Self Fund Residency?

[FaisalResidency]

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Just wondering if anyone has ever self-funded their residency? I heard of some gulf states arabs doing it so they can get residency positions as the money seems to have dried up there?

Anyone know or read anything about this?

 

[AdmiralChz]

You want to find your OWN residency... What? Like make negative money? Geesh, not sure labor laws in the states would allow that.

 

[FaisalResidency]

I'm helping someone who made a lot of money in another business and wants to practice medicine because he cares deeply to do so. The limitation on residency spots
is based on funding. Why can't he fund it himself?

 

[FaisalResidency]

Artificial bottlenecks to our dreams shouldn't be stopped for a few hundred grand.

 

[Crayola227]

the limitation is beyond that - the site has to have enough patients/cases of specific types to go around to makes sure you get enough "experience" out of the residency, the ACGME determines how many residents can be adequately trained at a specific site

sometimes they might approve say 20 spot, but only give enough funding so it ends up being 15, then maybe the hospital decides to fund another 2, bringing it to 17. But they could never go past 20. And if they did they would likely lose accreditation because then the argument is that the education is compromised for all if they have say 25 residents when they were approved for 20.

it also raises ethical questions of like bribery

like, did the program take you because you are the most qualified or did you essentially bribe them?

so the issues aren't just purely funding

 

[FaisalResidency]

Crayola,

So in your example and the way i understand it is that there is a gap between approved spots and funded spots creating a shadow inventory
of residency positions that is limited by government funding meanwhile we have a severe physician shortage.

Current system benefits those in power and current doctors at the expense of those wanting to be in medicine and the communities that
lack healthcare providers.

 

[AdmiralChz]

A lot of people hate the phrase "slippery slope" but few people are in as good financial situation as your friend. This could create a system where even MORE debt is added onto graduating physicians and they might be faced with no choice but to somehow continue with the loans to pay for a job? Yikes.

 

[Angry Birds]

Just wondering if anyone has ever self-funded their residency? I heard of some gulf states arabs doing it so they can get residency positions as the money seems to have dried up there?

Anyone know or read anything about this?

I think the Gulf states thing is very different. The state is paying for a qualified medical graduate to complete a residency, the catch being that they need to practice in their home country for a number of years after graduation. It's a way of importing medical experience from the United States.

It's certainly not some rich person paying to have his son complete a residency to be called a doctor. The funding simply comes from a different government.

 

[biryani86]

Just wondering if anyone has ever self-funded their residency? I heard of some gulf states arabs doing it so they can get residency positions as the money seems to have dried up there?

Anyone know or read anything about this?

Tufts Univ. usually has this kind of setup for various specialties, I believe Radiology there still has such spots every alternate year.

 

[Mad Jack]

Tufts Univ. usually has this kind of setup for various specialties, I believe Radiology there still has such spots every alternate year.

That would likely land them on probation, as the only program I ever heard of doing so fell afoul of the ACGME and ended up on probation due to a violation of the institutional requirements. Years ago, this was allowed, but not these days.

II.B. Financial Support for Residents: Sponsoring and participating sites must provide all residents with appropriate financial support and benefits to ensure that they are able to fulfill the responsibilities of their educational programs.

 

[FaisalResidency]

ACGME keeps spouting about lack of supply of physicians and the huge problems it faces yet won't allow people to determine
their own future?

Sounds pretty duplicitous. Most of the AMA, ACGME, AAMC etc. are run by doctors that want the standards to keep going up
as it reflects their own self perception and also they're incentivized by shortages as its boosts current physician income.

People should be able to determine if they want to borrow to cover the costs.

 

[Mad Jack]

ACGME keeps spouting about lack of supply of physicians and the huge problems it faces yet won't allow people to determine
their own future?

Sounds pretty duplicitous. Most of the AMA, ACGME, AAMC etc. are run by doctors that want the standards to keep going up
as it reflects their own self perception and also they're incentivized by shortages as its boosts current physician income.

People should be able to determine if they want to borrow to cover the costs.

It's more about the law if unintended consequences- without strict controls, residencies used to be quite abusive of residents. The rules are designed to maximize the fairness with which resident are treated, and to prevent programs from engaging in unethical practices.

 

[Gpan]

sure let's BUY your way through life. Buying your way into a position is not at all a new concept. Good luck sleeping at night or answering your co workers question: "so how did you get here?" . PATHETIC !!!!!!!

I know I know, people buy their spots in school ALL THE TIME. That does not make it right !!!

