Ticket to Ride
The New York Times suggests that cash is increasingly being preferred to insurance by doctors in Manhattan. The doctors want to avoid dealing with the insurance ‘caps’ that may be charged for procedures.
Efforts by insurers to rein in health care costs by holding down physician fees — especially for primary care doctors, who play a critical role in health care though they are among the lowest paid doctors — appear to be accelerating the trend, and some patients say it’s getting harder to find an in-network physician …
a new survey of 13,575 doctors from around the country by The Physicians Foundation found that over the next one to three years, more than 50 percent plan to take steps that reduce patient access to their services, and nearly 7 percent plan to switch to cash-only or concierge practices, in which patients pay an annual fee or retainer in addition to other fees.
The cash-upfront trend raises an uncomfortable question. Can the Affordable Care Act, intended to widen access to health care, succeed by expanding insurance coverage if primary-care doctors are walking away from insurance? …
A June report by the Medicare Payment Advisory Commission, which advises Congress and focuses primarily on the government plan for seniors, suggests adults ages 50 to 64 are having more trouble getting an appointment with a new physician …
The country is already facing a shortage of physicians, according to the Association of American Medical Colleges. By 2025, the nation will have 100,000 fewer doctors than needed, according to the association. With fewer medical students choosing to go into primary care, shortages in this area are expected to become especially acute.
When economists find that capacity in a given industry is declining and that shortages are emerging they usually look at the price incentive structure to identify the problem.
Several tens of millions of people are going to be entering the market with Affordable Care insurance policies in hand but will they find any doctors who’ll take them? “When the Affordable Care Act’s insurance mandate takes effect in 2014, some 30 million newly covered patients—people generally treated in emergency rooms now—will be shopping for doctors. That’s a problem because the U.S. has 15,230 fewer primary-care physicians than it needs, according to the U.S. Department of Health and Human Services.”
Yet teaching hospitals aren’t rushing to fill the void. The federal government foots most of the bill for residency programs—and Congress has capped enrollment at about 85,000 students for the last 15 years
But if more patients and fewer doctors do not mean higher prices with the reimbursements capped they will mean even longer waiting lines. One acknowledged factor at work in reducing primary care physician availability is low expected earnings. “While medical schools are increasing enrollment, there are still few going into primary care because of lower pay … 97% of people in Massachusetts have health insurance. But nearly a third of them had trouble finding treatment in the last year.”
Even if residency programs are expanded, medical students themselves are choosing not to go into primary care practice. Student debt is one reason. “School debt and income expectations are two main reasons many medical students decide to enter a high-paying specialty instead of becoming primary care doctors, according to a new long-term study … By graduation, 30 percent of the students who entered medical school with the intention of becoming a primary care doctor switched their preference to a high-paying specialty … In 2010, 86 percent of medical students graduated with some education debt, according to the Association of American Medical Colleges. The average debt was $158,000, but 30 percent of graduates were more than $200,000 in debt.”
With the cost of producing primary care doctors rising and the reward of entering the profession falling availability is declining. So what can be done to ameliorate the situation?
According to Michael Lind at Salon the answer is simple. “Experts know that the answer to health costs is regulating what doctors, hospitals and pharma companies can charge”. Medical access and procedures should not be limited. All that is required is to make people charge less for it. Here’s how Lind thinks it should work.
In all-payer regulation, every few years the government bargains with representatives of health care providers—doctors, hospitals and pharma companies—to set prices for medical goods and services. The fee schedule that results from the negotiations is binding on all providers, public or private. All-payer regulation keeps prices down, in otherwise different health care delivery systems, including the Swiss system based on individual mandates to buy (nonprofit) private insurance and Japan’s fee-for-service system.
The process appears to resemble the negotiations that politicians periodically have with teacher’s unions. Will it work? We’ll soon find out.
The great conceit of government is the illusion that by creating a certificate of entitlement it automatically creates that physical resource as well. Nobody imagines that it will result in more paper chasing fewer services.
In money as in insurance this can result in the debasement of the coinage. People are vaguely aware that adding a zero to all the dollar bill denominations will not make them ten times richer. But many have not yet realized there is a difference between having an insurance certificate ‘entitling’ them to medical care and the actual existence of that medical care resource.
