonwealth fund, stat, robert wood johnson foundation, and health affairs for some fairly easy to digest health policy stuff.

Healthcare triage is good if you like youtube videos.

 

[allantois]

https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/primary-care-national-projections2013-2025.pdf

 

[907914]

My friend and I got into a heated debate today about this and (yes I know there are lots of threads on here already) but does anyone have a good source like a long article or even a contemporary nonfiction book that honestly and objectively distills the complicated landscape of healthcare in the US?
Long answer short, an advisor simply put the MD shortage as a by product of Congress not releasing funds for residency funding, which is where the bottleneck is. Is that an accurate description?

On your health with Dr. Zorba - Every Sunday mid afternoon on your local NPR station. It comes on right after WHYY’s You Bet Your Garden

 

[aldol16]

If you're really interested, I would look into primary data sources. There are survey and database data out there compiled by multiple government and non-governmental sources. I would just be very careful about reading anything from someone not well versed in the healthcare landscape. People like to spout opinions even when they have no idea how medicine works so beware of that.

In short, most of data (from my view of it, maybe there's more recent stuff out that I haven't seen) doesn't show an MD shortage. It's more of an allocation problem. In an ideal system, you would have an ideal number of MDs per each unit of population (adjusted for illness severity). If that number were calculated (I'm not aware of any sources that attempt this), I would guess that our number of MDs currently exceeds that number. The problem is, everybody wants to live on the coasts and in cities. That's why you have physician shortages in rural areas and saturation in urban, coastal areas.

 

[LizzyM]

@aldol16 got it right. It's the allocation issue... it is difficult to find anyone who wants to be a primary care provider in a small town, 2 hours from anything that looks like a metropolitan area or a major medical center. You handle the routine and preventive care but if anything is really wrong, you refer to the big city. And you and your family are living in a small town with limited opportunities for the kids' schooling, employment for a spouse, social life, etc. And it starts on Match Day... no one thinks a good match list is one that includes a bunch of family medicine residencies in Nowheresville Alabama or North Dakota. If it were not for J-1 visas for foreign medical graduates, some of these areas would have no residents or attending physicians at all.

 

[aldol16]

It also has to do with the medical education system in this country from before you even get into medical school. Medical school is such a huge commitment and we all go into medicine with these idyllic goals to help people but at some point, you realize that you also have to take care of yourself. You sacrifice so many years to become a doctor that you've basically pissed your 20s and early 30s away by the time you're an attending. It's hard to justify going off to smalltown USA to help people instead of going to one of those coastal areas where you can enjoy life in your time off. And where your family can have more opportunity.

 

[Seihai]

@aldol16 got it right. It's the allocation issue... it is difficult to find anyone who wants to be a primary care provider in a small town, 2 hours from anything that looks like a metropolitan area or a major medical center. You handle the routine and preventive care but if anything is really wrong, you refer to the big city. And you and your family are living in a small town with limited opportunities for the kids' schooling, employment for a spouse, social life, etc. And it starts on Match Day... no one thinks a good match list is one that includes a bunch of family medicine residencies in Nowheresville Alabama or North Dakota. If it were not for J-1 visas for foreign medical graduates, some of these areas would have no residents or attending physicians at all.

I think another big problem is the limited pay in rural areas compared to the big cities. You simply might not make enough money to justify the cost of schooling/debt that you'll have if you take on a lower salary by working in a rural area. The debt forgiveness and incentive programs were supposed to try to tackle this dimension of the problem, but I think that those have largely failed or been inadequate. Admittedly, I don't have enough of a perspective on the issue to have a credible opinion on that.

 

[aldol16]

I think another big problem is the limited pay in rural areas compared to the big cities. You simply might not make enough money to justify the cost of schooling/debt that you'll have if you take on a lower salary by working in a rural area. The debt forgiveness and incentive programs were supposed to try to tackle this dimension of the problem, but I think that those have largely failed or been inadequate. Admittedly, I don't have enough of a perspective on the issue to have a credible opinion on that.