 

[FaisalResidency]

sure let's BUY your way through life. Buying your way into a position is not at all a new concept. Good luck sleeping at night or answering your co workers question: "so how did you get here?" . PATHETIC !!!!!!!

I know I know, people buy their spots in school ALL THE TIME. That does not make it right !!!

The same people that would have become doctors years ago are sitting in limbo due to a lack of funding.
If someone wants to make up that differential more power to them.

I'll sleep fine at night. Many of the current doctors don't mind the limited funding as it keeps their income
disproportionately higher than it should be. I wonder how they sleep at night??

 

[Gpan]

The same people that would have become doctors years ago are sitting in limbo due to a lack of funding.
If someone wants to make up that differential more power to them.

I'll sleep fine at night. Many of the current doctors don't mind the limited funding as it keeps their income
disproportionately higher than it should be. I wonder how they sleep at night??

Haha IF and only IF you or your friends have the balls, intelligence and good work ethic to crack it in this field legitimately then I would welcome in open arms. This is like a brotherhood. Noone should be allowed to cut corner or weasel his/her way into this noble profession.

 

[FaisalResidency]

Haha IF and only IF you or your friends have the balls, intelligence and good work ethic to crack it in this field legitimately then I would welcome in open arms. This is like a brotherhood. Noone should be allowed to cut corner or weasel his/her way into this noble profession.

Gpan I respect your journey but that attitude is why there are restrictions from originally AMA, and now ACGME and others to restrict the number of doctors in America.

I love medicine, its great, but the control these doctors with this mentality have had for decades has left our country with inflated healthcare costs and we desperately need
more physicians in this country.

The number of residency positions by specialty are limited and even they are not being filled.

I found a petition somewhere for ACGME to let charity, alternative funding or even personal funding of current approved spots but unfilled due to lack of funding.

I'll see if I can find it.

 

[FaisalResidency]

Some people I know joined medicalresidencyresources who is trying to allow people to self-fund. They had a petition going
to push ACGME to let people or companies or charities fund their spots. Think the petition is on their site which is just the
company name .com.

 

[FaisalResidency]

Tufts Univ. usually has this kind of setup for various specialties, I believe Radiology there still has such spots every alternate year.

They let you fund their excess unfunded spots if you qualify??

Thanks,

 

[AdmiralChz]

The number of residency positions by specialty are limited and even they are not being filled.

Well, almost all specialty positions end up being filled after SOAP from what I understand... but IF this were true then how in the world would making someone pay for it (as opposed to, you know, getting a resident's salary) help fill these positions? It's simple labor economics, or just common sense...

 

[Gpan]

Gpan I respect your journey but that attitude is why there are restrictions from originally AMA, and now ACGME and others to restrict the number of doctors in America.

I love medicine, its great, but the control these doctors with this mentality have had for decades has left our country with inflated healthcare costs and we desperately need
more physicians in this country.

The number of residency positions by specialty are limited and even they are not being filled.

I found a petition somewhere for ACGME to let charity, alternative funding or even personal funding of current approved spots but unfilled due to lack of funding.

I'll see if I can find it.

Why don't you quit blaming other people for your problem? If you want to match then do better on rotations, study harder, score better on those exams. Instead you choose to sit there and whine like a bunch of millennial generation kids. ALWAYS SOMEONE ELSE'S FAULT right?

 

[FaisalResidency]

Why don't you quit blaming other people for your problem? If you want to match then do better on rotations, study harder, score better on those exams. Instead you choose to sit there and whine like a bunch of millennial generation kids. ALWAYS SOMEONE ELSE'S FAULT right?

How do you think it adversely affects society when we have a significant shortage of Physicians in the United States? How do you think it affects society when
30-40 million Americans are in areas that even the AMA considers federally designated shortage areas?

Its a major problem that many are in the crosshairs of and wish to provide a useful and needed service.

Don't think that has anything to do with being a millennial.

 

[FaisalResidency]

Well, almost all specialty positions end up being filled after SOAP from what I understand... but IF this were true then how in the world would making someone pay for it (as opposed to, you know, getting a resident's salary) help fill these positions? It's simple labor economics, or just common sense...

I think the problem economically is more macro. In labor or any form of economics supply will equal demand in the long run in order to have the price of these
services be at the point of equilibrium.

As we have a significant shortage of physicians due to a archaic system of government paying for Graduate Medical Education, the supply side is not being properly
met. This creates a shortage which then drives up salaries and wages to physicians at the cost of society and lower quality service. As physicians have unemployment
rates under 1/2 of 1%, have near certain job security and produce the highest wages of any large scale profession in this country and makes being a physician
to most financially rewarding when factoring in time, unemployment and consistency and duration of income.