Obamacare, Obama Phones and other types of Obama Cheese are ultimately tickets of entitlement at a given price or gratis. But they are ‘free’ only in a manner of speaking. They still require real goods and services to satisfy the certificate; they still have real costs. Reality, not the piece of paper is the final arbiter of actual meaning. You can have the ticket, but is there a bus?
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One of the demonstrated failures with regulation is the assumption that those regulated will not change their behavior. Cut the earnings of primary care doctors and medical students will not transfer into higher-paying specializations. When will the regulators ever learn?
Doctors are supposed to operate under the guideline of “First, do no harm”. It is a pity the same guideline does not apply to the Political Class and their regulatory running dogs.
Lind is completely ignorant of reality. But that is to be expected from salon and their ilk.
It almost looks like central planning doesn’t work…but we know better, don’t we?
There’s more to economics than just sitting through a class. *sigh*
Ban medical insurance entirely and the cost crisis is solved.
No doctor can stay in business charging more than people are willing to pay.
It used to work that way in the 50s.
Prices charged varied according to ability to pay, and that’s how everybody got medical care.
That was possible because medical care couldn’t be transferred, and it was an economics textbook example of such a service.
There are good reasons for physicians not to enter family practice. Not only is its pay among the lowest of the specialties, but family practice physicians are soon to be replaced by Advance Practice Nurses. Currently trained at the Masters Level, they will be given Doctorates starting in 2015. They will become the first line treaters within the next 10 years, for better and for worse.
Physicians should concentrate on doing what no one else can do or is trained to do. Advance Practice Nurses will soon have training that the public and the regulators will deem sufficient to screen patients and perform most routine follow-up. This is already happening under the “supervision” of physicians but will soon be allowed to operate without such “supervision” in rural areas or such areas of greater need like inner city clinics.
This will be the way the US will solve the doctor shortage. Whether or not it will affect the quality of care is something that remains to be seen. But it will increase the quantity of care.
Let me close with a story of the Rabbi and his wagon driver. They had been going from town to town for years to locations in which the Rabbi would give a short speech and then answer questions. After decades the wagon driver said, “Rabbi, I have heard you for so long that I am sure I could do your job just as well as you can.” So the Rabbi agreed to change clothes and drive the wagon, while the wagon driver would give the speech and answer questions. Everything went well until someone asked a question that the wagon driver had never heard. As he stood for a moment in stunned silence, wondering what to do, he finally said, “That question is so simple, even my wagon driver could answer it!”
Price controls causing scarcity and shortages? In Manhattan? Inconceivable!
Wretchard, said “The process appears to resemble the negotiations that politicians periodically have with teacher’s unions. Will it work? We’ll soon find out.” One word “Chicago”!
batman (#5) I’ve run into these at my Pri Care Doc, experince was good but it was a temp situtation, My thoughts are in the air on this still…
What spring are they drinking from, these people who believe that declaring something to be so can make it so? The monks in a monestery at least grow their own food, wash and mend their own clothes, and repair the roofs over their heads. What have the ‘Ones We Have Been Waiting For’ ever done other than collect fat paychecks that were completely disconnected from any value they may have produced.
This administration is an object lesson in why you should NEVER give an academic political power. Their only experience is in teaching an ideal that does not exist in the real world. Their base of knowledge is fixed; the value of pi does not change, but its application in the real world is in constant motion. “All of Gaul is divided into three parts” is the opening line from De Bello Gallico, and will be a thousand years from now, but Gaul itself is being remade daily, hourly, and whoever must deal with that change may be informed by Caesars words, but must use a judgement tempered in a far more hostile classroom than Harvard or Yale can provide.
GET THEM OUT, GET THEM OUT, GET THEM OUT.
6. Eric J.
Price controls causing scarcity and shortages? In Manhattan? Inconceivable!
In the words of Inigo Montoya;
” I don’t think that word means what you think it does.”
Medical care costs have necessarily become less affordable once the patient gets past the first tier. Only part of that involves government intervention, although that, too, will surely become more skewed as the DHHS bureaucracy tightens its grip.
Pharmaceutical and specialized medical equipment costs are the big reason why so many find it necessary to become part of a healthcare insurance group. If you’re not there, it becomes unaffordable to get specialized treatment.