Pay in rural areas can actually be higher than in many urban centers (I think this is probably more likely than not in most places). Basic supply and demand economics. People who will go work in the rural places can make a lot of money - especially if they're some sort of specialist. Conversely, you may take a pay cut to work at the urban centers because the market is saturated with physicians.

 

[Seihai]

Pay in rural areas can actually be higher than in many urban centers (I think this is probably more likely than not in most places). Basic supply and demand economics. People who will go work in the rural places can make a lot of money - especially if they're some sort of specialist. Conversely, you may take a pay cut to work at the urban centers because the market is saturated with physicians.

Is this as true if you work in an underserved area as a family physician? My thought was that you're not going to be making much money if your patients can't afford to pay for regular care.

 

[AnatomyGrey12]

I think another big problem is the limited pay in rural areas compared to the big cities. You simply might not make enough money to justify the cost of schooling/debt that you'll have if you take on a lower salary by working in a rural area. The debt forgiveness and incentive programs were supposed to try to tackle this dimension of the problem, but I think that those have largely failed or been inadequate. Admittedly, I don't have enough of a perspective on the issue to have a credible opinion on that.

Pay in rural areas is often much higher than in the urban areas. Like a lot more in many cases.

 

[AnatomyGrey12]

Is this as true if you work in an underserved area as a family physician? My thought was that you're not going to be making much money if your patients can't afford to pay for regular care.

Yes. FM docs in rural areas can often clear 300k working in a rural area, compared to as low as 180k in urban/large metropolitan areas.

 

[Engrailed]

As an aside, I wish there were more doctors who took govt health insurance. This applies to a lot of the ppl on this forum too.. all of these super high stat ppl go to a fancy med school and then as an attending, BOOM, “sorry we dont take medicare, medicaid, only the best private health plans.” Is there any way to change that? I worked at a large well known hospital and most of the doctors are like that, sadly🙁

 

[Seihai]

Yes. FM docs in rural areas can often clear 300k working in a rural area, compared to as low as 180k in urban/large metropolitan areas.

Thanks for the correction; I'd made some incorrect assumptions about the nature of pay in a rural area. I'll make sure to read up a lot more on this topic!

 

[907914]

Thanks for the correction; I'd made some incorrect assumptions about the nature of pay in a rural area. I'll make sure to read up a lot more on this topic!

Sounds like your assumptions matched mine. I figured the highest paid doc woul be big city, academic, best hospital...but apparently it is the exact opposite.

 

[AnatomyGrey12]

Sounds like your assumptions matched mine. I figured the highest paid doc woul be big city, academic, best hospital...but apparently it is the exact opposite.

Yeah and academics make less than private practice docs typically too.

 

[and 99 others]

@aldol16 got it right. It's the allocation issue... it is difficult to find anyone who wants to be a primary care provider in a small town, 2 hours from anything that looks like a metropolitan area or a major medical center. You handle the routine and preventive care but if anything is really wrong, you refer to the big city. And you and your family are living in a small town with limited opportunities for the kids' schooling, employment for a spouse, social life, etc. And it starts on Match Day... no one thinks a good match list is one that includes a bunch of family medicine residencies in Nowheresville Alabama or North Dakota. If it were not for J-1 visas for foreign medical graduates, some of these areas would have no residents or attending physicians at all.

Do the majority of J-1 visas go into these residencies? Or is it just that the majority of these residencies are taken by people with J-1 visas?

 

[LizzyM]

Do the majority of J-1 visas go into these residencies? Or is it just that the majority of these residencies are taken by people with J-1 visas?

I don't have any data to answer these questions.

 

[aldol16]

Sounds like your assumptions matched mine. I figured the highest paid doc woul be big city, academic, best hospital...but apparently it is the exact opposite.

Yeah and academics make less than private practice docs typically too.