All I wish to do is to find a way to tap into that future income to allow more people to practice medicine as our country direly needs more physicians.

 

[biryani86]

They let you fund their excess unfunded spots if you qualify??

Thanks,

Well you typically have to be a citizen of a country that has a setup with Tufts. So, for example, a Saudi citizen who is interested in Radiology residency at Tufts, can get the Saudi government to pay for an unfunded ACGME accredited PGY spot. There are many people that get into such spots.

http://medicine.tufts.edu/About-Us/...d-Professional-Advancement/Residency-Programs

http://medicine.tufts.edu/~/media/T...s/Hospital Programs Availability 03-26-14.pdf

 

[Mad Jack]

Gpan I respect your journey but that attitude is why there are restrictions from originally AMA, and now ACGME and others to restrict the number of doctors in America.

I love medicine, its great, but the control these doctors with this mentality have had for decades has left our country with inflated healthcare costs and we desperately need
more physicians in this country.

The number of residency positions by specialty are limited and even they are not being filled.

I found a petition somewhere for ACGME to let charity, alternative funding or even personal funding of current approved spots but unfilled due to lack of funding.

I'll see if I can find it.

Turning medicine into a plutocracy won't fix things, that's for sure. If they allowed self-funding, as in the old days, then hospitals could just keep all of the funding that is normally passed on to residents, and tell them to "self-fund" their own salaries. Or they could accept unlimited people that were willing to pay. Or they could force all residents to subsidize their own training on top of what is already being provided by Medicare. There's a lot of slippery slope stuff that could happen, and that's why the practice is banned- back in the day residents were abused quite heavily financially, with positions offering no salary or compensation aside from room and board. The vast majority of people would prefer to not go back to such a system, particularly since it only benefits those few who are wealthy enough for it to not be a problem.

 

[FaisalResidency]

Turning medicine into a plutocracy won't fix things, that's for sure. If they allowed self-funding, as in the old days, then hospitals could just keep all of the funding that is normally passed on to residents, and tell them to "self-fund" their own salaries. Or they could accept unlimited people that were willing to pay. Or they could force all residents to subsidize their own training on top of what is already being provided by Medicare. There's a lot of slippery slope stuff that could happen, and that's why the practice is banned- back in the day residents were abused quite heavily financially, with positions offering no salary or compensation aside from room and board. The vast majority of people would prefer to not go back to such a system, particularly since it only benefits those few who are wealthy enough for it to not be a problem.

Those arguments would mean that Harvard Business School should let everyone in because they'd make more money as would every
educational institution in this country. If someone wants an MBA they can go to Wharton or they can go to University of Phoenix.

Wharton will only allow the best in which they give scholarships to some but to most they charge for the education received.

Why should medicine be different?

 

[Mad Jack]

Those arguments would mean that Harvard Business School should let everyone in because they'd make more money as would every
educational institution in this country. If someone wants an MBA they can go to Wharton or they can go to University of Phoenix.

Wharton will only allow the best in which they give scholarships to some but to most they charge for the education received.

Why should medicine be different?

Because that's the way we used to do it and it was horrible. This isn't a thought exercise, we already know how things played out in the past and that is the precise reason things are the way they are today. Residents were abused, and hospitals had zero incentive to not do so. The ACGME leveled the playing field so that residents wouldn't have to live like indentured servants in a first world country, which is essentially what they were in times past. Screw anyone that would want to sell the vast majority of their peers down the river just so they could get ahead- that's precisely the sort of person we don't need in medicine.

 

[Gpan]

How do you think it adversely affects society when we have a significant shortage of Physicians in the United States? How do you think it affects society when
30-40 million Americans are in areas that even the AMA considers federally designated shortage areas?

Its a major problem that many are in the crosshairs of and wish to provide a useful and needed service.

Don't think that has anything to do with being a millennial.

and letting UNQUALIFIED person PAY for the tittle would fix that problem??????????
In medicine QUALITY >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> QUANTITY
I would NOT feel safe if my Doctor or my Family's Doctor paid his/her way through school/residency. Would YOU ????

 

[FaisalResidency]

and letting UNQUALIFIED person PAY for the tittle would fix that problem??????????
In medicine QUALITY >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> QUANTITY
I would NOT feel safe if my Doctor or my Family's Doctor paid his/her way through school/residency. Would YOU ????

Is is safe to trust a lawyer from Harvard Business School because he paid Harvard tuition?