So now the Dems may be pushing more folks out of the first tier with their meddling due to lack of availability – not lack of affordability. They must hasten to find someone to blame. Perhaps Romney?
My advice: get healthy and endeavor to stay that way.
e @ 10: Medical care costs have necessarily become less affordable once the patient gets past the first tier.
Yeah, it’s not the 1950s anymore, the technology, drugs, etc are going to be much more expensive, and only spreading the cost around somehow makes it practical. Yet, there may be limits to what spreading it around can do, and then you start having to be confiscatory just to support the technology, the bureaucracy, and the coercion. It is a very tough problem.
b @ 5: Advance Practice Nurses will soon have training that the public and the regulators will deem sufficient to screen patients and perform most routine follow-up.
This was what they told us in school in the 1970s was appropriate and effective, only took 40 years to get there. I’ve seen a little of it done already. I’m tentatively OK with it. Part of that is my being extremely dissatisfied with the quality of physicians and their standards of care as thngs are, perhaps freeing them up to mostly be a second level resource, will work all the way around. Most of my annual checkup is done by technicians and phlebotomists and whatnot anyway, so what’s the diff?
“That question is so simple, even my wagon driver could answer it!”
+ aleph(1)
And you know that the Liberal response will be to add more rules and regs (all Physicians ad mandated to provide X% of their time to Medicare/Medicaid/etc) rather than admitting than interfering in a free market leads to this. I guess that 2000+ pages of new law wasn’t long enough then.
“Experts” are the death of this country.
Batman #5:
Physicians should concentrate on doing what no one else can do or is trained to do. Advance Practice Nurses will soon have training that the public and the regulators will deem sufficient to screen patients and perform most routine follow-up. This is already happening under the “supervision” of physicians but will soon be allowed to operate without such “supervision” in rural areas or such areas of greater need like inner city clinics.
This will be the way the US will solve the doctor shortage. Whether or not it will affect the quality of care is something that remains to be seen. But it will increase the quantity of care.”
The question is, who among us will volunteer for these lesser trained mid level providers?
Inherent in the attitude of those who are blithe about this anticipated transition is the (perhaps unconscious) belief that it will be the families and children of “other people” who will utilize these lesser trained caregivers, while they themselves will still get the head honcho experienced doc for those services.
It is the primary care guys who are, perhaps, the most important ones to be highly qualified. Bad or incorrect diagnosis at the beginning of taking care of a sick person will insure a bad result.
The desire by bureaucrats and politicians to generate lots of mid level providers in order that they can promise (not necessarily deliver) more care at the current level of quality (as if!) for a lot less money by taxing the rich so that the average person has a lower health cost per year and therefore more money to spend on stuff and fun, thereby voting to keep the bureaucrats in power, is what is behind this. This was the promise of Hillarycare: more care and the same or better qualiy for more people, and it will magically cost eveyone less. It’s is one of the pincers of a two pronged squeeze on small-practice doctors, dentists, eye clinics, etc., the other being a hyperregulatory environment which makes it nearly impossible for smaller practices to compete.
Some fields in life really do require the top half of a percent of talent to be done right. Sports strikes are the best example of this. Bring in the next tier down, even thought they might be the next 1/2%, and the end result is pretty horrible.
At least in sports it’s entertainment, not people’s life and limb.
@#12 Steeple: You are correct. That is precisely what will happen. And then the procedure heavy professions will move to other locations, as their wealthy patrons set up US style facilities in Mexico, Costa Rica, and post-Castro Cuba.
My “modest solution” for years has been to ban every medication, procedure, and diagnostic test discovered or created after 1964. That will immediately lower the cost of health care and make it equally mediocre for everyone. The alternate “modest solution” is to kill everyone over age 80 who consumes more than they put into the system, a la Soylent Green. Perhaps both will be implemented by the panels in the new law. Wait and see.
OT, but things heating up between Turkey and Syria:
Turkey Strikes Syria In Response To Weekend Shelling of Turkish Village
It is like the solution to money. If there are not enough of them just print more doctors. No need for expensive education just print out more visas. There are plenty of debt-free doctors waiting to come over from Asia, the Middle East and South America.
Soon near all doctors will work for a large corporation or hospital system. That is who will do the negotiating with the government and its proxy insurance companies. I hope that people do not get the impression that medicare and insurance companies just pay whatever you charge now. They do not. What will happen in Obama care is that big hospitals, who will continue to buy up smaller hospitals and medical practices, will see more revenue. If they need to make a little less on primary care they will make up for it elsewhere.