The rule for compensation is basically the more RVUs you generate, the more your compensation is going to be. Your RVUs take a hit if 1) you're not generating any (i.e. our current system rewards procedural specialties) and 2) if you're in academia. The latter is because you have protected teaching/research time, which is going to take away from you generating RVUs which leads to lower revenue. When you're in private practice, you're basically an RVU-generating factory because that's all you're doing all day err day.

 

[aldol16]

As an aside, I wish there were more doctors who took govt health insurance. This applies to a lot of the ppl on this forum too.. all of these super high stat ppl go to a fancy med school and then as an attending, BOOM, “sorry we dont take medicare, medicaid, only the best private health plans.” Is there any way to change that? I worked at a large well known hospital and most of the doctors are like that, sadly🙁

This is unfortunately a consequence of the system we're in. It's how hospitals run. If Medicare is the standard and you assume that a hospital breaks exactly even with what Medicare pays it, then Medicaid pays at a substantially discounted rate. I can't remember how much less on the dollar off the top of my head. So they have to make up those losses (and from uninsured) via private payers. Then they also need to make a small profit (if they're a for-profit institution) so they have to charge private payers a bit more than that still. So you have private payers paying maybe 130% of Medicare rates (estimate off the top of my head).

There's no easy way to get around this. If you go single payer, you're now working in a monopsony. As the single buyer of healthcare services, the government gains unlimited bargaining power and it's my opinion that healthcare workers will suffer. Especially if you took out large loans in advance, thinking that you'll be able to pay it off, provide for your family and kids, and still live a nice life. Plus whenever the government gets involved in something, it usually goes to ****. So in my opinion, the private payer system needs to stay. The other way to do it is to get everybody - and I mean everybody - insured so that hospitals aren't losing so much money on uninsured and Medicaid patients. Obamacare tried to do that but large swathes of the population remain uninsured.

 

[Engrailed]

This is unfortunately a consequence of the system we're in. It's how hospitals run. If Medicare is the standard and you assume that a hospital breaks exactly even with what Medicare pays it, then Medicaid pays at a substantially discounted rate. I can't remember how much less on the dollar off the top of my head. So they have to make up those losses (and from uninsured) via private payers. Then they also need to make a small profit (if they're a for-profit institution) so they have to charge private payers a bit more than that still. So you have private payers paying maybe 130% of Medicare rates (estimate off the top of my head).

There's no easy way to get around this. If you go single payer, you're now working in a monopsony. As the single buyer of healthcare services, the government gains unlimited bargaining power and it's my opinion that healthcare workers will suffer. Especially if you took out large loans in advance, thinking that you'll be able to pay it off, provide for your family and kids, and still live a nice life. Plus whenever the government gets involved in something, it usually goes to ****. So in my opinion, the private payer system needs to stay. The other way to do it is to get everybody - and I mean everybody - insured so that hospitals aren't losing so much money on uninsured and Medicaid patients. Obamacare tried to do that but large swathes of the population remain uninsured.

I get what you mean, and it’s just human nature to fend for uourself and maximize profit etc but Im not gonna lie, in a fancy hospital (still nonprofit) that treats mainly private insurance holders etc, ocassionally when I do come across a doctor who takes any and all insurance, it gives me some joy. I remember one doctor actually wrote on his website he makes an effort to accomdate all insurance payments forms for the sake of health equity and access!

 

[aldol16]

I get what you mean, and it’s just human nature to fend for uourself and maximize profit etc but Im not gonna lie, in a fancy hospital (still nonprofit) that treats mainly private insurance holders etc, ocassionally when I do come across a doctor who takes any and all insurance, it gives me some joy. I remember one doctor actually wrote on his website he makes an effort to accomdate all insurance payments forms for the sake of health equity and access!

I definitely think that a lot of students at these top schools still hold those idyllic views. Somewhere between here and residency/fellowship, that changes. I suspect it has to do with the following factors: 1) the policy of wherever it is you find work afterwards, either with a group practice or otherwise or 2) you learn about the difficulties of running a small business (which is really what private practice is). If your group is hiring you expecting you to generate X revenue, you better generate that revenue. It's a tough world out there.