A hospital or specialty group should still need to accept the credentials of the person, it is just that Graduate Medical Education
is not profitable to hospitals so something must be done as the US government subsidizing our education is not right.

A resident physician is receiving an education and if he receives a Government Scholarship than great and if not, he needs to be
able to find a way to pay for it himself.

 

[Mad Jack]

Is is safe to trust a lawyer from Harvard Business School because he paid Harvard tuition?

A hospital or specialty group should still need to accept the credentials of the person, it is just that Graduate Medical Education
is not profitable to hospitals so something must be done as the US government subsidizing our education is not right.

A resident physician is receiving an education and if he receives a Government Scholarship than great and if not, he needs to be
able to find a way to pay for it himself.

You say it's about helping patients and increasing access, and yet the policies you enact would likely decrease the number of people able to become physicians and make the path basically only open to the wealthy, hmmmm... It's almost like you have an agenda...

 

[Gpan]

Is is safe to trust a lawyer from Harvard Business School because he paid Harvard tuition?

A hospital or specialty group should still need to accept the credentials of the person, it is just that Graduate Medical Education
is not profitable to hospitals so something must be done as the US government subsidizing our education is not right.

A resident physician is receiving an education and if he receives a Government Scholarship than great and if not, he needs to be
able to find a way to pay for it himself.

Are you really this delusional ??? You equate paying tuition for college to PAYING YOUR WAY INTO A JOB (yes , training but still a competitive JOB) ???? And NO I would not trust ANYONE who PAYS his or her way through life, whether it be law school , medical school, engineering school, whatever professions. I think I'm done talking to a wall.

 

[NotAProgDirector]

This entire discussion is based on the assumption that programs are limited by funding. As was mentioned higher in the thread, this is usually not true. In fact, you'll see that there are multiple threads talking about completing a second residency and the funding shortfall that incurs -- and the overall assessment of those of us involved with GME is that the funding issue for second residencies is not an issue in the vast majority of situations. Plus, if a new program opens then new funding is allocated to that program. Hence, outside funding of additional residency spots is unlikely to be of benefit.

So what's up with the Tuft's program? I don't really know. But I expect that the amount they charge to foreign governments for training spots is far above what is paid by Medicare (total guess on my part -- I have nothing to back this up). It ends up being a small program that makes some extra money for the hospital if they have an international grad with outside funding.

Self funding is a very slippery slope. Once we allow that, then programs may simply start to rank applicants based on their funding source rather than their academic achievements. Although one could consider that a success of the free market, I'm not a fan. Of course, that system might favor your entry into a GME program, so I can see why you think it would be OK.

 

[FaisalResidency]

This entire discussion is based on the assumption that programs are limited by funding. As was mentioned higher in the thread, this is usually not true. In fact, you'll see that there are multiple threads talking about completing a second residency and the funding shortfall that incurs -- and the overall assessment of those of us involved with GME is that the funding issue for second residencies is not an issue in the vast majority of situations. Plus, if a new program opens then new funding is allocated to that program. Hence, outside funding of additional residency spots is unlikely to be of benefit.

So what's up with the Tuft's program? I don't really know. But I expect that the amount they charge to foreign governments for training spots is far above what is paid by Medicare (total guess on my part -- I have nothing to back this up). It ends up being a small program that makes some extra money for the hospital if they have an international grad with outside funding.

Self funding is a very slippery slope. Once we allow that, then programs may simply start to rank applicants based on their funding source rather than their academic achievements. Although one could consider that a success of the free market, I'm not a fan. Of course, that system might favor your entry into a GME program, so I can see why you think it would be OK.

Over 42,000 people applied and only 25,000 people were accepted in the match program. Adding 25,000 physicians a year which 2.5% while the median age of physicians is nearing
retirement is really terrible for our system. It causes huge areas of the country to have a lack of access to healthcare providers.

The limitation is that teaching Graduate Medical Education while paying them salaries is not profitable. They only due so because of government funding and due
to being perceived as a high quality teaching institution and not a profit motive.

That's not sustainable and its limiting the supply of much needed physicians in the US.

I don't mind paying $150-$180k to make $300k+ and double the salary of what would be made otherwise teaching science, or pharmaceutical firm.

That www medicalresidencyresources com company says they are trying to set that up and its free unless they offer me a position and I accept
it but then i need to fork over the $180,000. They set me up with banks that can lend me the money on a 20 year payback.

 

[NotAProgDirector]

Over 42,000 people applied and only 25,000 people were accepted in the match program. Adding 25,000 physicians a year which 2.5% while the median age of physicians is nearing
retirement is really terrible for our system. It causes huge areas of the country to have a lack of access to healthcare providers.