What is really happening with Obama care is not socialism, it is much more like fascism. I am not sure which is worse. At least with a government job the benefits are good and you have some job security. The corporate sharks will eat you for lunch.
It’s all all right though ’cause love is free:
was feelin’ . . . so bad,
I asked my family doctor just what I had,
I said, “Doctor, . . .
(Doctor . . .)
Mr. M.D., . . .
(Doctor . . .)
Now can you tell me, tell me, tell me,
What’s ailin’ me?”
(Doctor . . .)
He said, “Yeah, yeah, yeah, yeah, yeah,
(Yeah, yeah, yeah, yeah, yeah)
Yes, indeed, all you really need . . .
(Is good lovin’)
Gimme that good, good lovin . . .
(Good lovin’)
All I need is lovin’ . . .
(Good lovin’)
Good lovin’, baby.
What a bargain!-In exchange for giving the federal government complete access to our medical records, we get screwed at the service end.
“That question is so easy, my Vice-President Biden could answer it.”
b @ 15: My “modest solution” for years has been to ban every medication, procedure, and diagnostic test discovered or created after 1964.
My modest solution runs the other way, require your first-line professionals to run the numbers past a Google medical robot (expert system). They are allowed to override, but have to be on the record.
I hate saying that, and a lot rides on the quality of the bot(s), but back in those expert system days (1980s) part of the negative reaction was that the bots did better than the average doctors, and that was a looooong time ago in computer technology terms.
The medical profession is still fighting technology and modernization the way the music industry fought downloads, the way Obama fights fracking. At least doctors today, we presume, know how to use Google and a smart phone, shouldn’t be individually as technophobic as back then.
Eventually molecular biology and super high-tech genetics and diagnostics will solve a lot of these problems, but the big changes are still a generation or three away.
–
d @ 18: “That question is so easy, my Vice-President Biden could answer it.”
“That question is so easy, my Hildabeast can answer it!”
… only we’re not sure just where in the world she is right now, but we have all of our satellites tuned to detect excessive pant suits and the CIA should have a camera on her within the next 18 hours.
As more and more days go by it becomes clear and clear, the 0bama Administration, the Hildabeast State Department aren’t just incompetent, they are intentionally! Let me say that again, INTENTIONALLY derelict in their duties to our Consulates and Embassies, this behavior is not isolated to the Foreign Service ether and one can only guess just how bad they are with those departments they loath! America wake the F@#kup!(To steal the words of a Bigoted Hollywood Movie star elitist) Our payback will be beyond horrid with these people in charge today and it should come as no shock! America will get what we’ve asked for from our (lousy) leaders, one can only hope China or Russia even Pakistan do not wake up to the sheer weakness America is in… Again our God has turned his back on this land and the fallen one will have his way, Pray ye Men and Women for thy Children, beg for God’s Mercy! Now is the time to stand up and be counted, put your differences aside and demand our leaders be true to our God, fight for his truth, his light to lead us, let this not be our hour of Dusk from which Darkness shall reign.
In most states, nurse practitioners (as opposed to physician assistants) are permitted to practice without physician supervision, and they do an excellent job. For most patients, health maintenance and even care of serious conditions can be provided by someone with less than an MD degree. However, there are two factors, or illusions, that affect the feasibility of blissful provision of medical care for all.
First, a sizable fraction of the patient pool have chronic problems of obesity, substance abuse, nutritional neglect, and problems related to live-style. Certainly many lower-income people and elderly people fall in this category. The implicit expectation held out by the health activists is that all people have some inherent right to the same condition of health (not just access to care) as the “privileged.” This is an impossible goal, and to engender that hope in the popular mind is to blame poor health, and ultimately death, on class difference. This is absurd and guaranteed to persist as a source of unending social division.