The limitation is that teaching Graduate Medical Education while paying them salaries is not profitable. They only due so because of government funding and due
to being perceived as a high quality teaching institution and not a profit motive.

That's not sustainable and its limiting the supply of much needed physicians in the US.

I don't mind paying $150-$180k to make $300k+ and double the salary of what would be made otherwise teaching science, or pharmaceutical firm.

That www medicalresidencyresources com company says they are trying to set that up and its free unless they offer me a position and I accept
it but then i need to fork over the $180,000. They set me up with banks that can lend me the money on a 20 year payback.

This really is the wrong forum to have this discussion, but here we are.

Your argument is conflating several issues.

The first question is whether we need more training positions here in the US. Yes, the number of applicants exceeds the number of positions available, but the vast, vast majority of USMD's and DO's all get spots, so what we're really asking is whether we should allow more US IMG's, or more non-US IMG's into the system. Which really translates to this question: "Do we need more doctors?"

That question is very difficult to answer. Some would say yes, and point to the patients who cannot get seen by a PCP because there are not enough. Or point to the fact that there will be lots of baby boomers getting older and more ill shortly. But others would say that it's really a distribution problem -- we have plenty of docs, just not in the right places. And training lots of docs to take care of the baby boomers doesn't make a ton of sense -- they will all die long before all of those new docs retire, and then we (might) have a glut. And this ignores the question of whether we should have more NP's or PA's to provide primary care (which is very controversial).

But even if we assume that we do need more physicians, my point above is that money is not usually the limiting factor. It's resources -- enough ICU time, clinic preceptors / rooms, etc. Those things can't be bought with money. Put another way, creating a system that stimulates programs to create slots so they can claim more money seems a really bad idea -- you're likely to get additional training slots in marginal programs that are just "out to make a buck". Although some programs have spots funded by a foreign government, this is very uncommon -- most programs don't want to get into that business because of all the possible conflicts.

And last, I'm assuming/hoping you don't need a visa. There is little question in my mind that any setup like this (you pay a third party, who then "funds" your residency, and then those funds are returned to you as salary) would constitute visa fraud for an H visa. The H rules are very clear that your employer needs to pay you a prevailing wage, and this type of setup is unlikely to pass legal muster. The rules for a J visa are less rigid, but I am concerned that the State Dept might still frown on this.

Anyway, the best of luck with finding a position.

 

[FaisalResidency]

This really is the wrong forum to have this discussion, but here we are.

Your argument is conflating several issues.

The first question is whether we need more training positions here in the US. Yes, the number of applicants exceeds the number of positions available, but the vast, vast majority of USMD's and DO's all get spots, so what we're really asking is whether we should allow more US IMG's, or more non-US IMG's into the system. Which really translates to this question: "Do we need more doctors?"

That question is very difficult to answer. Some would say yes, and point to the patients who cannot get seen by a PCP because there are not enough. Or point to the fact that there will be lots of baby boomers getting older and more ill shortly. But others would say that it's really a distribution problem -- we have plenty of docs, just not in the right places. And training lots of docs to take care of the baby boomers doesn't make a ton of sense -- they will all die long before all of those new docs retire, and then we (might) have a glut. And this ignores the question of whether we should have more NP's or PA's to provide primary care (which is very controversial).

But even if we assume that we do need more physicians, my point above is that money is not usually the limiting factor. It's resources -- enough ICU time, clinic preceptors / rooms, etc. Those things can't be bought with money. Put another way, creating a system that stimulates programs to create slots so they can claim more money seems a really bad idea -- you're likely to get additional training slots in marginal programs that are just "out to make a buck". Although some programs have spots funded by a foreign government, this is very uncommon -- most programs don't want to get into that business because of all the possible conflicts.

And last, I'm assuming/hoping you don't need a visa. There is little question in my mind that any setup like this (you pay a third party, who then "funds" your residency, and then those funds are returned to you as salary) would constitute visa fraud for an H visa. The H rules are very clear that your employer needs to pay you a prevailing wage, and this type of setup is unlikely to pass legal muster. The rules for a J visa are less rigid, but I am concerned that the State Dept might still frown on this.

Anyway, the best of luck with finding a position.

Thanks for your well thought out response and the information.

But I have to disagree with you on a few points:

Physician Shortage: In any shortage the less favorable areas will lack supply. Physician unemployment rates are less than half of 1%, so they'll have employment literally everywhere
and anywhere they go. The trade off of making more money being in a rural community is not enough to sway a physician to instead want a better quality of life in a big metropolitan city.

Supply should be enough that demand is filled and that is not the case. Physicians make high incomes in metropolitan cities and don't have to make the choice to be unemployed or go to a small town.

As an example barren areas of the Dakotas were found to have shale oil and thousands and thousands of people moved to a terrible terrain as the need for employees was theree.

A less than 1/2 of 1% unemployment rates means shortage. And there are THOUSANDS AND THOUSANDS of people that have medical degrees and are in this country and can help.

 

[<L>]

As an example barren areas of the Dakotas were found to have shale oil and thousands and thousands of people moved to a terrible terrain as the need for employees was theree.

Been to some of the "boomtowns" on the edge of the Bakken lately? They ain't doing so hot.

The fact that EVERYONE on this forum can see through your self-proclaimed altruism, and yet you still keep digging might explain why you haven't found a residency to actually pay you. Self-awareness goes a long way in US medical education.

 

[NotAProgDirector]

Thanks for your well thought out response and the information.

But I have to disagree with you on a few points:

Physician Shortage: In any shortage the less favorable areas will lack supply. Physician unemployment rates are less than half of 1%, so they'll have employment literally everywhere
and anywhere they go. The trade off of making more money being in a rural community is not enough to sway a physician to instead want a better quality of life in a big metropolitan city.

Supply should be enough that demand is filled and that is not the case. Physicians make high incomes in metropolitan cities and don't have to make the choice to be unemployed or go to a small town.

As an example barren areas of the Dakotas were found to have shale oil and thousands and thousands of people moved to a terrible terrain as the need for employees was theree.

A less than 1/2 of 1% unemployment rates means shortage. And there are THOUSANDS AND THOUSANDS of people that have medical degrees and are in this country and can help.

You do make some valid points, although there may be other forces at work.

Your assumption is that the physician market is saturatable -- that if we have more physicians they will fill jobs, and then there will be more physicians than jobs in the more desirable areas, and that will force physicians to move to less desirable areas. This is a really interesting question. Some data suggests that this is not the case -- that increasing the supply of physicians in an area simply makes each physician care for a smaller panel of patients, and then see those patients more frequently / order more tests / do more procedures / recommend more aggressive treatment so that their income remains unchanged. This has been demonstrated in multiple fields and markets. If this is the case, then increasing the supply of physicians will not in itself result in physicians moving to less desirable areas.

 

[deleted480308]

You do make some valid points, although there may be other forces at work.

Your assumption is that the physician market is saturatable -- that if we have more physicians they will fill jobs, and then there will be more physicians than jobs in the more desirable areas, and that will force physicians to move to less desirable areas. This is a really interesting question. Some data suggests that this is not the case -- that increasing the supply of physicians in an area simply makes each physician care for a smaller panel of patients, and then see those patients more frequently / order more tests / do more procedures / recommend more aggressive treatment so that their income remains unchanged. This has been demonstrated in multiple fields and markets. If this is the case, then increasing the supply of physicians will not in itself result in physicians moving to less desirable areas.

I'd add that national medicare pricing also reduces the cost differential a free market would provide between regions of scarcity and regions of surplus.

 

[SouthernSurgeon]

I'd add that national medicare pricing also reduces the cost differential a free market would provide between regions of scarcity and regions of surplus.

Medicare rates are price adjusted by region

 

[deleted480308]

Medicare rates are price adjusted by region

I'd love to read more about this....do you have a link?

And is it rural pays more than urban or is more of a cost of living type calculation?

 

[FaisalResidency]

You do make some valid points, although there may be other forces at work.

Your assumption is that the physician market is saturatable -- that if we have more physicians they will fill jobs, and then there will be more physicians than jobs in the more desirable areas, and that will force physicians to move to less desirable areas. This is a really interesting question. Some data suggests that this is not the case -- that increasing the supply of physicians in an area simply makes each physician care for a smaller panel of patients, and then see those patients more frequently / order more tests / do more procedures / recommend more aggressive treatment so that their income remains unchanged. This has been demonstrated in multiple fields and markets. If this is the case, then increasing the supply of physicians will not in itself result in physicians moving to less desirable areas.

Thanks. Really enjoy the discussion.

That is a truly a sad state that if we add more physicians they'll do unnecessary procedures to make up for the loss in income and not move to an area that has a need.
Any physician that would do that should lose their license to practice.

I think if physicians see fewer patients and spend more time with them society will be better off, though the physician income may drop off unless people go to areas with
a need for physicians. As that gap widens it will attract people to those areas in my opinion.