Second, no system or type of health care will result in the elimination of illness and death, or will correct the natural differences in individual health conditions and ultimate demise. Failure to acknowledge this fact results in such absurdities as the state being ordered to pay for sex change operations, weight reduction surgery, cosmetic procedures, and so forth. There is no end to the expense and no society can have the means to provide every such perceived need to stave off unpleasantness, discomfort, dissatisfaction with one’s inherent health, physique, or age, and the inevitable death of every individual under widely different circumstances and degrees of unpleasantness. The issue of governmental subsidy of “orphan drugs” is an example of these issues at play. Do we socialize every personal problem? On the other hand, who should draw the line limiting how far to go? A “death panel” in some bureaucracy? The ultimate fact to remember is that denial of coverage is not denial of care. Insurance companies do not kill people. Living results in death. As William Penn said, “We can not learn to live until we learn to die.”
As Victor Davis Hanson once related about Greece, getting a telephone installed was a multi-month affair with the state-run phone system but passing out an “incentive bonus” to the government-authorized service technician could cut that down to a few days. Economies with government-controlled prices are rife with black markets as any former inhabitant of the USSR could tell you. In socialism, everything is free but unfortunately, there’s never anything on the shelves. Of course, one wouldn’t expect any of the fools who write at Salon to understand this, for they likely consider history, like economics and math, to be just another racist conspiracy to make the black president look bad.
“The process appears to resemble the negotiations that politicians periodically have with teacher’s unions.”
This has worked so well with the schools and is now being expanded into medical care, that I think it should be used for everything.
After all, isn’t food more critical than medical care? You can go for decades without any medical care but you can’t go for more than a few days without food.
And gasoline! Perhaps Doug can tell us how well the State of Hawaii did when it decided to regulate the price of gasoline.
We should use this process for everything! Why are medical care and education so special?
The independent duty Navy Chief Corpman or Doc does a good job.
Why don’t we mandate that everyone is entitled to a free college education. That PhDs must donate 20 hours a week to the indigent. That they may not charge more for their services then a fixed schedule. Who wants to sign up for 7 years of indentured servitude and $150,000 in debt?
I think that there is a sentiment in this governing class that the burgeoning student loan debt, not dischargable in bankruptcy, is actually an opportunity for the government, not a crisis to solve.
Let me explain.
As more and more students owe more and more money that is not dischargable in bankruptcy, and fewer and fewer can pay the loans back by getting decent jobs, the government is going to step in to manage the crisis by forgiving the loans in exchange for the graduates doing what the government wants done. In the case of medicine, that will include going into underserved specialties or subspecialties or practicing in underserved areas. The government will pay off the loan (perhaps even with a haircut for the banks, who cannot complain) and they will have a cadre of servants who cannot say no.
Think about it.
25 – Guessed
The government already does that. I have a brother and sister-in-law both practicing in the wilds of the Eastern Shore of Maryland. Some portion of their loan gets forgiven for a set number of years of service in the under-served area. Not all.
Michael Lind’s proposal to limit the payment for service rendered is what is written into current Medicare law, {OR was, prior to ACA} whereby the payments to the serving doctors is to be reduced annually. Thing is, Congress has refused to go along {as well they should unless they want a physicians revolt} with the very law they wrote. They pass legislation annually to counter the reduction. They have never, to my knowledge, allowed the statute to fully reduce the payments to physicians.
tom
My take is that 90% of patients don’t really have the impetus to get better. They got sick over years and they will not change to improve. We should keep the costs to a minimum with that segment. Those are sunk costs and provide little return in increased health or productivity. I am overjoyed that the mid-level providers can give them a confessional for their physical failings and palliate their pain. That is a service and it may be the only thing that gives hurting people a benefit. Most of these people know they will not change and many will tell you as much. This is not mental illness, most of them are realistic and appreciate the sham that is internal medicine and pain management as more theatre than cure.
The issue is that mid-level providers order more tests and labs in my experience than physicians. They have fewer data points due to decreased training and are reliant on the labs. They have adopted the adage that we have pretty much cracked the nut and medicine is now a science not an art. As a result they are parts-changers not mechanics. In a capitated system they will get crushed or they will adapt to a lower level of diagnostic accuracy.
Either we pay more for training (Mediscare funds MD/DO residencies)and for loan repayment (I’m OK with that, preferably state or local programs), or we import and crush the native John Galts, they will be as f@#$ed as the lawyers with crushing debt they can’t repay. I am 100% sure we will choose the latter, it is the least expensive way and protects the interest of the hospitals and pharma. That’s precisely why I got my ass out of that whole goat-rope.