 

[FaisalResidency]

I'd love to read more about this....do you have a link?

And is it rural pays more than urban or is more of a cost of living type calculation?

That rural physicians can bill for certain specialists work is what drives up their income as well if there are none in the area.
They end up becoming a more generalist physician.

 

[Crayola227]

That's why they like to recruit future docs from the sticks like me

Many of us are familiar with a rural lifestyle

I would prefer the suburbs of a large city
but I get all these ads that make big promises for docs to go practice in rural locations

I think as someone who grew up on hobby farm, you can get someone like me to want to get out there
I would have horses, a yearly steer for meat, chickens, and a huge garden (I've always done some gardening)
camp, take out the canoe and go fishing
it'd be fun to have a couple kids and do all that outdoors stuff with them
add in kids and I'd have a bunch more animals
4 H with pygmy goats?

I think if you recruit docs that are pretty serious about rural medicine AND offer incentives for rural practice we might as a society better address this

 

[NotAProgDirector]

Thanks. Really enjoy the discussion.

That is a truly a sad state that if we add more physicians they'll do unnecessary procedures to make up for the loss in income and not move to an area that has a need.
Any physician that would do that should lose their license to practice.

My prior answer was somewhat incomplete / vague.

It's not thought to be a conscious decision -- i.e. the problem isn't (in most cases) that physicians are just ordering more tests / doing more things just to make money. It's that when resources are tight / constrained, physicians tend to focus them on the people that really need them, and the grey zone / borderline situations get pushed off.

And example: You see a diabetic whose A1c is 8.5%. You decide to get more aggressive with their BS control by adding some new med (or increasing the dose of the old med, etc). You need to see them back in the office for follow up. How long before you see them again?

Imagine that you have a very full practice with very few openings in your schedule. In that case, you'll probably see them back in 3 months. You might have your nurse call in 1 month and see how they are doing. You might check an A1c in 6 weeks again, then see them 6 weeks after that again with an A1c. Maybe you'll adjust their meds over the phone in between.

Now imagine you have a mostly empty practice. in that case, you'll probably see them back in 1 month, and probably see them every month. The same med changes will get made, but now the patient has many more visits, and hence more health care costs.

The same thing happens with everything. The easier it is to get something, the more likely physicians are to order it for borderline cases -- when cost effectiveness is low. It's human nature.

I think if physicians see fewer patients and spend more time with them society will be better off, though the physician income may drop off unless people go to areas with a need for physicians. As that gap widens it will attract people to those areas in my opinion.

This would only exacerbate any physician shortage (if there is one). It's not clear that longer visits with physicians will really make any difference. My personal experience is that my ability to affect my patient's weight / smoking status / poor health habits is incredibly limited, and that more time with them will not change that at all.

Hell, I'm somewhat overweight, and I spend all day (and night) with myself, and I can't get myself to change my habits...

 

[FaisalResidency]

My prior answer was somewhat incomplete / vague.

It's not thought to be a conscious decision -- i.e. the problem isn't (in most cases) that physicians are just ordering more tests / doing more things just to make money. It's that when resources are tight / constrained, physicians tend to focus them on the people that really need them, and the grey zone / borderline situations get pushed off.

And example: You see a diabetic whose A1c is 8.5%. You decide to get more aggressive with their BS control by adding some new med (or increasing the dose of the old med, etc). You need to see them back in the office for follow up. How long before you see them again?

Imagine that you have a very full practice with very few openings in your schedule. In that case, you'll probably see them back in 3 months. You might have your nurse call in 1 month and see how they are doing. You might check an A1c in 6 weeks again, then see them 6 weeks after that again with an A1c. Maybe you'll adjust their meds over the phone in between.

Now imagine you have a mostly empty practice. in that case, you'll probably see them back in 1 month, and probably see them every month. The same med changes will get made, but now the patient has many more visits, and hence more health care costs.

The same thing happens with everything. The easier it is to get something, the more likely physicians are to order it for borderline cases -- when cost effectiveness is low. It's human nature.



This would only exacerbate any physician shortage (if there is one). It's not clear that longer visits with physicians will really make any difference. My personal experience is that my ability to affect my patient's weight / smoking status / poor health habits is incredibly limited, and that more time with them will not change that at all.

Hell, I'm somewhat overweight, and I spend all day (and night) with myself, and I can't get myself to change my habits...

Competition inherently does the opposite. Groups with limited supply have the ability to gouge customers, whereas competition will breed increased information
and better pricing to those that are able to take care of a disease with less visits and less procedures. Eventually payers (insurance, medicare etc.) will understand this
and not allow excess work on people. For right now the shortage of physicians allows for these shenanigans.

 

[Mad Jack]

Over 42,000 people applied and only 25,000 people were accepted in the match program. Adding 25,000 physicians a year which 2.5% while the median age of physicians is nearing
retirement is really terrible for our system. It causes huge areas of the country to have a lack of access to healthcare providers.

The limitation is that teaching Graduate Medical Education while paying them salaries is not profitable. They only due so because of government funding and due
to being perceived as a high quality teaching institution and not a profit motive.

That's not sustainable and its limiting the supply of much needed physicians in the US.

I don't mind paying $150-$180k to make $300k+ and double the salary of what would be made otherwise teaching science, or pharmaceutical firm.

That www medicalresidencyresources com company says they are trying to set that up and its free unless they offer me a position and I accept
it but then i need to fork over the $180,000. They set me up with banks that can lend me the money on a 20 year payback.

The trouble is that most medical students can't afford that, so less positions, not more, would be offered. The average US medical student us taking on between 200-400k already, another 200k would create insurmountable levels of debt that would be impossible to pay off care of the magic that is compound interest. Combine that with the likely reduced number of residencies that would come about in a free market GME system (as the only reason Medicare pays at all is that private funding does not exist- were programs to start accepting private funding, Medicare would follow through with what they have wanted to do for some time and defund GME), and you end up with a system that is worse for patients, worse for doctors, and worse for the country. The only people that would benefit would be the rich, and that's not something we abide in America.

 

[Mad Jack]

Thanks for your well thought out response and the information.

But I have to disagree with you on a few points:

Physician Shortage: In any shortage the less favorable areas will lack supply. Physician unemployment rates are less than half of 1%, so they'll have employment literally everywhere
and anywhere they go. The trade off of making more money being in a rural community is not enough to sway a physician to instead want a better quality of life in a big metropolitan city.

Supply should be enough that demand is filled and that is not the case. Physicians make high incomes in metropolitan cities and don't have to make the choice to be unemployed or go to a small town.

As an example barren areas of the Dakotas were found to have shale oil and thousands and thousands of people moved to a terrible terrain as the need for employees was theree.

A less than 1/2 of 1% unemployment rates means shortage. And there are THOUSANDS AND THOUSANDS of people that have medical degrees and are in this country and can help.

We have a low unemployment rate because we have the right number of physicians, not too many. If physician unemployment were even 2%, that would be an impetus for residency closures. As to maldistribution, there is a lot of research out there on it- we don't have a shortage, we've got a distribution problem that has urban areas seriously overserved for various reasons. Health care does not follow normal apply and demand rules- Medicare isn't going to pay you drastically more for an office visit in ND than they will in NYC, despite the fact that the demand is substantially higher. So people go to the cities, where they make lower wages and see less patients due to the competition, but enjoy their lives more.

 

[Mad Jack]

Medicare rates are price adjusted by region

It isn't a big enough adjustment to compensate for the demand curve.

 

[deleted480308]

It isn't a big enough adjustment to compensate for the demand curve.

and the googling I did showed a price adjustment by cost of living (so NY would actually make more) not by area of need (in order to pay rural more).....anyone have any word on this?

iirc, one of the ongoing controversy is crna's getting a rural "pass through" boost in reimbursement that is inexplicably denied to to anesthesiologists

 

[Mad Jack]

Competition inherently does the opposite. Groups with limited supply have the ability to gouge customers, whereas competition will breed increased information
and better pricing to those that are able to take care of a disease with less visits and less procedures. Eventually payers (insurance, medicare etc.) will understand this
and not allow excess work on people. For right now the shortage of physicians allows for these shenanigans.

I think you miss the fact that one cannot effectively gouge customers in most medical fields- insurance companies generally have a fairly inflexible fee schedule (you might end up plus or.minus fifteen percent), and privately paying individuals don't exist in great enough numbers to maintain most practices, let alone to let you gouge them.

 

[Mad Jack]

and the googling I did showed a price adjustment by cost of living (so NY would actually make more) not by area of need (in order to pay rural more).....anyone have any word on this?

iirc, one of the ongoing controversy is crna's getting a rural "pass through" boost in reimbursement that is inexplicably denied to to anesthesiologists

https://www.ruralhealthinfo.org/topics/medicare

If you get rural health clinic designation, or you work in a CAH or similar access level hospital, you get paid a premium over regular Medicare rates. There's red tape and such, but if you do the right things, extra money can be had.